Ignite Medical Resort Dyer LLC

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents received Activities of Daily (ADL) assistance related to bathing, hair washing, repositioning and eating for 2 of 3 residents reviewed for ADLs. (Residents F and G)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received treatment and care in accordance with professional standards, related to medications not administered timely and as ordered by the Physician, for 1 of 7 residents reviewed for quality of care. (Resident D)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were provided with laboratory (lab) services, related to lab tests not completed as ordered for 2 of 3 residents reviewed for lab services. (Residents D and E)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents' records were accurate and complete, related to documentation of the amount of urine found after bladder scans were completed, for 2 of 4 residents reviewed for bladder scans. (Residents D and E)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 1 and CNA 2) when providing care to a residents who were in Enhanced Barrier Precautions (EBP) for 2 of 4 residents reviewed for EBP. (Residents F and J)

Inspectors wroteBased 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. (Resident B)The Immediate Jeopardy began on 7/27/25, when the facility was unaware that the resident had exited the facility without supervision. [...]

Inspectors wroteBased 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)

Inspectors wroteBased on record review and interview, the facility failed to ensure treatment orders were updated and completed as ordered for 1 of 3 residents reviewed for non-pressure related skin conditions. (Resident H)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure G-tube (gastrostomy tube, a tube inserted directly into the stomach) placement and/or residual was checked prior to instilling a bolus feeding as well as flushing the tube after the feeding had infused. The facility also failed to ensure the amount of G-tube residual was documented for 3 of 3 residents reviewed for tube feeding. (Residents D, C and E)

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents who were left to complete nebulizer treatments independently had been assessed for safe self-administration for 1 of 4 residents reviewed for respiratory services. (Resident 29)

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician was notified of elevated blood sugars, blood pressure medications and insulin being held, and medication refusals for 3 of 3 residents reviewed for notification of change. (Residents 52, 154, and 264)

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed related to terminal prognosis and hospice care for 1 of 27 MDS assessments reviewed. (Resident 44)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed and in place for edema, compression glove use, and oxygen for 1 of 27 resident care plans reviewed. (Resident 60)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure professional standards of quality were maintained related to a CNA placing a tube feeding pump on hold for 1 of 2 residents reviewed for tube feeding. (Resident 73)

Inspectors wroteBased on record review and interview, the facility failed to assist a resident to see an eye doctor for 1 of 1 resident reviewed for vision. (Resident 29)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure G-tube (gastrostomy tube, a tube inserted directly into the stomach) flushes were instilled via gravity for 1 of 6 residents observed for medication administration. (Resident 202)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents received the necessary care and treatment related to oxygen administration for 1 of 4 residents reviewed for respiratory care. (Resident 60)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 1 of 6 residents observed during medication administration. Two medication errors were observed during 26 opportunities for error in medication administration. This resulted in a medication error rate of 7.69%. (Resident 66)

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were kept in a locked medication cart at all times for 1 of 6 residents observed during medication administration. (Resident 66)

Inspectors wroteBased on record review and interview, the facility failed to assist a resident to obtain dental care for 1 of 1 resident reviewed for dental services. (Resident 29)

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical record was complete and accurately documented related to medication administration documentation and medication orders for 1 of 27 records reviewed. (Resident 42)

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician was notified in a timely manner of a medication that was unavailable for 1 of 3 residents reviewed for notification of change. (Resident E)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff member (CNA 1) when providing care to a resident (Resident G) who was in Enhanced Barrier Precautions (EBP) for 1 of 4 residents reviewed for EBP.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing, related to interventions not in place and a treatment was not completed as ordered and care planned for 1 of 3 residents reviewed for pressure ulcers. (Resident G)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (LPN 1 and LPN 2) when providing care to a resident (Resident G) who was in Enhanced Barrier Precautions (EBP) for one random observation for infection control.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's responsible party was promptly notified after a significant change in status related to an intravenous (IV) site placement, changes in medications and medication times for 1 of 3 residents reviewed for notification of change. (Resident D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for residents who needed assistance related to long fingernails for 1 of 5 residents reviewed for ADLs. (Resident F)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure areas of bruising were assessed and monitored for 1 of 3 residents reviewed for skin conditions non-pressure related. (Resident K)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a peripheral intravenous (IV) catheter was maintained, monitored and assessed for patency for 2 of 3 residents reviewed for IV catheters. (Residents G and D)

