Elmbrook Home

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Elmbrook Home

1811 9th Avenue NW Ardmore, OK 73401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 REDACTED], 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.

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