Meadowbrook Nursing Center

In the surveyor’s words

From the most serious findings on record at Meadowbrook Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 17, 2026

  On 03/11/26, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent accident hazards related to smoking. On 03/02/26, Resident #26 was smoking in their room while wearing oxygen. The oxygen combusted which caused a facial burn, singed beard, and mustache hair. On 03/11/26 at 2:56 p.m., the Oklahoma State Department of Health verified the existence of an IJ situation. On 03/11/26 at 3:05 p.m., the administrator was notified of the IJ situation. An IJ template was provided to the administrator. On 03/12/26 at 10:47 a.m., an acceptable POR (plan of removal) was received. The POR read in part, Plan of Removal for lJ Amended 3/12/2026 at 0950 [9:50 a.m.]1. Notify MedicaI Director2. […]

• Actual harm, isolatedF600Jul 31, 2023

  Based on observation, record review, and interview, the facility failed to ensure residents did not experience resident to resident abuse for two (#10 and #16) of two residents sampled for abuse. The facility failed to ensure: a. Res #80 did not assault and injure Res #10 and #16. b. Res #10 was assessed for psychosocial harm and interventions were put in place to mitigate the harm after the assault by Res #80. c. a follow up of Res #16 possible brain bleeding caused by the assault by Res #80 was conducted. d. they instituted new interventions to protect the staff, the resident, or other residents when the facility the facility knew or should have known Res #80 was capable of aggressive behaviors towards others and had continued behaviors. […]

• No harm, potential for more than minimal, widespreadF732Mar 17, 2026

  Based on observation, interview, and record review, the facility failed to ensure nurse staffing was posted.The administrator identified 34 residents who resided in the facility. Findings: On 03/12/26 at 1:30 p.m., nurse staffing information was not observed posted in the facility. On 03/13/26 at 9:28 a.m., a dry erase board was observed by the nurse's station that contained the date, staff name with titles, census, and how many residents were in the hospital. An undated policy titled, Staffing Requirement Policy, read in part, Daily staffing reports will be posted for residents and visitors to view. On 03/13/26 at 9:28 a.m., LPN #2 stated they posted nurse staffing information on the dry erase board by the nurse's station. […]

• No harm, potential for more than minimal, widespreadF835Mar 17, 2026

  Based on observation, record review, and interview, the facility failed to have effective administration who utilized its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility administration failed to:a. report allegations of abuse to OSDH,b. investigate allegations of abuse,c. develop/implement comprehensive care plans, d. review and revise care plans, ande. provide supervision to prevent accident hazards related to smoking. The administrator identified 34 residents who resided at the facility.Findings: a. Based on record review and interview, the facility failed to ensure allegations of abuse were reported to OSDH for 1 (#4) of 1 sampled residents who were reviewed for abuse. […]

• No harm, potential for more than minimal, widespreadF865Mar 17, 2026

  Based on observation, record review, and interview, the facility failed to maintain an effective Quality Assessment and Performance Improvement (QAPI), as evidenced by failure to demonstrate systematic identification, reporting, investigation, analysis, and prevention of adverse events and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility had systematic problems with identification of abuse allegations, reporting abuse allegations to OSDH, development of comprehensive care plans/revision of care plans, and adequate supervision to prevent accident hazards related to smoking.The administrator identified 34 residents who resided in the facility.Findings: Please refer to CMS form 2567 with exit… […]