Ignite Medical Resort Edmond, LLC

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure;a. breathing treatments were monitored during administration for 1 (#18) of 1 sampled resident reviewed for breathing treatments, andb. oxygen tubing, nasal canula, BIPAP mask were labeled with the date they were administered and placed in a bag when not in use for 2 (#3 and #10) sampled residents reviewed for oxygen and BIPAP treatments. The DON identified four residents received breathing treatments, 51 residents required supplemental oxygen, and four residents had BIPAP treatments.

Inspectors wroteBased on record review and interview, the facility failed to complete pre and post assessments of dialysis monitoring for 1 (#7) of 1 sampled resident reviewed for dialysis. The DON identified one resident who received dialysis at the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to:a. maintain a clean ice machine; b. wash/sanitize hands before handling/storing dishes removed from the clean side of the dish machine; and,c. meet the minimum hot water temperatures for the wash and rinse cycles for the sanitizing of dishes cleaned in the dish machine. The DON identified 72 residents ate meals prepared in the kitchen.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection prevention control measures were in place for a. oxygen tubing labeled with the date and stored in a bag when not in use for 1 (#10) of 2 sampled residents reviewed for respiratory care;b. BIPAP mask labeled with the date and stored in a bag when not in use for 1 (#3) of 2 sampled residents reviewed for respiratory care;c. sanitary laundry delivery during 1 of 1 observation;d. legionella surveillance in the water system; ande. the use of enhanced barrier precautions when performing supra-pubic catheter care for 1 (#3) of 1 resident observed for urinary catheter care. The administrator identified 68 residents resided in the facility, 4 residents had BIPAPS, and 51 residents had orders for supplemental oxygen. The DON identified four residents with indwelling urinary catheters.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide reasonable accommodation of a bariatric bed for 1 (#3) of 1 sampled resident reviewed for accommodation of needs. The DON identified 73 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to limit a physician's order for a prn anti-anxiety medication to 14 days for 1 (#4) of 5 sampled residents reviewed for unnecessary medications. The DON identified seven residents received anti-anxiety medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure a physician discharge order was obtained for 1 (#78) of 1 sampled residents reviewed for a planned discharge. The DON identified 162 residents discharged in the past 6 months.

Inspectors wroteBased on record review and interview, the facility failed to provide a bed hold policy and discharge notice to resident representative for 2 (#76 and #9) of 2 sampled residents reviewed for bed hold policies. The DON identified 162 residents had been discharged from the facility in the last six months.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure MDS assessments were accurately coded to reflect the resident's status for 2 (#3 and #5) of 23 sampled residents reviewed for accurate MDS assessments. The administrator identified 68 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure showers were provided for dependent residents for 1 (#15) of 2 sampled residents who were reviewed for activities of daily living. The DON identified 10 residents who were dependent on staff for showers/bathing.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a safe smoking assessment was completed to prevent accidents and hazards for 1 (#10) of 1 sampled resident reviewed for safe smoking assessments to prevent accidents and hazards. The administrator identified no residents who smoke, and the facility was a non-smoking facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure indwelling urinary catheters were secured for 1 (#1) of 4 sampled residents reviewed for urinary catheters. The DON identified four residents had indwelling urinary catheters.

Inspectors wroteBased on record review and interview, the facility failed to ensure a clinical rationale had been documented for a declined gradual dose reduction for 2 (#11 and #5) of 5 sampled residents reviewed for unnecessary medications. The DON identified seven residents who received psychotropic medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure monitoring for anticoagulants for 1 (#11) of 5 sampled residents reviewed for unnecessary medications. The DON identified 22 residents received an anticoagulant medication.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure treatment carts were secured for 1 (400 hall) of 4 treatment carts observed. The DON identified four treatment carts in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure radiology services were provided for 1 (#2) of 1 sampled resident reviewed for radiology services. The DON identified 68 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure an allegation of abuse was reported to the State agency within two hours for 1 (#1) of 3 sampled residents reviewed for abuse. The DON identified 55 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from physical abuse for two (#2 and #5) of three sampled residents reviewed for abuse. LPN #1 identified 59 residents resided in the facility.

Inspectors wroteBased 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. Fifty-six residents received meals prepared by dietary services.

Inspectors wroteBased on record review and interview, the facility failed to complete a nurse aide performance review once every 12 months for two (CNA #1 and CNA #2) of two CNA records reviewed for annual competencies. The staff roster, dated 04/24/24, documented 31 CNAs are employed by the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were offered the choice to formulate advanced directives for two (#31 and #163) of 15 sampled residents reviewed for advanced directives. The Administrator identified 58 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to obtain a discharge order for one (#61) of three discharged residents reviewed. The Executive Director identified 58 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was completed within 48 hours for one (#28) of 15 sampled residents reviewed for baseline care plans. The Executive Director identified 58 residents resided in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to develop and implement a comprehensive care plan for two (#9 and #28) of 15 residents reviewed for care plans. The Executive Director identified 58 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a discharge summary was complete for one (#61) of three sampled residents reviewed for discharge. The Executive Director identified 58 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to administer medications as ordered for one (#264) of five sampled residents observed for medication administration. The Executive Director identified 58 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to have a proper indication for the use of ordered medications for two (#4 and #262) of six sampled residents reviewed for unnecessary medications The Executive Director indicated 58 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to disinfection a glucometer before or after its use on a resident. RN #2 identified three residents required the use of this glucometer for blood glucose monitoring.

Inspectors wroteBased on record review and interview, the facilty failed to ensure a bath/shower was provided to a resident who required assistance from staff for one (#1) of three sampled residents reviewed for ADL assistance. The facility census, dated 12/04/23, documented 67 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were available and administered as ordered for one (#1) of three sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 09/26/23, documented 54 residents resided in the facility.

Inspectors wroteOn 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. Immediate action(s) taken for the resident(s) found to have been affected include: [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a physician was notified timely when: A. an unstageable wound had been identified by staff for one (#157), B. a resident had a stage two pressure ulcer to obtain a treatment and when signs and symptoms of infection had been identified for one (#153), and C. a medication was unavailable and could not be administered as ordered for one (#19) of three sampled residents reviewed for notification. The Resident Census and Conditions of Residents report, dated 03/13/23, documented 59 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a medication was administered timely for one (#19) of six sampled residents reviewed for medication. The Resident Census and Conditions of Residents report, dated 03/13/23, documented 59 residents resided in the facility.