Ignite Medical Resort Tulsa: Care Protocol Failures - OK
The resident, identified as #3 in inspection records, had undergone toe amputation surgery and was discharged from the hospital on March 14 with specific instructions: follow up with podiatry within two weeks for suture removal.
Hospital discharge orders were clear. The patient needed to see a podiatrist by March 21 for post-surgical care. The resident had been admitted to Ignite Medical Resort on March 20 with moderate cognitive impairment and multiple serious conditions including peripheral vascular disease and end-stage renal disease.
A medication note dated March 21 documented the plan: "Remove sutures/staples from amputation sites to L [left] toes unless contraindicated. Contact [the physician] with any concerns. One time only for 1 [one] day Appt [appointment] Monday [03/24/25]. Pt [patient] wanted surgeon to remove sutures."
The appointment was scheduled for March 24. Transportation was arranged.
Nobody showed up.
On October 17, the social services director explained what happened: "The appointment on 03/24/25 was cancelled due to the staff did not see on the dashboard, Resident #3 had an appointment that day."
The director of nursing confirmed the failure. The appointment was scheduled and transportation was set up, but staff missed the appointment on the dashboard. They had to notify the physician after the fact and get instructions to remove the sutures at the facility instead.
A physician encounter note from March 24 shows the confusion. It reads: "Visit Type: Follow up Transition of Care: No transition occurred. Details: This is a copy of a signed encounter note documented in GEHRIMED. Progress Note .Plan: Continue current medical regimen. No changes. Patient has follow-up appointment today."
The missed appointment created a cascade of delays. The resident's family representative explained the consequences during an October 14 interview: the delay in therapy was caused by the missed appointment that would have provided orders for weight bearing as tolerated. Resident #3 could have gotten more therapy before discharging home.
The facility scrambled to reschedule. The director of nursing said they managed to get a new appointment for April 9.
But the resident discharged on April 8 — one day before the rescheduled visit.
The two-week delay meant Resident #3 spent additional time in the nursing home instead of recovering at home. The missed podiatry appointment prevented timely weight-bearing orders that would have allowed more intensive therapy during the stay.
Federal inspectors reviewed the case as part of a complaint investigation in November. They found the facility failed to ensure appropriate treatment and care according to medical orders for the resident.
The inspection report shows 88 residents lived at Ignite Medical Resort during the review period. Inspectors examined three residents' medical appointments and found problems with one case — the amputation patient whose critical follow-up was missed because staff didn't check their scheduling system.
The facility's dashboard system was supposed to alert staff to upcoming appointments. Instead, it became the reason a post-surgical patient's care was delayed by two weeks, extending their nursing home stay and limiting their therapy options before returning home.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ignite Medical Resort Tulsa, LLC from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
IGNITE MEDICAL RESORT TULSA, LLC in TULSA, OK was cited for violations during a health inspection on November 21, 2025.
Hospital discharge orders were clear.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.