Cycle 1
Health 2024-08-07 · Fire 2024-08-07
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Chouteau, OK
Meadowbrook Nursing Center
5-star overall rating with 4-star inspections with $7,443 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
113 East Jones, Chouteau, OK
(918) 476-8918
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
65
Certified beds
Average residents
24
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bgm Estate
Operator or chain grouping
Approved since
1996-08-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 2 overall / 3 health / 3 staffing / 3 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
1.09
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
3.86
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.55
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
5.65
CMS adjusted total nurse staffing hours
Case-mix index
0.93
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
44%
Annual nurse turnover · state 56% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 7 · 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 33 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 47 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
90.3%
9.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
94.6%
1.6 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.5% |
4.5%
1 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 3.8% · Q3 4.3% · Q4 8.3% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.3%
3.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
3.6%
2.2 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 5.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.0% |
25.3%
17.3 pts better
|
19.6%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 19.0% · Q3 4.8% · Q4 0.0% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
18.6%
18.6 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.2% |
15.5%
2.7 pts worse
|
16.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.0% |
14.1%
10.1 pts better
|
14.9%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 4.8% · Q4 10.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.1%
2.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · 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 · 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 | 9.5% |
17.8%
8.3 pts better
|
19.8%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 14.4% · Q3 0.0% · Q4 7.9% · 4Q avg 9.5% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
5.1%
3.9 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 4.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
75.0%
21.2 pts better
|
81.7%
14.5 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 96.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-31 · Fire 2023-07-31
13 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2020-02-13 · Fire 2020-02-13
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-08
F · Potential for more than minimal harm
2024-08-07
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-10-08
E · Potential for more than minimal harm
2023-07-31
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 2024-02-16
E · Potential for more than minimal harm
2023-07-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-12
F · Potential for more than minimal harm
2020-02-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-02-17
E · Potential for more than minimal harm
2020-02-13
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2020-03-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-08-07
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 2024-09-30
G · Actual harm
2023-07-31
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 2023-08-18
E · Potential for more than minimal harm
2023-07-31
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 2023-08-18
E · Potential for more than minimal harm
2023-07-31
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 2023-08-18
E · Potential for more than minimal harm
2023-07-31
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 2023-08-18
E · Potential for more than minimal harm
2023-07-31
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-31
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-31
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-31
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-31
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-31
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-31
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-31
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2023-08-18
E · Potential for more than minimal harm
2020-02-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-13
E · Potential for more than minimal harm
2020-02-13
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2020-02-27
E · Potential for more than minimal harm
2020-02-13
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2020-03-17
E · Potential for more than minimal harm
2020-02-13
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 2020-03-17
E · Potential for more than minimal harm
2020-02-13
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2020-03-13
Penalties and ownership
What sits behind the stars
$7,443
2023-07-31
Fine
Fine · fine $7,443
Fine
Ownership
Bgm Estate LLC
5% Or Greater Direct Ownership Interest · Organization
Mitchell, Kelly
5% Or Greater Direct Ownership Interest · Individual
Belt, Miranda
Corporate Officer · Individual
Lowrimore, Morgan
W-2 Managing Employee · Individual
Pitts, Jaci
Corporate Officer · Individual
Taylor, Sandra
W-2 Managing Employee · Individual
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#2
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4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
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