Ignite Medical Resort Tulsa, LLC

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Oct 31, 2024

  A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective [DATE], related to the facility's failure to ensure a nurse practitioner (NP #1) did not give a verbal order to a facility admission nurse (LPN #1) to reduce all enoxaparin (an anticoagulant medication) orders coming from acute care hospitals to a three-day course. The facility failed to ensure Resident #1 received their full 30-day course of enoxaparin as ordered by an acute care hospital physician which had the potential to result in serious injury or harm. On [DATE], the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to ensure physician medication orders were followed as written. […]

• No harm, potential for more than minimal, patternF761Dec 11, 2024

  Based on observation, record review, and interview, the facility failed to ensure medications were securely stored on halls 200 and 300. The DON identified five medications carts in the facility. Findings: The undated Medication Storage policy, read in part, All drugs and biologicals will be stored in locked compartments .During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. On 12/09/24 at 4:06 p.m., LPN #1 on hall 300, walked into a resident room leaving the medication cart unlocked and unattended. On 12/09/24 at 4:07 p.m., LPN #1 returned to the medication cart, then walked into another resident room leaving the cart unlocked and unattended. […]

• No harm, potential for more than minimal, isolatedF761Aug 13, 2026

  Based on observation and interview, the facility failed to ensure medications were secured for 1 (Tower 2) of 2 sampled medication carts observations. The administrator identified 100 residents resided in the facility. Findings: On 8/12/26 at 10:24 a.m., an unattended medication cart was observed in Tower 2. Several unidentified pills were observed in a medication cup sitting on top of the unattended cart. On 8/12/26 at 10:25 a.m., the administrator in training stated the medication belonged inside of the cart not and not on top of it. They stated it could have been a danger to other residents. On 8/12/26 at 10:28 a.m., Registered Nurse #1 stated they were waiting to give a resident their pills, and they had set the medication cup full of pills on top of the med cart. […]

• No harm, potential for more than minimal, isolatedF684Nov 21, 2025

  Based on record review and interview, the facility failed to ensure a medical appointment was attended for 1 (#3) of 3 sampled residents reviewed for medical appointments.The administrator identified 88 residents resided in the facility.Findings:A review of hospital discharge orders, dated 03/14/25, read in part, Discharge instructions Patient needs to follow-up with podiatry 2 weeks after surgery. 3/21/25.An admission assessment, dated 03/20/25, showed a BIMS of 12 which indicated Resident #3 was moderately impaired for daily decision making. […]

• No harm, potential for more than minimal, isolatedF690Dec 11, 2024

  Based on observation, record review, and interview, the facility failed to ensure the catheter bag and tubing were maintained to prevent infection for one (#151) of one sampled resident who was reviewed reviewed for indwelling urinary catheter. The roster matrix identified 12 residents who had indwelling urinary catheters. Findings: Resident #151 had diagnoses which included obstructive and reflux uropathy. The Care Plan, dated 12/10/24, read in part, Attach my catheter bag to bedside to drain and ensure it is closed drainage system and not touching the floor. On 12/10/24 at 8:54 a.m., Resident #151 was observed in bed with the catheter bag and tubing laying on the floor beside the bed. On 12/10/24 at 2:46 p.m., the resident's catheter bag was observed touching the floor. […]