Ignite Medical Resort Edmond, LLC

In the surveyor’s words

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

• Immediate jeopardy, patternF686Mar 17, 2023

  On 03/16/23, an IJ situation was determined to exist due to the facility failing to ensure: a. Resident #153, who admitted with a blister to their left heel was thoroughly assessed on admission and weekly, monitored for changes, physician notified, and interventions implemented. This resulted in sepsis, osteomyelitis, and left BKA, and b. Resident #157 was thoroughly assessed on admission and an unstageable pressure ulcer was identified four days after admission. On 03/16/23 at 2:30 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 03/16/23 at 2:48 p.m., the Administrator and DON were notified of the IJ situation. On 03/16/23 at 11:19 p.m., an acceptable plan of removal was provided. The plan of removal documented: .1. […]

• No harm, potential for more than minimal, widespreadF812Apr 25, 2024

  Based on observation, record review, and interview, the facility failed to ensure: a. food items in the refrigerator were properly labeled and had identified use by dates, b. food items were discarded on or before the manufacturer expiration dates, c. leftovers in the refrigerator were dated and used within at least 3 days, d. food items were stored at the appropriate temperatures, e. only clean utensils were used when accessing bulk foods, f. staff in the kitchen with beards wore beard restraints, g. clean dishware was not exposed to splash and covered or inverted, and h. dishwasher rinse cycles were routinely tested for proper chemical sanitization. The Administrator identified 58 residents resided at the facility. […]

• No harm, potential for more than minimal, patternF655Nov 25, 2025

  Based on observation, record review, and interview, the facility failed to provide baseline care plans to the resident and representative for 2 (#76 and #15) of 23 sampled residents reviewed for baseline care plans.The DON identified 68 residents resided in the facility.Findings:1. An undated Baseline Care Plan policy, read in part, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .The baseline care plan will: Be developed within 48 hours of a resident's admission .The supervising nurse, or supervising nurse shall verify within 48 hours that a baseline care plan has been developed. […]

• No harm, potential for more than minimal, patternF656Nov 25, 2025

  Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan focus was developed to address a resident's respiratory needs and a resident's oral care needs for 2 (#3 and #5) of 23 sampled residents reviewed comprehensive care plans. The administrator identified 68 residents resided in the facility. Findings: An undated facility policy titled 'Noninvasive Ventilation (CPAP, BIPAP, AVAPS, Trilogy),' read in part, The facility will obtain an order for the use of CPAP, BIPAP, AVAPS, or Trilogy device and settings from the practitioner.A personal CPAP, BIPAP, AVAPS, or Trilogy device may/may not be brought into the facility for the resident use. If brought in, the nurse/respiratory therapist will verify the settings on the machine prior to use. […]

• No harm, potential for more than minimal, patternF657Nov 25, 2025

  Based on record review and interview, the facility failed to ensure care plans were reviewed and revised for 2 (#12 and #61) of 23 sampled residents reviewed for care plan revisions.The DON identified 68 residents resided in the facility.Findings:1. An annual assessment, dated 08/17/25, showed Resident #12 had a BIMS of 14 which indicated they were cognitively intact for daily decision making. The assessment showed a diagnosis of depression. Section N of the assessment showed no antipsychotic or antianxiety medications were administered during the look back period. Section N showed an antidepressant medication was administered during the look back period. […]