Ignite Medical Resort Dyer LLC

In the surveyor’s words

From the most serious findings on record at Ignite Medical Resort Dyer LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 31, 2025

  Based on observation, record review and interview, the facility failed to initiate and update effective resident-specific interventions to prevent the elopement from the facility of a resident with a diagnosis of dementia and history of exit-seeking behaviors for 1 of 5 residents reviewed as elopement risk. The resident had indicators of being an elopement risk and behaviors of wanting to exit the facility. The resident exited the building without supervision, through the main front door entrance, and the facility was unaware of the resident's whereabouts. The resident ambulated approximately 0.15 miles from the facility on a highly traveled four lane road and was returned to the facility by Emergency Services staff. […]

• No harm, potential for more than minimal, widespreadF812Apr 29, 2025

  Based on observation, record review, and interview, the facility failed to keep the kitchen clean and in good repair related to food not labeled and dated for 1 of 1 kitchen. This had the potential to affect 86 residents who resided in the facility and received food from the kitchen. (The Main Kitchen) Findings include: During the Initial Kitchen Sanitation Tour on 4/21/25 at 9:17 a.m. with the Kitchen Manager, the following was observed: 1. In the dry storage room, there was a large unlabeled storage bin containing a white powder and an unlabeled container partially filled with yellow liquid. 2. In the walk-in cooler, there was a partially full, unlabeled squeeze bottle containing a red/brown substance. There was an uncovered bucket filled with cut-up potatoes and water. […]

• No harm, potential for more than minimal, patternF695Jul 31, 2025

  Based on observation, record review and interview, the facility failed to ensure oxygen was available on the crash cart (mobile unit with life-saving equipment used in medical emergencies) for 1 of 2 crash carts reviewed. (A Wing) Finding includes:On 7/31/25 at 1:25 p.m., the A wing crash cart near Room A160 was observed with the A Wing Unit Manager. The oxygen tank on the cart were empty. During an interview at that time, the A Wing Unit Manager indicated the oxygen tank was empty and she would replace it. She was unsure how often the oxygen tank level was checked but the crash cart supplies were checked daily. During an interview on 7/31/25 at 2:08 p.m., the Director of Nursing (DON) indicated the crash cart oxygen should be checked daily. […]

• No harm, potential for more than minimal, patternF684Apr 29, 2025

  Based on observation, record review, and interview, the facility failed to ensure bruises were assessed and monitored for 2 of 2 residents reviewed for non-pressure related skin conditions, signs and symptoms of constipation were monitored for 1 of 1 resident reviewed for constipation, edema was monitored and assessed for 1 of 3 residents reviewed for edema and medications were held per blood pressure parameters for 1 of 5 residents reviewed for unnecessary medications. (Residents 91, 255, 60, 27, and 264) Findings include: 1. During a random observation on 4/22/25 at 10:14 a.m., an area of reddish/purple discoloration was noticed on Resident 91's left forearm. The record for Resident 91 was reviewed on 4/23/25 at 12:17 p.m. […]

• No harm, potential for more than minimal, patternF554Mar 11, 2024

  Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders to administer their own medications, orders were present for the medications, and a self-administration of medication assessment was completed, for 5 of 5 residents reviewed for self-administration of medication. (Residents J, L, H, M, and K) Findings include: 1. During a random observation on 3/4/24 at 2:45 p.m., a bottle of Nasal Relief nasal spray was observed on the window ledge in Resident J's room. During random observations on 3/5/24 at 9:09 a.m. and 11:15 a.m., the nasal spray remained on the resident's window ledge. The record for Resident J was reviewed on 3/5/24 at 2:44 p.m. […]