Inspectors wroteBased on record review and interview, the facility failed to ensure clinical records were complete and accurately documented related to falls for 1 of 3 residents reviewed for falls. (Resident E) The facility also failed to document that treatments were completed as ordered for 1 of 3 residents reviewed for pressure ulcers and 1 of 3 residents reviewed for skin conditions non-pressure related. (Resident K)

Inspectors wroteBased on record review and interview, the facility failed to provide and document sufficient information for a resident who was being transferred to the hospital emergency room (ER), related to the circumstances of a resident being transferred to the ER not documented in the resident's record and transfer information was not provided to the Emergency Medical Services (EMS) and hospital, for 1 of 3 residents reviewed for transfers and discharges. (Resident E)

Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed related to falls, medications, and behaviors for 2 of 8 MDS assessments reviewed. (Residents G and J)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure individualized Care Plans were developed and implemented related to a knee immobilizer and behaviors for 2 of 8 residents reviewed for care plans. (Resident J and G) See F744 for additional information regarding Resident G.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received the necessary care and services related to antibiotics not administered, a blood sugar level not obtained, and physician notification of elevated blood sugar levels not completed as ordered for 1 of 8 residents reviewed for quality of care. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to ensure a thorough investigation of a fall was completed which included the root cause of the fall and failed to initiate an intervention related to the circumstances of the fall, for 1 of 3 residents reviewed for falls. (Resident D)

Inspectors wroteBased record review and interview, the facility failed to ensure a resident with dementia received appropriate treatment and services to meet his needs, related to ongoing behaviors without input from the Interdisciplinary Team (IDT) and Social Service, no identification of behavior type, no Care Plan with interventions for the behaviors, no updated nursing interventions for the behaviors, no interventions attempted, and no interventions attempted for the behaviors before medication was administered, for 1 of 1 resident reviewed for dementia/behaviors. (Resident G)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (LPN Wound Nurse 3 and LPN Wound Nurse 4) when providing pressure ulcer treatments for 1 of 1 random observation (Resident J). This had the potential to affect 13 residents who required wound treatments.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the posted Nurse Staffing Information was current and included only the staff who were scheduled for Long Term Care. This had the potential to affect all residents who resided in the facility during July and August, 2024.

Inspectors wroteBased on record review and interview, the facility failed to provide residents' medical records to the resident/Power of Attorney (POA) in a timely manner after a request was made for 2 of 3 residents reviewed for medical record requests. (Residents G and H)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff member (CNA 1) when emptying out a urinary catheter drainage bag for a resident who was in Enhanced Barrier Precautions (EBP) for 1 of 1 random observation. (Resident J)

Inspectors wroteBased 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)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide ADL (activities of daily living) assistance to dependant residents, related to completing scheduled showers, nail care, removing facial hair, hair washing, and oral care, for 5 of 6 residents reviewed for ADL care. (Residents P, Q, M, C, and N)

Inspectors wroteBased on record review and interview, the facility failed to ensure clinical records were complete, related to meal consumption intake, for 4 of 6 residents reviewed for food. (Residents Q, M, E, and N)

Inspectors wroteBased on record review and interview, the facility failed to ensure infection control guidelines for vaccinations were in place and implemented, related to offering and providing the COVID vaccine, for 4 of 5 residents reviewed for vaccinations. (Residents 41, 77, 198, and 247)

Inspectors wroteBased on record review and interview, the facility failed to implement a system to prevent misappropriation of resident property, related to no documentation of narcotics being signed out of the facility's emergency medication machine, for 1 of 1 residents reviewed for pain management. (Resident Q)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an ongoing activity program was implemented for cognitively impaired dependent residents, for 1 of 2 residents reviewed for activities. (Resident 26)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure areas of bruising were assessed and monitored for 1 of 2 residents reviewed for skin conditions non-pressure related. The facility also failed to ensure treatment orders were obtained for excessive diarrhea for 1 of 1 residents reviewed for constipation and transportation was arranged for surgical appointments for 1 of 1 residents reviewed for change in condition. (Residents 13, Q, and 5)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate for 3 of 4 residents reviewed for respiratory care (Residents M, 5 and 45)

Inspectors wroteBased on record review and interview, the facility failed to administer pain relief medication as ordered by the Physician, related to the administration of narcotic medication, for 1 of 1 residents reviewed for pain management. (Resident Q)

