Shawnee Care Center
Inspection Findings
F-Tag F0757
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, record review, and interview, the facility failed to ensure a gradual dose reduction for
a psychotropic medication was initiated when ordered by the physician for 1 (#1) of 3 sampled residents whose medications were reviewed.The MDS coordinator identified 39 residents who received psychotropic medications.Findings:On 08/11/25 at 4:20 p.m., Res #1's medications were reviewed with CMA #1. A pill medication blister card, dated 07/07/25, showed a 30-day supply of olanzapine 15 mg tablets. The card showed the first dose of olanzapine 15 mg (an antipsychotic medication) had been popped on 07/19/25 and six tablets currently remined in the blister card.An undated face sheet showed Res #1 had diagnoses which included bipolar disorder and recurrent depressive disorders.A physician order, dated 12/16/24, showed to administer olanzapine 20 mg daily.A pharmacist monthly medication review, dated 07/01/25, showed a request for a gradual dose reduction of olanzapine 20 mg daily. The review showed the physician had agreed to decrease the dosage to 15 mg daily.A quarterly assessment, dated 07/07/25, showed Res #1 had a BIMS score of 11 and was moderately cognitively impaired. The assessment showed Res #1 had no symptoms of depression, no behaviors, and had received antipsychotic and antidepressant medication.A physician order, dated 07/07/25, showed to discontinue olanzapine 20 mg daily.A physician order, dated 07/07/25, showed to administer olanzapine 15 mg daily.A medication error report, dated 07/19/25, showed the dosage of olanzapine was changed from 20 mg daily to 15 mg daily on 07/07/25. The report showed CMA #1 was unaware the dosage had changed and continued to administer 20 mg daily until the error was noticed on 07/19/25. The report showed no apparent effects as an outcome for Res #1.On 08/11/25 at 4:20 p.m., CMA #1 stated the first dose of olanzapine 15 mg had been administered out of the pill medication blister card on 07/19/25. On 08/11/25 at 4:23 p.m., CMA #1 was asked what dosage of olanzapine Res #1 had received from 07/08/25 through 07/18/25. CMA #1 stated they had not realized
the physician order had changed from 20 mg daily to 15 mg daily on 07/07/25 and continued to give the 20 mg pill until the error was noticed on 07/19/25. CMA #1 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. On 08/12/25 at 12:15 p.m., the DON stated they completed an investigation after they were informed of a possible medication error for Res #1 on 07/19/25. They stated the physician order for olanzapine had changed from 20 mg to 15 mg daily on 07/07/25. The DON stated Res #1 continued to receive olanzapine 20 mg daily until the medication error was verified on 07/19/25. They stated CMA #1 should have verified
the correct dosage on the pill card with the physician order prior to administration. The DON stated Res #1 received the wrong dosage of olanzapine for 11 days.
Residents Affected - Some
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Shawnee Care Center in Shawnee, OK inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Shawnee, OK, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Shawnee Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.