Cycle 1
Health 2024-08-15 · Fire 2024-08-15
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Madill, OK
Brookside Nursing Center
1-star overall rating with 1-star inspections with abuse icon flag with $39,487 in total fines with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
310 Brookside Drive, Madill, OK
(580) 795-2100
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Elmbrook Management Company
Operator or chain grouping
Approved since
1995-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 3 overall / 4 health / 3 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.10
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
4.07
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,373
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Performance 74.51% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.52
Baseline 3.53 hours · Performance 3.79 hours · Measure score 2.52 · Achievement 2.52 · Improvement 0.68
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.53% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 9.38% · Lower 95% interval 7.22% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.73% |
95.27%
2.5 pts better
|
Numerator 43 · Denominator 44 |
| Falls with major injury | 6.82% |
0.77%
6.1 pts worse
|
Numerator 3 · Denominator 44 |
| Discharge self-care score | 38.46% |
53.69%
15.2 pts worse
|
Numerator 10 · Denominator 26 |
| Discharge mobility score | 42.31% |
50.94%
8.6 pts worse
|
Numerator 11 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 4.55% |
2.29%
2.3 pts worse
|
Numerator 2 · Denominator 44 · Adjusted rate 4.46% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 73 |
| Staff flu vaccination coverage | 1.18% |
42%
40.8 pts worse
|
Numerator 1 · Denominator 85 |
| Discharge function score | 34.62% |
56.45%
21.8 pts worse
|
Numerator 9 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 36.36% |
25.2%
11.2 pts better
|
Numerator 8 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.3
0.8 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.2 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.9
0.1 pts better
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
90.3%
7.8 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 98.2% · Q3 98.0% · Q4 97.9% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
94.6%
3.7 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
4.5%
1.1 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.8% · Q3 4.0% · Q4 6.4% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.3% |
3.3%
7 pts worse
|
11.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 11.8% · Q3 13.3% · Q4 7.7% · 4Q avg 10.3% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
3.6%
3 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.6% |
25.3%
9.3 pts worse
|
19.6%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 34.1% · Q3 32.6% · Q4 42.9% · 4Q avg 34.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.6% |
18.6%
4 pts worse
|
16.7%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 10.7% · Q3 25.9% · Q4 40.0% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.9% |
15.5%
0.6 pts better
|
16.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.8% |
14.1%
3.3 pts better
|
14.9%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 14.0% · Q3 14.3% · Q4 6.1% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
2.1%
0.5 pts better
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.0% · Q3 2.1% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.8%
2.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.3% |
17.8%
5.5 pts better
|
19.8%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 5.7% · Q3 15.7% · Q4 21.3% · 4Q avg 12.3% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
5.1%
4.6 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.9% |
75.0%
19.1 pts worse
|
81.7%
25.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 55.2% · Q2 63.0% · 4Q avg 55.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
17.1%
5.1 pts better
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 13.3% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.9%
0.9 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.1% |
74.0%
11.9 pts worse
|
79.7%
17.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
27.0%
8.2 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 20.0% · Expected 25.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-02 · Fire 2023-08-02
3 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-07-22 · Fire 2021-07-22
7 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-15
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-15
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-15
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-15
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-01
E · Potential for more than minimal harm
2021-07-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-07-22
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2021-08-13
C · Minimal harm
2021-07-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-13
Inspection history
Recent health citations
J · Immediate jeopardy
2025-04-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-30
J · Immediate jeopardy
2025-04-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-30
E · Potential for more than minimal harm
2024-08-15
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-10-01
G · Actual harm
2023-08-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-07
E · Potential for more than minimal harm
2023-08-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-09-07
E · Potential for more than minimal harm
2023-08-02
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-09-07
E · Potential for more than minimal harm
2023-08-02
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-09-07
E · Potential for more than minimal harm
2021-07-22
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-07-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-07-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-07-22
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-07-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-07-22
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2021-08-13
Penalties and ownership
What sits behind the stars
$31,426
2025-04-11
Fine
Fine · fine $31,426
Fine
$8,061
2023-08-02
Fine
Fine · fine $8,061
Fine
Ownership
Coble, Tom
5% Or Greater Direct Ownership Interest · Individual
Coble, Tom
Operational/Managerial Control · Individual
Coble, Tom
Corporate Officer · Individual
Gordon, Ely
Operational/Managerial Control · Individual
Hassanshahi, Amber
Operational/Managerial Control · Individual
Hassanshahi, Amber
Corporate Officer · Individual
Lodes, Jason
Operational/Managerial Control · Individual
Lodes, Jason
Corporate Officer · Individual
Madill Property Co LLC
Operational/Managerial Control · Organization
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#3
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