Elmbrook Home
Elmbrook Home in Ardmore, OK — inspection on August 26, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
01/31/25, the family was notified when Resident #1 was sent to the hospital. LPN #3 stated they received a written warning for not notifying Resident #1's family representative on 01/31/25. LPN #3 stated they had an in-service training on notification to family representatives after a change in condition. On 08/26/25 at 8:30 a.m., the DON stated LPN #3 did not notify the family representative of Resident #1 on 01/31/25 when the resident was sent to the hospital.
The DON stated the family representative was notified by the medical flight pilot.
The DON stated they did a PIP and in-service over notifying family representatives after a change in condition.
The DON stated LPN #3 received a written corrective action on 02/07/25 for not notifying the family representative of Resident #1.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Elmbrook Home
1811 9th Avenue NW Ardmore, OK 73401
SUMMARY STATEMENT OF DEFICIENCIES
facility handwritten statement from CMA #1, dated 05/26/25, read in part, Saturday 05/24/25, I was med (medication) aide on 2 p.m. to 10 p.m., 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. [They] said OK and went to working on getting it from the pharmacy.A facility document titled Corrective Action Notice, dated 05/26/25, read in part, [LPN #5] displayed unprofessionalism toward family members. [LPN#5] 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 note showed LPN #5 was suspended for 4 days.
The note was signed by the DON on 05/27/25.A facility document titled Resident Concern Form, dated 05/26/25, showed Resident #2 did not receive their scheduled antibiotics on 05/24/25 and 05/25/25.
The note showed actions taken included internal investigation, corrective action, implement a PIP on medication adherence, and audits. A facility document titled In-service Training Report, dated 05/26/25, showed the DON in-serviced 16 nurses and CMAs on the following topics:a. e-Kit,b. ensuring medications were in the building, andc. the emergency phone number for the pharmacy. Resident #2's urine culture lab results, dated 05/28/25, showed Resident #2's urine was positive for Escherichia coli with [NAME] 10,000-50,000 cfu/ml (colony forming unit per milliliter). A facility document titled Monthly QA/PI Committee Meeting, dated 06/16/25, showed a QAPI meeting was held.
The QAPI meeting addressed the e-kit for medications, medications being available, and regulatory compliance. On 08/25/25 at 8:00 a.m., physician #1 stated Resident #2 was very ill with kidney cancer and they had UTI's consistently due to their disease process.
Physician #1 stated based upon the lab values from the urine sample taken at the hospital on [DATE], they would have discontinued the antibiotic Macrobid prescribed on 05/23/25.
Physician #1 stated Resident #2 was not harmed as a result of not getting the prescribed antibiotic for two days. On 08/25/25 at 11:28 a.m., CMA #1 was asked about Resident #2's medication administration. CMA #1 stated on 05/24/25, they were passing medications when they realized Resident #2's Macrobid antibiotic was not available. CMA #1 stated they notified LPN #5 the medication was not available and marked on the MAR the antibiotic was not given to the resident. CMA #1 stated they were in-serviced on ensuring medications were available and given following physician orders.On 08/25/25 at 11:53 a.m., NP #1 stated they prescribed the Macrobid antibiotic on 05/23/25 for Resident #2. NP #1 stated 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. On 08/26/25 at 8:30 a.m., the DON stated Resident #2 not receiving their prescribed antibiotic on 05/24/25 and 05/25/25 was a failure on the staff for not utilizing the e-kit.
The DON stated they did a PIP, in-serviced all CMAs and nurses on medication policy and procedure, did corrective action on involved staff, and QA/PI the event on 06/16/25.
Facility ID: