Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ignite Medical Resort Edmond, Llc during CMS and state inspections, most recent first.
Multiple infection control deficiencies were identified, including failure to date and properly store oxygen and BIPAP equipment for two residents, lack of enhanced barrier precautions during supra-pubic catheter care, delivery of uncovered laundry to resident rooms, and absence of documented legionella surveillance and water management practices. Staff interviews confirmed lapses in following facility policies for infection prevention.
Failure to Provide Baseline Care Plans to Residents and Representatives: The facility did not provide baseline care plans to two residents or their representatives after admission. One resident had dementia, HTN, restless leg syndrome, and respiratory disorders, and another resident had depression; both had BIMS scores of 15. Staff completed undated baseline preference forms, but one form was not signed or dated by staff, and the record did not show that either resident or representative received a copy of the baseline care plan.
A facility failed to develop comprehensive care plan focuses for a resident's BIPAP/respiratory needs and another resident's oral care needs. One resident had a BIPAP at bedside and said they used it nightly, but there was no BIPAP order and no respiratory focus in the care plan. Another resident was observed without teeth, said they wanted dentures and had not seen a dentist, but the care plan had no dental/oral care concern and assessments were inconsistent about edentulous status.
Care plans were not reviewed and revised for 2 residents. One resident with depression had an antidepressant order for sertraline, but the care plan did not address antidepressant or psychotropic medication use. Another resident was observed with a urinary catheter and leg bag, but the care plan did not include a catheter focus. The MDS coordinator said both omissions were oversights.
A resident receiving a nebulizer treatment was left without staff in the room, and the nurse did not assess lung sounds before or after the treatment as ordered. In addition, oxygen tubing, a nasal cannula, and a BIPAP mask were observed without date labels and not stored in bags when not in use; staff confirmed the equipment was not bagged, and one resident’s BIPAP use was not supported by an order or care plan focus.
Missed Dialysis Monitoring Assessments: The facility failed to complete required pre- and post-dialysis assessments for a resident with ESRD, DMII, and an AV fistula. The resident’s care plan called for monitoring the dialysis site, fluid status, and labs, but multiple dialysis monitoring forms were missed or left incomplete, and the DON stated the missing assessments were not documented.
Kitchen sanitation deficiencies were observed when the ice machine had black buildup on the cover, evaporator area, reservoir tray, and nearby components. In the dish room, the dietary manager and a cook handled dirty dishes and then clean dishes without sanitizing their hands, while the dish machine initially ran below required temperatures and the chemical sanitizer was not connected; staff gave mixed answers about whether the unit used hot water or chemical sanitization.
Failure to provide bariatric bed accommodation: A resident who was paraplegic, obese, and cognitively intact was observed on an air mattress that did not allow room to turn, while the care plan and MD orders did not address a bariatric bed. Nursing later discussed mattress concerns for pressure relief, and the resident reported being told a larger bed would be provided on admission but had not received one.
A resident with chronic pulmonary embolism, pneumonia, HF, AFib, and SOB received PRN lorazepam multiple times, and the facility had active PRN lorazepam orders for restlessness or agitation that were not limited to the required 14-day stop date. The DON stated the facility policy limited PRN anxiety meds to 14 days and that the order was missed during review; no documented rationale for extending the order was provided by the end of survey.
Missing Physician Discharge Order for Planned Resident Discharge: A resident with dementia and a BIMS score of 15 was planned for discharge to an ALF after care planning meetings with the resident, POA, and IDT. The record showed the resident was discharged and transported by family, but the chart did not contain a physician discharge order, and the DON confirmed no such order had been documented.
Failure to Provide Bed Hold Policy and Discharge Notice: The facility failed to provide a bed hold policy and discharge notice to the resident representative for two residents reviewed for bed hold practices. One resident with dementia, HTN, and respiratory disorders was transferred to the hospital for lethargy, and another resident with CHF and AKI was sent out for hematemesis; both had BIMS scores of 15 and discharge assessments anticipating return, but the DON and administrator confirmed the required documentation was not in the record.
