Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elmbrook Home during CMS and state inspections, most recent first.
A dependent resident with moderately impaired cognition and chronic pain returned from the ER and was assisted to bed by a CNA and an LPN, who moved the resident up in bed by having the CNA reach across and pull the draw sheet from both sides while the LPN lifted under the knees, rather than positioning one staff member on each side of the bed and using the draw sheet correctly. The resident reported calling out that their arm hurt during the maneuver, but the staff continued the movement, and the resident was later observed with a bandage and dark purple bruising on the forearm. Other CNAs, an LPN, and a restorative aide described the correct repositioning method and indicated that a pain complaint should trigger assessment and appropriate response.
A resident with a history of unspecified pain and moderately impaired cognition, who had PRN Tylenol ordered and a care plan to monitor for pain and skin changes, was moved up in bed by a CNA and an LPN using an improper technique. During the repositioning, the resident cried out that their arm hurt, but the LPN did not perform a pain assessment and instead assumed the complaint was related to chronic pain, while the CNA reported not hearing a pain complaint. Later observations noted a bandage and dark purple bruising on the resident’s forearm, indicating the facility failed to follow its pain protocol requiring assessment of pain characteristics with a standardized tool.
A resident with multiple medical conditions and moderate cognitive impairment was transferred to the hospital for an acute CVA, but the family representative was not notified by facility staff as required by policy. The LPN involved did not document or communicate the transfer, and the family only learned of the event from the medical flight pilot. The DON confirmed the lapse in notification.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A facility failed to refer a resident with newly diagnosed mental illness for a level II PASARR evaluation. The resident was initially admitted with a level I PASARR, but later diagnosed with a mood disorder and unspecified psychosis. The facility did not update the PASARR status, and the regional nurse consultant confirmed the absence of a PASARR policy.
A resident with a history of breast cancer experienced a delay in scheduling a mammography due to the facility's failure to transcribe a physician order in a timely manner. Despite a nurse's note indicating the need for an urgent mammogram, the order was not presented until weeks later, leading to a delay in the referral process. The delay was attributed to the need for a 3-D mammography, which required a specific physician order.
The facility failed to follow its smoking policy, requiring supervision for all residents while smoking. Two residents with Alzheimer's disease were involved in incidents highlighting this deficiency. One resident, assessed as a safe smoker, was allowed to keep cigarettes in their room and smoked independently with oxygen in place. Another resident, with severe cognitive impairment, fell while smoking with family members. Staff confirmed deviations from the policy, and the DON acknowledged the need for policy rewording.
A facility failed to properly dispose of blood-contaminated glucometer strips for a resident with diabetes. The RN disposed of the strips in the resident's trashcan instead of the sharps container, contrary to the facility's policy. The RN admitted to being nervous and stated that they normally would have used the sharps container. The DON confirmed the policy for proper disposal.
A resident with Alzheimer's and other conditions was fed a pureed meal by a CNA who was watching a video on their cell phone, violating the facility's policy against cell phone use during care. The LPN and DON confirmed this was against policy and an ongoing issue.
A resident with multiple health conditions, including Alzheimer's dementia and coronary artery disease, reported feeling cold in their room, which was confirmed by a temperature reading of 67.6 degrees Fahrenheit. Despite the RN reporting the issue to maintenance, no effective action was taken, and the resident continued to feel cold even when the temperature was recorded at 71.4 degrees Fahrenheit. The administrator was unaware of the complaint until later and initiated a grievance report.
A facility failed to complete an MDS discharge assessment for a resident discharged with a right femur fracture. The oversight was identified during a review, and the MDS coordinator acknowledged the missed assessment. The facility lacked a policy for comprehensive assessments, which may have contributed to the issue.
The facility failed to store medications properly as per policy. A resident's medications were found unattended on a counter at the nurses station, contrary to the requirement that they be locked in a medication cart. Both an RN and the ADON confirmed this lapse.
Improper Repositioning Technique Causing Forearm Injury and Unaddressed Pain Complaint
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper repositioning and safe transfer techniques for a dependent resident who required assistance of two staff for activities of daily living. The resident, who had moderately impaired cognition with a BIMS score of 11 and a diagnosis including unspecified pain, was observed on multiple occasions with a bandage and dark purple bruising on the right forearm. The resident reported that a CNA and an LPN attempted to pull them up in bed, with the CNA leaning over and pushing down on the resident’s arm while moving them up in bed. The resident stated they hollered and told staff their arm was hurting, but the staff continued to move them. Staff interviews confirmed that the resident had just returned from the emergency room when the LPN and CNA assisted them to bed and moved them up in bed. The LPN stated the CNA reached over the resident and grabbed the draw sheet from both sides while the LPN placed an arm under the resident’s knees to move the resident up, and acknowledged hearing the resident say, “Ow my arm,” but assumed it was related to chronic arm pain. The CNA described the same technique and acknowledged that it was not the correct method, stating that one person should have been on each side of the bed using the draw sheet. Other CNAs, an LPN, and a restorative aide described the correct procedure as having one staff member on each side of the bed and using a draw sheet or pad to move a resident up, and nursing staff described that a complaint of pain should prompt assessment and repositioning, with further actions and documentation if pain persisted.
