Ignite Medical Resort Norman, LLC

Inspectors wroteOn 07/11/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to prevent a significant medication error by administering the wrong dose of morphine (an opioid) to Resident #3. On 07/11/25 at 12:34 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 07/11/25 at 2:23 p.m., the administrator and the general manager were notified of the IJ situation and the IJ template was provided. On 07/14/25 at 2:00 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,IJ removal Plan - Ignite Medical Resort [NAME]. Ignite Medical Resort [NAME] is committed to ensuring the safety and well-being of all residents and operates in substantial compliance with Federal and State laws and regulations. [...]

Inspectors wroteOn 07/11/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to prevent a significant medication error for Resident #3. On 07/11/25 at 12:34 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 07/11/25 at 2:23 p.m., the administrator and the general manager were notified of the IJ situation and the IJ template was provided. On 07/14/25 at 2:00 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,IJ removal Plan - Ignite Medical Resort [NAME]. Ignite Medical Resort [NAME] is committed to ensuring the safety and well-being of all residents and operates in substantial compliance with Federal and State laws and regulations. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide pain medication to a resident as ordered for 1 (#1) of 3 sampled residents reviewed for medication as ordered. The general manager identified 36 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure dirty linens were handled in a manner to prevent cross contamination during:a. incontinent care for 1 (#1) of 3 sampled residents observed for incontinent care; and b. a hall observation. The general manager identified 36 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure physician orders were followed for tube feeding administration and removal of a Foley catheter for one (#4) of three sampled residents reviewed for physician orders. The administrator identified 39 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure dependent residents were showered for one (#3) of three sampled residents reviewed for ADLs. The administrator identified 39 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide baths/showers as scheduled for one (#36) of three sampled residents reviewed for activities of daily living. The DON identified 47 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to prevent an injury to a resident during transfers for one (#29) of two residents sampled for accidents and hazards. The Administrator identified 47 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure oxygen tubing was labeled and dated, per professional standards of care for three (#4,26, and #93) of three resident sampled for respiratory care. The DON identified 5 residents had orders for oxygen therapy.

Inspectors wroteBased on observation, record review, and interview, the facility failed to perform an entrapment risk assessment prior to installing bed or side rails for two (#2 and #86) of two residents and failed to obtain a physician order for the medical rationale and use of bed rails prior to installation for one (#86) of two sample residents reviewed for accident hazards. The DON identified 44 residents whose beds were equipped with a bed rail of any type.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident medications were administered according to physician ordered parameters for three (#12, 88, and #89) of five sampled residents reviewed for unnecessary medications. The DON identified 47 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident who received psychotropic medications had an acceptable diagnoses/indication for the use of an antipsychotic medication for three (#12, 88, and #89) of five sampled residents reviewed for unnecessary medications. The ADON identified 21 residents who received psychotropic medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food items were labeled with the date opened in the refrigerators, maintain a clean and sanitary kitchen during two of two kitchen observations. The DON identified 47 residents received nutrition form the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident assessments were accurately coded for one (#4) of 12 sampled residents reviewed for accurate assessments. The administrator identified 47 Residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician orders were followed for obtaining weekly weights for one (#36) of one sampled resident reviewed for weights. The DON identified 47 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to cover a residents nebulizer mask when not in in use to prevent the spread of infection for one (#35) of three residents sampled for infection control practices for nebulizer mask. The DON identified 14 residents used nebulizer's.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for nine (#12, 21, 24, 25, 30, 32, 42, 54, and #55) of sixteen sampled residents reviewed for bathing. The Resident Census and Conditions of Residents form documented 39 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a discharge summary was completed for one (#38) of three sampled residents reviewed for discharge summaries. The Resident Census and Conditions of Residents form documented 39 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a multi podus boot was in place per physician order for one (#28) of one sampled resident reviewed for multipodis boots. The Resident Census and Conditions of Residents form documented 39 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care to assure safety related to the administration of injections for one (#42) of two residents reviewed for medication administration. The Resident Census and Conditions of Residents form documented 12 residents received injections.

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing information, which included all the required components, in an area where it could be reviewed by all residents and visitors. The Resident Census and Conditions of Residents form documented 39 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner. The facility failed to: a. clean the oven and hand washing sinks. b. wear hair restraints when in the kitchen. c. perform hand hygiene after touching unclean surfaces during meal service and meal pass. The Census and Conditions of Residents form documented 36 residents lived in the facility.

Inspectors wroteBased on record review, observation, and interview, it was determined the facility failed to provide baths/showers as scheduled for two (#30 and #38) of two sampled residents. The Census and Conditions of Residents form documented 36 residents lived in the facility.