Cycle 1
Health 2025-01-30 · Fire 2025-01-30
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Ardmore, OK
Southbrook Healthcare, Inc
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
832 Isabel Southwest, Ardmore, OK
(580) 223-5901
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Elmbrook Management Company
Operator or chain grouping
Approved since
1996-05-13
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
0.77
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.71
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
4.46
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
8%
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
10,061
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.02% · Performance 23.32% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.57
Baseline 10.52% · Performance 9.37% · Measure score 1.57 · Achievement 0 · Improvement 1.57
Total nurse turnover
3.8
Performance 48.15% · Measure score 3.8 · Achievement 3.8 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.25
Baseline 4.34 hours · Performance 4 hours · Measure score 3.25 · Achievement 3.25 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.99% |
10.72%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 128 · Observed rate 23.44% · Lower 95% interval 10.46% |
| Discharge to community | 51.92% |
50.57%
1.4 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 40.48% · Lower 95% interval 44.61% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.72% |
95.27%
3.5 pts better
|
Numerator 77 · Denominator 78 |
| Falls with major injury | 3.85% |
0.77%
3.1 pts worse
|
Numerator 3 · Denominator 78 |
| Discharge self-care score | 65.71% |
53.69%
12 pts better
|
Numerator 23 · Denominator 35 |
| Discharge mobility score | 57.14% |
50.94%
6.2 pts better
|
Numerator 20 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 78 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.37% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 14.71% · Lower 95% interval 5.7% |
| Staff COVID-19 vaccination coverage | 2.11% |
8.2%
6.1 pts worse
|
Numerator 2 · Denominator 95 |
| Staff flu vaccination coverage | 25.69% |
42%
16.3 pts worse
|
Numerator 28 · Denominator 109 |
| Discharge function score | 62.86% |
56.45%
6.4 pts better
|
Numerator 22 · Denominator 35 |
| Transfer of health information to provider | 91.67% |
95.95%
4.3 pts worse
|
Numerator 44 · Denominator 48 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 40% |
25.2%
14.8 pts better
|
Numerator 8 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
90.3%
5.8 pts better
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 96.5% · Q3 96.6% · Q4 94.9% · 4Q avg 96.1% |
| 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 | 3.0% |
4.5%
1.5 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.8% · Q3 5.1% · Q4 3.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.8% |
3.3%
2.5 pts worse
|
11.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 7.5% · Q3 1.9% · Q4 8.0% · 4Q avg 5.8% |
| Percentage of long-stay residents who lose too much weight | 0.5% |
3.6%
3.1 pts better
|
5.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.6% |
25.3%
3.3 pts worse
|
19.6%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 20.4% · Q3 26.0% · Q4 38.5% · 4Q avg 28.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
18.6%
6.6 pts better
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 8.6% · Q3 13.9% · Q4 17.1% · 4Q avg 12.0% · 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 | 5.5% |
15.5%
10 pts better
|
16.3%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 5.1% · Q4 4.4% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.6% |
14.1%
1.5 pts better
|
14.9%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 20.5% · Q3 9.5% · Q4 6.8% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
2.1%
1.7 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
2.8%
0.2 pts better
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 5.2% · Q4 3.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.5% |
17.8%
1.3 pts better
|
19.8%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 18.9% · Q3 18.3% · Q4 10.8% · 4Q avg 16.5% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
5.1%
3.8 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.8% · Q4 1.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.6% |
75.0%
1.6 pts better
|
81.7%
5.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 59.6% · Q2 81.4% · Q3 87.1% · Q4 87.5% · 4Q avg 76.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.8% |
17.1%
0.3 pts better
|
12.0%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 17.5% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 8.5% |
1.9%
6.6 pts worse
|
1.6%
6.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 10.0% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.0% |
74.0%
19 pts better
|
79.7%
13.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
27.0%
6.1 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 20.0% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-02 · Fire 2023-11-02
2 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-14 · Fire 2022-09-14
7 health deficiencies
Top issue: Resident Rights (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-30
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-30
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-02-07
F · Potential for more than minimal harm
2022-09-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-10-14
F · Potential for more than minimal harm
2022-09-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-10-14
F · Potential for more than minimal harm
2022-09-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-14
F · Potential for more than minimal harm
2022-09-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-14
F · Potential for more than minimal harm
2022-09-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-14
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 2022-10-17
E · Potential for more than minimal harm
2022-09-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-15
E · Potential for more than minimal harm
2022-09-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-14
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2022-10-20
C · Minimal harm
2022-09-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-09-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-30
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-02-14
E · Potential for more than minimal harm
2024-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-03
D · Potential for more than minimal harm
2023-11-02
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-12-08
F · Potential for more than minimal harm
2022-09-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-09-14
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 2022-10-21
E · Potential for more than minimal harm
2022-09-14
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 2022-10-21
E · Potential for more than minimal harm
2022-09-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-14
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 2022-10-21
D · Potential for more than minimal harm
2022-09-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-21
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
Corporate Officer · Individual
Kelley, Craig
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
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
#2
Elmbrook Home
Ardmore, OK
3-star overall rating with 3-star inspections with 9 recent health deficiencies 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
Jump out