Elmbrook Home: Family Not Told Resident Airlifted - OK
The nurse on duty that night, identified in inspection records as LPN #3, never made the call.
That single failure is at the center of a complaint inspection conducted at Elmbrook Home, a nursing facility at 1811 9th Avenue NW in Ardmore, on August 26, 2025. Federal inspectors rated the violation as causing minimal harm or potential for actual harm, and found it affected few residents. But the circumstances it exposed — a family waiting, a plane lifting off, a pilot delivering news that a nurse was supposed to deliver — are not abstract.
The Director of Nursing confirmed the account directly to inspectors. The family representative of Resident #1 was not notified on January 31 when the resident was sent to the hospital. The DON said the family representative was notified by the medical flight pilot.
LPN #3 acknowledged receiving a written warning on February 7, 2025, roughly a week after the incident. The nurse also confirmed attending an in-service training on the topic of notifying family representatives after a change in resident condition. The DON described the facility's response as a Performance Improvement Plan, in addition to the in-service.
The corrective action came after the fact. On the night it mattered, Resident #1's family did not hear from the people responsible for their loved one's care. They heard from someone whose job was to fly the plane.
What the inspection report does not say is whether the family had time to meet the flight. It does not say whether they were able to say anything to their loved one before departure. It does not say what condition Resident #1 was in, or what had changed, or what the outcome of the hospitalization was.
What it says is that the call was never made. And that the facility, when asked about it seven months later, confirmed that without apparent dispute.
Elmbrook Home received a deficiency citation under F0580, which covers the requirement that facilities notify a resident's family or legal representative of changes in the resident's condition. The violation was classified at a scope and severity level indicating the harm was limited, or that harm was possible but not certain. That classification shapes how regulators respond. It does not change what happened on January 31.
The DON told inspectors the facility completed a Performance Improvement Plan and held staff training. LPN #3 received written corrective action. The systems, the facility would argue, have been addressed.
But a Performance Improvement Plan does not reach backward. It does not put a phone in a nurse's hand on a January night when a resident is being rushed out the door. It does not give a family the chance to know, in real time, that something serious is happening to someone they love.
The medical flight pilot told them. That is the record.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 4, 2026 · Our methodology
Elmbrook Home in Ardmore, OK was cited for violations during a health inspection on August 26, 2025.
The nurse on duty that night, identified in inspection records as LPN #3, never made the call.
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.