Failure to Assess and Manage Pain During Improper Repositioning
Penalty
Summary
The facility failed to ensure a resident was properly assessed for pain during repositioning in bed. The resident had a diagnosis that included unspecified pain and a physician order for PRN Tylenol Arthritis Pain 650 mg every six hours as needed. A quarterly assessment documented moderately impaired cognition with a BIMS score of 11, and the care plan directed staff to monitor for skin changes and for pain and/or discomfort. The facility’s Pain-Clinical Protocol required staff and the physician to identify pain characteristics, including location, intensity, frequency, pattern, and severity, and to use a consistent, standardized pain assessment tool appropriate to the resident’s cognition level. After returning from the emergency room, the resident reported that a CNA and an LPN attempted to move them up in bed, during which the CNA leaned over and pushed down on the resident’s arm, causing pain. The resident stated they hollered and told staff their arm was hurting, but staff continued to move them up in bed. The LPN later acknowledged hearing the resident say, "Ow my arm," but did not assess for new pain, assuming it was the resident’s chronic shoulder pain, and did not determine the pain’s location or characteristics. The CNA described using an improper technique to move the resident up in bed by reaching across and pulling the draw sheet from one side, while the LPN lifted under the knees. Subsequent observations showed a bandage and dark purple bruising on the resident’s right forearm, and the DON reported being informed of bruising by the resident’s family member.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to ensure that responsible parties were notified of a change in condition for one resident. According to facility policy, a nurse is required to notify the resident's representative within twenty-four hours of a change in the resident's medical or mental condition, unless otherwise instructed by the resident. In this case, a resident with diagnoses including atrial flutter, epilepsy, nutritional disorder, and chronic kidney disease, and with moderately impaired cognition, was sent to the emergency room following a physician's order. Documentation showed that the resident was admitted to the hospital with an acute cerebrovascular accident. Despite the facility's policy, there was no documentation in the resident's progress notes indicating that the family representative was notified of the hospital transfer. The family representative confirmed they were not informed by facility staff and only learned of the transfer from the medical flight transport pilot. The LPN involved acknowledged the lack of notification and documentation, and the DON confirmed that the family was not notified by staff at the time of the transfer.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Update PASARR for Resident with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to refer a resident with newly diagnosed mental illness to the OHCA for a level II PASARR evaluation. This deficiency was identified for one of two sampled residents reviewed for PASARR. The resident was admitted to the facility with a level I PASARR indicating no need for a level II evaluation. However, after admission, the resident was diagnosed with a mood disorder and unspecified psychosis. Despite these new diagnoses, the facility did not reevaluate the resident's PASARR status. The regional nurse consultant confirmed that the PASARR had not been updated and reported that the facility lacked a policy for PASARR evaluations.
Delayed Mammography Scheduling for Resident with Breast Cancer History
Penalty
Summary
The facility failed to transcribe a physician order and schedule a mammography in a timely manner for a resident with a history of breast cancer. The resident had a past surgical history of a partial mastectomy on the left side and was noted to have a lump in the breast tissue under the left arm. A nurse's note dated December 26, 2024, indicated that a mammogram should be scheduled as soon as possible. However, the physician order for the diagnostic mammogram was not presented until January 16, 2025, indicating a delay in the transcription and scheduling process. During interviews, it was revealed that the referral for the mammography was only sent to the hospital on the morning of January 16, 2025, despite the nurse's note from December 2024. The LPN involved acknowledged the delay, stating it had been 16 or 17 days since the notification to schedule the mammography. The Director of Nursing confirmed that the scheduling had taken a couple of weeks, and the RN involved admitted there had been a scheduling issue. The delay in scheduling the mammography was attributed to the need for a 3-D mammography due to the presence of a lump, which required a specific physician order that was not obtained in a timely manner.
