Elmbrook Home: Antibiotic Doses Missed Two Days - OK
The resident, identified in inspection records as Resident #2, was supposed to receive Macrobid antibiotic doses on May 24 and May 25 to treat a urinary tract infection. The medication wasn't in the building either day.
On the afternoon of May 24, certified medication aide CMA #1 discovered the antibiotic wasn't available during the 3 p.m. medication pass. In a handwritten statement dated May 26, the aide wrote: "I was supposed to give Macrobid around [3:00 p.m.] but it wasn't there, and I let [LPN #5] know it wasn't there and that I put it down as not given."
The licensed practical nurse told the aide "OK and went to working on getting it from the pharmacy," according to the statement.
But the medication still wasn't available the next day.
Laboratory results from May 28 confirmed Resident #2's urine was positive for E. coli bacteria, with colony counts between 10,000 and 50,000 per milliliter. The antibiotic had been prescribed by nurse practitioner NP #1 on May 23, one day before the first missed dose.
LPN #5 faced suspension for four days following the incident. A corrective action notice dated May 26 stated the nurse "displayed unprofessionalism toward family members" and "did not ensure medications were in the building in a timely manner and did not follow the facility protocols on ensuring meds were given, and the emergency kit was utilized."
The director of nursing signed the suspension notice on May 27.
Elmbrook Home maintains an emergency medication kit, known as an "e-kit," specifically for situations when prescribed medications aren't available through normal pharmacy channels. Staff failed to use it during the two-day period when Resident #2's antibiotic was missing.
Following the incident, the director of nursing conducted in-service training for 16 nurses and medication aides on May 26. The training covered three topics: using the e-kit, ensuring medications were in the building, and the emergency phone number for the pharmacy.
The facility also implemented a performance improvement plan focused on medication adherence and began conducting audits, according to a resident concern form dated May 26.
During the August inspection, physician #1 told state investigators that Resident #2 "was very ill with kidney cancer and they had UTI's consistently due to their disease process." The doctor said the resident suffered recurring urinary tract infections because of the underlying cancer.
Both the prescribing nurse practitioner and the resident's physician told inspectors the missed antibiotic doses caused no harm. Physician #1 stated that based on laboratory values from a hospital urine sample, "they would have discontinued the antibiotic Macrobid prescribed on 05/23/25" anyway.
NP #1 similarly told inspectors that "Resident #2 would not have been harmed as a result of not receiving the antibiotic because Resident #2 has bleeding from the kidneys related to their diagnosed illness of kidney cancer."
When questioned during the inspection, CMA #1 confirmed the sequence of events from May 24. The aide said they realized during medication rounds that "Resident #2's Macrobid antibiotic was not available" and properly notified the supervising nurse before marking the medication as not given on the resident's medication administration record.
The aide told inspectors they received additional training "on ensuring medications were available and given following physician orders" after the incident.
The facility's quality assurance committee addressed the medication failure during a June 16 meeting. Minutes from that session show the committee discussed "the e-kit for medications, medications being available, and regulatory compliance."
During the August inspection, the director of nursing acknowledged the breakdown in protocols. The DON told state investigators that Resident #2 missing prescribed antibiotics "was a failure on the staff for not utilizing the e-kit."
The nursing director outlined the facility's response: implementing a performance improvement plan, conducting in-service training for all medication staff, taking corrective action against involved employees, and reviewing the incident through the quality assurance process.
Despite the clinical assessments that no harm occurred, the incident highlighted gaps in Elmbrook Home's medication management systems. The facility had established emergency protocols specifically to prevent situations where residents go without prescribed medications, but staff failed to follow those procedures during the two-day period in May.
The missed doses affected a particularly vulnerable resident dealing with advanced kidney cancer and recurring infections, conditions that typically require consistent medical management to prevent complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elmbrook Home from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Elmbrook Home in Ardmore, OK was cited for violations during a health inspection on August 26, 2025.
The medication wasn't in the building either day.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.