Cycle 1
Health 2025-01-16 · Fire 2025-01-16
9 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Ardmore, OK
Elmbrook Home
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1811 9th Avenue Nw, Ardmore, OK
(580) 223-3303
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
126
Certified beds
Average residents
67
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Elmbrook Management Company
Operator or chain grouping
Approved since
1994-03-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 3 overall / 4 health / 3 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.48
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.78
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
4.50
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,629
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 24.78% · Performance 26.05% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.19% · Performance 12.97% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.09
Performance 59.21% · Measure score 1.09 · Achievement 1.09 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.45
Baseline 4.22 hours · Performance 4.06 hours · Measure score 3.45 · Achievement 3.45 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 15.79% |
10.72%
5.1 pts worse
|
Worse than the National Rate · Eligible stays 156 · Observed rate 24.36% · Lower 95% interval 12.23% |
| Discharge to community | 46.89% |
50.57%
3.7 pts worse
|
No Different than the National Rate · Eligible stays 132 · Observed rate 37.88% · Lower 95% interval 38.54% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.02% |
95.27%
3.8 pts better
|
Numerator 101 · Denominator 102 |
| Falls with major injury | 2.94% |
0.77%
2.2 pts worse
|
Numerator 3 · Denominator 102 |
| Discharge self-care score | 56.6% |
53.69%
2.9 pts better
|
Numerator 30 · Denominator 53 |
| Discharge mobility score | 52.83% |
50.94%
1.9 pts better
|
Numerator 28 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 0.98% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 102 · Adjusted rate 1.13% |
| Healthcare-associated infections requiring hospitalization | 12.97% |
7.12%
5.9 pts worse
|
Worse than the National Rate · Eligible stays 99 · Observed rate 19.19% · Lower 95% interval 8.78% |
| Staff COVID-19 vaccination coverage | 0.93% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 108 |
| Staff flu vaccination coverage | 29.92% |
42%
12.1 pts worse
|
Numerator 38 · Denominator 127 |
| Discharge function score | 66.04% |
56.45%
9.6 pts better
|
Numerator 35 · Denominator 53 |
| Transfer of health information to provider | 94.74% |
95.95%
1.2 pts worse
|
Numerator 36 · Denominator 38 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 39 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.3
0.1 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.8 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
2.9
0.5 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.9 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
90.3%
7.2 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 94.9% · Q3 96.6% · Q4 98.4% · 4Q avg 97.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.6%
5.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
4.5%
1.6 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.7% · Q3 3.4% · Q4 4.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.3%
3.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.6%
3.6 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
25.3%
10 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 14.6% · Q3 11.1% · Q4 20.5% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.6% |
18.6%
4 pts better
|
16.7%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 15.8% · Q3 18.9% · Q4 11.1% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.0% |
15.5%
0.5 pts worse
|
16.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q3 21.9% · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.3% |
14.1%
4.2 pts worse
|
14.9%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 20.8% · Q3 22.7% · Q4 18.6% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
2.1%
1.6 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.8%
1.5 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.7% |
17.8%
6.1 pts better
|
19.8%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 11.9% · Q3 8.1% · Q4 15.6% · 4Q avg 11.7% |
| Percentage of long-stay residents with pressure ulcers | 0.3% |
5.1%
4.8 pts better
|
5.1%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.4% |
75.0%
12.6 pts worse
|
81.7%
19.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 61.7% · Q2 61.4% · Q3 55.0% · Q4 71.8% · 4Q avg 62.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.8% |
17.1%
6.7 pts worse
|
12.0%
11.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 23.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.3% |
1.9%
5.4 pts worse
|
1.6%
5.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 10.7% · Q3 7.4% · Q4 4.0% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.4% |
74.0%
0.4 pts better
|
79.7%
5.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.1% |
27.0%
9.1 pts worse
|
23.9%
12.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.1% · Observed 38.2% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-05-26 · Fire 2022-05-26
0 health deficiencies
No concentrated health issue counts in this cycle.
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-16
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-16
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-02-24
F · Potential for more than minimal harm
2023-10-26
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-02-12
F · Potential for more than minimal harm
2023-10-26
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-10-26
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-02-12
F · Potential for more than minimal harm
2022-05-26
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-09-30
F · Potential for more than minimal harm
2022-05-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-30
F · Potential for more than minimal harm
2022-05-26
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-05-26
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-05-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-05-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-05-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-05-26
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-05-26
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-05-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-05-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-06-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Not marked corrected
D · Potential for more than minimal harm
2025-08-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Not marked corrected
E · Potential for more than minimal harm
2025-01-16
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-02-17
E · Potential for more than minimal harm
2025-01-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-17
E · Potential for more than minimal harm
2025-01-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-17
E · Potential for more than minimal harm
2025-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-16
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-16
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-02-17
D · Potential for more than minimal harm
2024-04-30
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-05-27
Penalties and ownership
What sits behind the stars
Ownership
Coble, Tom
5% Or Greater Indirect Ownership Interest · Individual
Elmbrook Properties Inc
5% Or Greater Direct Ownership Interest · Organization
Coble, Tom
Operational/Managerial Control · Individual
Coble, Tom
Corporate Officer · Individual
Dixson, James
Operational/Managerial Control · Individual
Elmbrook Home, Inc.
Operational/Managerial Control · Organization
Elmbrook Properties Inc
Operational/Managerial Control · Organization
Lodes, Jason
Operational/Managerial Control · Individual
Lodes, Jason
Corporate Officer · Individual
Stevenson, Amanda
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Southbrook Healthcare, Inc
Ardmore, OK
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Lakeland Manor, Inc
Ardmore, OK
5-star overall rating with 5-star inspections with $12,606 in total fines with 2 fire-safety deficiencies in the latest cycle
#3
Woodview Home, Inc.
Ardmore, OK
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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