Ignite Medical Resort Edmond, Llc
Ignite Medical Resort Edmond, LLC in OKLAHOMA CITY, OK — inspection on November 25, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
nightly to help them breathe.
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.
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.
- On 10/01/25 at 8:00 a.m., laundry aide #1 was observed to deliver laundry to resident rooms uncovered.
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.
- An undated policy Legionella Surveillance, read in part, It is the policy of this facility to establish primary
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.