Parc Place Medical Resort: Infection Control Gaps - OK
The BIPAP breathing equipment belonged to Resident #3, who used the device nightly to help them breathe. Federal inspectors found the mask and attached hose sitting on the bedside dresser October 2, stored improperly in a way that could spread infection.
CNA #1 told inspectors the BIPAP sat on the bedside table with the mask stored in the top drawer, not in a protective bag. The infection preventionist confirmed observing the moisture-covered mask in the open drawer and stated masks should be bagged when not in use to prevent germs and infection spread.
The facility had no physician order or care plan documenting the resident's need for BIPAP therapy, despite the equipment's presence at bedside.
Staff confusion about infection control extended beyond breathing equipment. When asked about catheter care protocols, LPN #1 said they didn't recall that catheter care required evidence-based practices for infection prevention.
The Director of Nursing clarified that staff must use evidence-based practices with anybody who had a line, wound, or break in their body to protect residents from possible infection. She agreed the facility required staff to use proper protocols when performing supra-pubic catheter care.
Clean laundry presented another infection risk. On October 1 at 8:00 a.m., inspectors observed laundry aide #1 delivering laundry to resident rooms without protective covering.
The housekeeping supervisor explained the next day that resident clothes were supposed to be washed separately and delivered back to rooms in individual bags. They acknowledged that laundry aide #1 had failed to put the clothes in bags and confirmed awareness of the October 1 incident.
The facility's water management program existed only on paper. Despite having written policies for Legionella surveillance and water management to prevent dangerous bacterial infections, maintenance staff couldn't implement basic safety measures.
The Legionella surveillance policy stated it was facility policy to establish primary and secondary strategies for preventing and controlling Legionella infections. The water management program policy required developing plans for reducing the risk of legionellosis and other opportunistic pathogens in the facility's water systems based on nationally accepted standards.
The policy designated a water management team including facility leadership, the infection preventionist, maintenance employees, safety officers, risk and quality management staff, and the Director of Nursing. It required the Maintenance Director to maintain documentation describing the facility's water system, with copies kept in the water management program binder.
None of this existed in practice.
The maintenance supervisor told inspectors October 2 they had no facility map showing water flow throughout the building. They added sanitizer tablets to condensation pans in air conditioning units in the attic to prevent line stoppages and leaks, but kept no documentation of when they completed this work.
Most significantly, the maintenance supervisor said they were unaware of any water management plan or legionella prevention plan, despite the written policies requiring their involvement in both programs.
Legionella bacteria can cause severe pneumonia and death, particularly dangerous for elderly nursing home residents with compromised immune systems. The bacteria grows in warm water systems and can spread through building ventilation, making proper water management and documentation critical for resident safety.
The inspection revealed a facility where infection control policies existed in writing but failed in daily practice. Breathing equipment sat unprotected, clean laundry moved without covering, and water safety programs remained unknown to the staff responsible for implementing them.
Federal inspectors classified the violations as having minimal harm or potential for actual harm, affecting some residents. The October complaint investigation documented systematic breakdowns in basic infection prevention measures designed to protect vulnerable nursing home residents from preventable illness.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ignite Medical Resort Edmond, LLC from 2025-11-25 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 Edmond, LLC in OKLAHOMA CITY, OK was cited for violations during a health inspection on November 25, 2025.
The BIPAP breathing equipment belonged to Resident #3, who used the device nightly to help them breathe.
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.