Shawnee Care Center: Wrong Antipsychotic Dose Given 11 Days - OK
The resident, identified in inspection records only as Resident 1, had been prescribed olanzapine 20 mg daily since December 2024. On July 1, 2025, a pharmacist conducting a routine monthly medication review flagged the dosage and requested a gradual reduction. The physician agreed. On July 7, the doctor signed two orders: discontinue the 20 mg dose, begin 15 mg daily.
The medication aide, identified as CMA 1, never checked.
From July 8 through July 18, CMA 1 continued pulling 20 mg tablets from the old blister card and administering them to the resident. The first dose from the new 15 mg card wasn't given until July 19, the same day someone noticed the error.
Inspectors reviewed the blister cards on August 11. The 30-day supply of olanzapine 15 mg, dated July 7, showed its first tablet had been popped on July 19. Six tablets remained. The math told the story before anyone said a word.
When inspectors asked CMA 1 directly what dose Resident 1 had received between July 8 and July 18, the aide said they had not realized the physician order had changed and kept giving the 20 mg pill until the error was noticed. "They stated they should have verified the dosage shown on the physician order in the medical record with the dosage on the pill card prior to administration," the inspection report noted.
The director of nursing told inspectors she had opened an investigation after being informed of a possible medication error on July 19. She confirmed the sequence: the order changed July 7, the wrong dose continued through July 18, eleven days total. She said what CMA 1 had already said, that the aide should have cross-checked the pill card against the physician order before administering anything.
The medication error report filed at the time listed the outcome for Resident 1 as "no apparent effects."
Resident 1 carries diagnoses of bipolar disorder and recurrent depressive disorders. A quarterly assessment completed July 7, the same day the dosage change was ordered, showed the resident was moderately cognitively impaired with a BIMS score of 11, a cognitive screening measure where scores between 8 and 12 indicate moderate impairment. The assessment noted no symptoms of depression and no behavioral episodes at that time.
Olanzapine is an antipsychotic used to treat bipolar disorder and schizophrenia. The pharmacist's July 1 recommendation for a gradual dose reduction reflects a standard practice in nursing home care, where regulators and clinicians have long pushed facilities to periodically reassess whether residents still need antipsychotics at their current doses, or at all.
The gradual reduction the pharmacist requested, and the physician approved, never happened on schedule. Instead, Resident 1 received a higher dose than prescribed for nearly two weeks.
The facility's MDS coordinator told inspectors that 39 residents at Shawnee Care Center were receiving psychotropic medications at the time of the inspection.
Inspectors cited the deficiency at a level of minimal harm, meaning no serious injury was documented. The facility has not contested that finding in the public record reviewed for this report.
What the inspection record does not answer is whether anyone told Resident 1, who is moderately cognitively impaired, that they had been receiving the wrong dose of their antipsychotic medication for eleven days, or what, if anything, the facility said to the physician who had signed the reduction order on July 7 and whose instructions went ignored until the pill card made the error impossible to overlook.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shawnee Care Center from 2025-08-13 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Shawnee Care Center in Shawnee, OK was cited for violations during a health inspection on August 13, 2025.
The resident, identified in inspection records only as Resident 1, had been prescribed olanzapine 20 mg daily since December 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.