Survey Disaster of the Month: Shawnee Colonial Estates
40-bed facility in Oklahoma that got absolutely destroyed by surveyors in April. This is what happens when everything goes wrong at once.
The Facility
Shawnee Colonial Estates - Oklahoma
40 beds
Survey conducted April 2025
Multiple immediate jeopardy citations
The perfect storm of preventable disasters
Disaster #1: The Great Escape
What Happened
A dementia resident figured out the door code ("hold for 15 seconds"), walked right past the nurse's station, made it all the way to the parking lot, and kept going.
A visitor had to tell staff their resident was outside.
Let that sink in. A random visitor noticed before any staff member did.
The Citation
Surveyors found the facility failed to:
Properly secure exit doors
Monitor residents at risk for elopement
Train staff on elopement protocols
Have functional alarm systems
The Deeper Problem
The door code was literally "hold the button for 15 seconds." That's not security - that's a mild inconvenience. A determined dementia resident with enough time figured it out.
Question: How many other residents knew the code but hadn't tried it yet?
Disaster #2: Staff Training Catastrophe
The Smoking Gun
During the survey, a CNA admitted to investigators: "I had no idea what elopement meant."
Another staff member said they "never received training for residents trying to leave."
What This Really Means
If your staff doesn't know the WORD "elopement," what else don't they know?
Do they know what "immediate jeopardy" means?
Can they recognize signs of abuse?
Do they understand infection control?
Have they ever seen a care plan?
This wasn't a training gap. This was a training CANYON.
The Facility's Excuse
"We provided orientation."
Translation: Someone showed them where the break room was and handed them a name tag.
Disaster #3: The Mechanical Lift Situation
The Setup
Resident who's supposed to use a mechanical lift for ALL transfers. It's in their care plan. It's doctor-ordered. It's non-negotiable.
What Actually Happened
Staff were just picking them up manually.
The Excuses
"The battery was dead"
"Someone else was using it"
"We couldn't find it"
"It was easier to just lift them"
The Result
Resident falls.
Resident tells surveyor: "The staff were new and I told them to let me down easy when I started sliding."
Even the RESIDENT knew this was wrong.
The Aftermath
Immediate Jeopardy
The facility got hit with immediate jeopardy citations - the worst kind. This means surveyors determined residents were in immediate danger.
The Good News
To their credit, they fixed the immediate issues within 24 hours:
Door security upgraded
Staff training scheduled
Lift equipment repaired and backup purchased
Monitoring systems implemented
The Bad News
None of this should have been a surprise. These aren't new regulations. This is basic, fundamental nursing home operation.
What Other Operators Should Do
1. Test Your Door Security WITH Residents
Don't just test it with staff. Have a cognitive resident try to get out. If they can figure it out, so can someone with dementia given enough time.
2. Quiz Your CNAs on Basic Terms
Randomly ask your CNAs:
"What's elopement?"
"What's immediate jeopardy?"
"What's a care plan?"
"When do you use a mechanical lift?"
If they can't answer, you have a training problem.
3. Check Equipment BEFORE Surveyors Do
Are lift batteries charged?
Do you have backups?
Is equipment accessible?
Does staff know where everything is?
Dead equipment = liability = lawsuit = citation
4. Walk Your Facility Like a Surveyor
Once a month, pretend you're a surveyor:
Can residents get out easily?
Is staff paying attention?
Are care plans being followed?
Is equipment working?
Whatever you notice, surveyors will notice too.
The Lesson
This wasn't bad luck. This was preventable. Every single citation could have been avoided with:
Basic training
Functional equipment
Minimal supervision
Common sense
The Questions This Raises
How long was this going on? This didn't start the day before the survey.
What else is broken? If doors don't work and lifts are dead, what about fire systems? Emergency procedures? Medication storage?
Where was leadership? An administrator should have caught these issues months ago.
How did they pass previous surveys? Either they got lucky, or surveyors missed these issues before.
Bottom Line
Walk your facility. Talk to your staff. Test your systems.
Because if you don't, surveyors will - and they won't be gentle about it.
Have a survey disaster story you'd like to share (anonymously, of course)? Send it our way. We'll make sure the rest of the industry learns from your pain.