Failure to Supervise Residents While Smoking
Penalty
Summary
The facility failed to adhere to its smoking policy, which mandates supervision for all residents while smoking and prohibits residents from keeping smoking articles unless supervised. Two residents, both with Alzheimer's disease and other health conditions, were involved in incidents that highlighted this deficiency. The facility's policy, dated July 2017, requires quarterly re-evaluation of a resident's ability to smoke safely and stipulates that residents must be supervised at all times while smoking. The first resident, diagnosed with Alzheimer's dementia and other health issues, was assessed as a safe smoker with a risk of 0 and was allowed to keep cigarettes in their room, contrary to the facility's policy. Despite being cognitively intact according to an MDS assessment, the resident was observed smoking independently with oxygen in place, which poses a significant safety risk. Staff confirmed that the resident kept smoking materials in their room and smoked without supervision. The second resident, also with Alzheimer's disease and cognitive impairment, was involved in a fall incident while smoking with family members. Although the resident's smoking assessment indicated they could smoke independently, the MDS assessment documented severe cognitive impairment. Staff reported that the resident's cigarettes were kept at the nurse's station, and the resident was usually supervised while smoking. However, the facility's Director of Nursing acknowledged that the policy might need rewording to reflect actual practices, as some residents were allowed to keep smoking materials and smoke unsupervised based on nursing judgment.
Improper Disposal of Blood-Contaminated Supplies
Penalty
Summary
The facility failed to ensure proper disposal of blood-contaminated glucometer strips for one of the two sampled residents reviewed for finger stick blood sugar levels. The policy for blood sampling, dated 09/14/14, requires the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases, including discarding lancets and platforms into a sharps container. Resident #52, who has a diagnosis of diabetes mellitus, had a physician order for finger stick blood sugar levels twice daily. On 01/14/25, RN #2 was observed gathering supplies for a finger stick blood sugar test and disposed of the bloody glucometer strip in the resident's trashcan instead of the sharps container. The RN repeated the procedure and again improperly disposed of the contaminated strip. The RN admitted to being nervous and stated that they normally would have used the sharps container. The Director of Nursing confirmed that the facility's policy was to dispose of contaminated supplies in the sharps container.
Violation of Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat a resident with dignity and respect during assistance with eating. A resident with Alzheimer's disease, depression, and seizure disorder, who had severely impaired decision-making and required assistance with activities of daily living, was observed being fed a pureed meal by a CNA who was watching a video on their personal cell phone. This occurred during the noon meal, and it was noted that the use of cell phones while providing resident care was against facility policy. The LPN and DON confirmed that cell phone use during care was not allowed and acknowledged it as an ongoing issue, with staff frequently reminded to refrain from using phones except during breaks.
Failure to Maintain Comfortable Room Temperature for Resident
Penalty
Summary
The facility failed to maintain a comfortable room temperature for a resident, identified as Resident #16, who was part of a sample of four residents evaluated for environmental conditions. Resident #16 had multiple diagnoses, including atrial fibrillation, Alzheimer's dementia, muscle weakness, anxiety, coronary artery disease, iron deficiency anemia, chronic pain, and diabetes. An MDS assessment indicated that the resident was moderately impaired with cognition and used a wheelchair for mobility. During an observation, the resident was found lying in bed covered with blankets and reported feeling cold. The resident had placed blankets on the windowsill to mitigate the cold. A registered nurse (RN) confirmed that the room was consistently cold and had reported the issue to maintenance the previous week, but no effective action had been taken. A room temperature reading taken in Resident #16's room showed 67.6 degrees Fahrenheit, which was below a comfortable level. Two days later, the temperature was recorded at 71.4 degrees Fahrenheit, but the resident still reported feeling cold and was observed wearing a jacket. The administrator and maintenance staff confirmed the temperature reading. The administrator was unaware of the resident's complaint until the day before and initiated a grievance report. The resident expressed willingness to change rooms when asked by the administrator, indicating that the issue had not been resolved promptly or effectively by the facility's staff.
Failure to Complete MDS Discharge Assessment
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) discharge assessment for a resident who was discharged from the facility. The resident, who had been admitted with a diagnosis of right femur fracture, was discharged on September 7, 2024. However, the MDS discharge assessment was not completed at the time of discharge. This oversight was identified during a review of records and interviews, where the MDS coordinator acknowledged that the discharge assessment for the resident was missed. Additionally, it was noted that the facility did not have a policy in place for comprehensive assessments, which may have contributed to the oversight.
Improper Medication Storage
Penalty
Summary
The facility failed to ensure medications were stored properly and according to facility policy. During an observation, it was noted that a resident's medications were left unattended on the top of the counter at the north hall nurses station, with no staff in sight. The facility's policy, revised in April 2019, mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner. Both an RN and the ADON confirmed that the medications should have been locked in a medication cart, indicating a lapse in adherence to the facility's storage policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ardmore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southbrook Healthcare, Inc | 1.5 mi | ★★★★★ | 0 | 0 |
| Ardmore Center For Rehabilitation And Healthcare | 2.1 mi | ★★★★★ | 0 | 0 |
| Woodview Home, Inc. | 2.7 mi | ★★★★★ | 2 | 0 |
| Wilson Nursing Center | 15.5 mi | — | 0 | 0 |
| Lake Country Nursing Center | 16.8 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.