Ignite Medical Resort Edmond, Llc
Inspection Findings
F-Tag F0880
F 0880
nightly to help them breathe.
Level of Harm - Minimal harm or potential for actual harm
On 10/02/25 at 10:17 a.m., CNA #1 was asked about Resident #3's respiratory needs. CNA #1 stated Resident #3 had a BIPAP on their bedside table and the mask was in the top drawer not in a bag.
Residents Affected - Some
On 10/02/25 at 10:50 a.m., the IP stated they observed a BIPAP with a mask with visible moisture and hose attached to the BIPAP on Resident #3's bed side dresser in an open drawer not in a bag. The IP stated there was not a physician order or care plan focus on Resident #3's medical record for BIPAP therapy. The IP stated the mask should be bagged when not in use to prevent germs and spread of infection.
On 10/02/25 at 11:15 a.m., LPN #1 stated they did not recall catheter care required the use of EBP.
On 10/02/25 at 11:20 a.m., the DON stated EBP was used with anybody that had a line, wound, or break in their body, to protect the resident from possible infection. The DON agreed when staff performed supra-pubic catheter care, the facility required the staff to use EBP.
- 3. On 10/01/25 at 8:00 a.m., laundry aide #1 was observed to deliver laundry to resident rooms uncovered.
- 4. An undated policy Legionella Surveillance, read in part, It is the policy of this facility to establish primary
On 10/02/25 at 8:21 a.m., the housekeeping supervisor, stated resident clothes were washed separately and delivered back to their rooms in their own bag. They stated laundry aide #1 did not put the clothes in
the bag. They stated they were aware of the incident on 10/01/25 at 8:00 a.m.
and secondary strategies for the prevention and control of Legionella infections.
An undated policy Water Management Program, read in part, It is the policy of this facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens .in the facility's water systems based on nationally accepted standards .A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing .The Maintenance Director maintains documentation that describes the facility's water system. A copy is kept in the water management program binder.
On 10/02/25 at 9:10 a.m., the maintenance supervisor stated they had no facility map of the water flow in
the facility. The maintenance supervisor stated they added sanitizer tablets to the condensation pans in the air conditioning units in the attic to prevent the stopping up of lines and leaks. The maintenance supervisor stated they did not document when they completed that. The maintenance supervisor stated they were not aware of a water management plan or legionella prevention plan.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Ignite Medical Resort Edmond, LLC in OKLAHOMA CITY, OK inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in OKLAHOMA CITY, OK, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Ignite Medical Resort Edmond, LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.