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were managed appropriately, related to missed doses of an anticoagulant medication, for 1 of 5 residents reviewed for unnecessary medications (Resident Q)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 3 of 6 residents observed during medication pass. Three errors were observed during 29 opportunities for errors during medication administration. This resulted in a medication error rate of 10.34%. (Residents 49, 41, and J)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were properly stored, related to one unlabeled insulin vial and loose pills inside the medication drawers, for 1 of 4 medication carts observed. (North East Cart 2).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, related to improper disposal of a used lancet placed in the garbage can, for 1 of 1 residents observed for glucometer use. (Resident 41)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's family was notified of behaviors, medication changes, and transfers to the Emergency Room, for 1 of 5 residents reviewed for family notification. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to provide and document sufficient information for a resident who was being transferred to the hospital emergency room related to Transfer Forms/assessments not completed for 1 of 1 resident reviewed for transfer to an Emergency Room. (Resident B)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident with dementia received appropriate treatment and services to meet her needs, related to ongoing behaviors without input from the Interdisciplinary Team (IDT) and Social Service, no updated Care Plan with interventions for the behaviors, no interventions attempted and/or no documented effectiveness of the interventions, for 1 of 3 residents reviewed for dementia/behaviors. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's record was complete and accurate, related to no documentation of a resident's return from the Emergency room, no documentation of of an appeal of a NOMNC (Notice of Medicare Non-Coverage) letter, and events that occurred during a potential discharge of a resident and reasons for discharge from the facility, for 2 of 5 residents reviewed for medical records. (Residents B and E)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was free from unnecessary medications, related to a medication administered when the blood pressure was out of the prescribed parameter, for 1 of 1 resident reviewed for unnecessary medications. (Resident F)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents were invited to attend and participate in care planning conferences for 3 of 6 residents reviewed for participation in care planning. The facility also failed to ensure Care Plans were reviewed and revised related to behaviors for 1 of 21 Care Plans reviewed. (Residents E, 16, 31, and 26)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents received help with Activities of Daily Living (ADLs) related to dirty fingernails, transfers to the bathroom, shaves, and showers, for 4 of 7 residents reviewed for ADLs. (Residents B, F, H and G)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure signs and symptoms of constipation were monitored for 1 of 3 residents reviewed for constipation. The facility also failed to ensure areas of discoloration were assessed and monitored for 1 of 1 residents reviewed for anticoagulant medication side effects and 1 of 2 residents reviewed for skin conditions non-pressure related. The facility also failed to ensure fall follow-up was completed for a resident with a potential injury and documentation for a discharge was completed for 2 of 2 residents reviewed for hospitalization. (Residents E, C, D, and F)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders and an assessment to self-administer their own medications for 2 of 2 residents reviewed for self-administration of medication. (Residents 125 and 19)

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident was notified of a new medication for 1 of 2 residents reviewed for notification of change. (Resident F)

Inspectors wroteBased on record review and interview, the facility failed to monitor and assess a resident after antibiotic therapy had been started for a urinary tract infection (UTI) for 1 of 2 residents reviewed for UTI. (Resident 35)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the intake amounts of nutritional supplements were documented and food consumption logs were completed for residents with a history of weight loss for 2 of 4 residents reviewed for nutrition. (Residents B and G)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate and the nasal cannula was properly placed for 2 of 4 residents reviewed for respiratory services. (Residents 4 and H)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with complaints of pain received the appropriate scheduled medication to relieve the pain based on the resident's pain level for 1 of 3 residents reviewed for pain. (Resident C)

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were not used for excessive duration and monitored adequately related to medicated wipes and giving medications outside of blood pressure parameters for 2 of 5 residents reviewed for unnecessary medications. (Residents 42 and 4)

Inspectors wroteBased on record review, and interview, the facility failed to ensure residents did not receive unnecessary psychotropic medications without adequate indications for use for 1 of 5 residents reviewed for unnecessary medications. (Resident G)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was free from significant medication errors related to administering the wrong insulin for 1 of 6 residents observed during medication pass. (Resident 42)

Inspectors wroteBased on record review and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and a system of monitoring to improve resident outcomes and reduce antibiotic resistance related to a practitioner prescribing antibiotics for not true infections based on the McGeer Criteria for 1 of 2 residents reviewed for urinary tract infections (UTI). (Resident 35)