St Luke's Elmore Long Term Care

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 38 beds and averages 16.3 residents a day — about 43% occupied, or roughly 22 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 6.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.25 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.90 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 5.73 hrs/resident/day on weekends vs 7.51 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 2.72 to 1.08 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

• Potential for harm · F2026-01-23 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, and the FDA Food Code, the facility failed to ensure food was stored, prepared, and served under sanitary conditions to prevent contamination and ensure food was safe and unadulterated. These failures had the potential to expose residents to foodborne illness. Findings include:Food Code 3-101.11 stated food should be safe, unadulterated, and honestly presented.1.On 1/20/26 at 9:19 AM, during a brief kitchen tour a container of soft strawberries with fuzzy white substances was observed in the front kitchen fridge where fresh produce and snacks were stored.On 1/20/26 at 9:20 AM, the Food Service Manager stated the facility goes by visibility and if the produce appears spoiled, they will dispose of it. She confirmed the dietary staff should have disposed of the strawberry container.2. Food Code 3 302.11 - Separation and Protection documents ready to eat foods must be protected from cross contamination during preparation and service.Food Code 4 501.112 / 4 601.11 - Clean and Sanitized Food Contact Surfaces documented food contact surfaces…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-01-23 · tag F0842 — failed to keep accurate, complete medical records — widespread
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — the official record, unedited, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure resident records were safeguarded to prevent unauthorized access. This failure had the potential to allow misuse or disclosure of resident information. Findings include:On 01/20/26 at 9:40 AM, a medication cart was observed in the hallway in front of room [ROOM NUMBER]. The medication cart contained a laptop that was logged into the electronic medical record system, displaying access to multiple resident records. No staff member was present at the cart at the time of the observation.On 01/20/26 at 9:45 AM, the Interim Director of Nursing stated the expectation is that resident records are to remain secured to prevent unauthorized access.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-23 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — the official record, unedited, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interview, it was determined the facility failed to ensure a resident who was self-administering a medication was assessed to effectively do so. This was true for 1 of 1 resident (Resident #4), whose record was reviewed for self-administration of medications assessment. This failure placed Resident #4 at risk for adverse outcomes if she were to use the medication inappropriately. Findings include: Resident #4 was admitted to the facility on [DATE] with multiple diagnoses including leukemia and rheumatoid arthritis. On 1/22/26 at 8:34 AM, RN #1 was observed setting the single use vial of cyclosporine eye drops on Resident #4's bedside table and let her know she could use them whenever she wanted and to let him know later. On 1/22/26 at 9:44 AM, The Interim DNS stated Resident #4 had been observed by staff to appropriately self-administer her eye drops, but the facility did not perform or document a self-administration of medication assessment.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-23 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure resident assessments accurately reflected their diagnoses and specialized services. This was true for 2 of 8 residents (#1 and #5) whose Minimum Data Set (MDS) Assessments were reviewed. This failure placed Resident #1 and #5 at risk for adverse outcomes if their needs were to go unmet. Findings include:The MDS Assessment is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. 1. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including dementia, Parkinson's disease, kidney failure, and obstructive sleep apnea. On 1/20/26 at 2:25 PM the Interim DNS stated Resident #1 had never needed an invasive mechanical ventilator (a tube inserted into your airway through intubation or a surgical opening…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-23 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — the official record, unedited, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure a resident's care plan was comprehensive. This was true for 1 of 8 residents (Resident #5) whose care plans were reviewed. This failure placed Resident #5 at risk for her mental health needs to go unmet because her mental health diagnoses were not included in her care plan. Findings include:Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including heart disease, bipolar disorder, depression, and anxiety. Review of Resident #5's comprehensive care plan did not document her bipolar disorder, anxiety, and/or depression diagnoses or interventions for how staff were to care for her mental health needs. On 1/22/26 at 4:28 PM, the Resident Service Advocate, stated Resident #5's care plan did not have her bipolar disorder, depression, and anxiety disorders in her comprehensive care plan, and they were excluded in error.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-24 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 10 residents (Resident #4) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The Resident Assessment Instrument (RAI), revised 10/1/24, documented if a PASARR (Preadmission Screening and Resident Review) level II determined a resident has a serious mental illness then section A1500 of the MDS should be marked yes. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including bipolar disorder (a mental health condition characterized by significant mood swings) and anxiety disorder. Resident #4's medical record documented a PASARR level II, dated 7/11/22, was completed. Resident #4's admission MDS assessment, section A1500, dated 7/20/22, documented, no,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-24 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, policy review and record review, it was determined the facility failed to ensure medications were administered according to professional standards of practice. This was true for 1 of 1 resident (Resident #7) whose medications were observed in the medication cup inside the medication cart. This failed practice created the potential for residents to experience adverse effects when their medications were not administered according to the physician's order. Findings include: The facility's Medications - Ordering, Dispensing, Administration, Monitoring and Storage policy, revised 11/12/24 documented medications prescribed frequently than daily, but no more frequently than every 4 hours (ex: QID, TID, BID) may be administered within a window of 2 hours before or after the standardized scheduled time. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including stroke and dementia. A physician's order, documented Resident #7 was to receive the following…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-24 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, review of facility policies and procedure, review of Incidents and Accidents (I&As) reports, and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 2 of 3 residents (#14 and 170) reviewed for medication errors. This deficient practice created the potential for Resident #170 to experience harm when he was administered another resident's medications, and for Resident #14 when he received the wrong dose of insulin. Findings include: The facility's policy, Medications - Ordering, Dispensing, Administration, Monitoring and Storage, documented, medications will be administered according to the following rights of medication: The right patient, right medication, right dose, right time, right route, and right documentation. 1. A facility I&A report, dated 5/1/24, documented, during the morning medication rounds, Resident #170 received 8 medications meant for another resident. The medications included: Three medications Resident #170 was not prescribed: Vitamin C 500 mg,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 31 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in ID