MDS assessments were not accurately coded for two residents. One resident was observed with a BIPAP machine and stated they used it nightly, but the MDS recorded no CPAP/BIPAP use and the record had no order or care plan focus for it. Another resident was observed without teeth and stated they wanted dentures, yet the MDS coded the resident as not edentulous; staff confirmed the resident had no teeth and the care plan had no dental concern.
Missed Showers for Dependent Resident: A resident who was cognitively intact, had depression, and was dependent on staff for bathing did not receive all scheduled showers. Records showed the resident missed two shower opportunities, and the resident stated staff had not assisted when requested. CNA documentation and RN filing practices were noted, and the DON could not explain why the showers were missed.
Failure to complete a safe smoking assessment for a resident with impaired cognition who was identified as a tobacco user. The resident was observed using a walker to exit the building, then smoking unsupervised with a lighter and cigarettes in possession less than 15 feet from the entrance; staff confirmed the facility was non-smoking and had seen the resident smoke outside, but the record did not document a safe smoking assessment.
Unsecured Indwelling Urinary Catheter: A resident with an indwelling urinary catheter for urinary retention and severe cognitive impairment had catheter care observed, but the catheter was not secured before or after care. CNA staff stated they typically use a device to secure catheters but did not know why this resident's catheter was left unsecured, and an LPN and the DON both stated the catheter was supposed to be secured.
A facility failed to document a clinical rationale when GDRs were declined for two residents receiving psychotropic medications. One resident was on fluoxetine for depression, and the physician only marked minimal effective dose without explaining the rationale. Another resident had a pharmacist letter requesting GDRs for Abilify, hydroxyzine, and monitoring for venlafaxine, but the letter was not signed by the physician; the resident had dementia, depression, and psychotic disorder with delusions, and review of med regimen reviews showed no GDRs were requested by the pharmacist over the review period.
Failure to monitor anticoagulant therapy for a resident receiving Xarelto. The resident had quadriplegia and multiple sclerosis, and the care plan directed staff to monitor, document, and report signs or symptoms of anticoagulant complications. An LPN could not identify the side effects monitored for anticoagulant use, and the DON stated the resident had not been monitored for anticoagulant side effects.
An unlocked and unattended 400-hall treatment cart was observed containing insulin, heparin, medicated ointments, and wound cleanser/wound care supplies. RN #1 later locked the cart, and both RN #1 and the DON stated treatment carts are to be locked when unattended.
Failure to complete ordered radiology services for a resident with chronic pain and cognitive impairment. Physician visit notes documented left upper arm pain and ordered x-rays of the left humerus and elbow, but the ADON missed the notes and the DON confirmed the x-ray was not completed. The resident reported chronic shoulder pain managed with current meds and stated no radiologic or diagnostic testing had been done while at the facility.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents experienced inappropriate behavior from a CNA, leading to anxiety and fear. One resident, with anxiety and depression, reported rough handling and an inappropriate comment. Another resident, with physical limitations, reported a threatening comment and unprofessional attitude. The CNA was suspended and later left the facility.
The facility was found to have multiple food safety and sanitation deficiencies, including improperly labeled and expired food items, unsanitary storage conditions, and inadequate dishwashing practices. Staff failed to follow established policies for food handling and storage, leading to potential health risks for residents.
The facility did not complete annual competency reviews for two CNAs as required by their policy. The DON and Executive Director acknowledged the oversight, noting that while reviews are scheduled annually, the previous year's reviews were missing.
The facility did not offer two residents the choice to formulate advanced directives, as required. One resident had a fracture of the right arm, and another was recovering from knee replacement surgery. The Admissions Coordinator stated that the offer would be made during the admission contract signing process, which had not yet been completed for these residents.
A resident with conversion disorder and seizures was discharged without a physician's order, contrary to the facility's policy. A progress note recorded the discharge date and time, but the DON confirmed the lack of a required physician's order.
A facility failed to develop a baseline care plan within 48 hours for a resident admitted with acute kidney failure and gastrointestinal hemorrhage. Despite the facility's policy requiring such a plan, it was not found in the resident's clinical record. This was confirmed by an MDS Coordinator during an interview.
The facility failed to develop and implement comprehensive care plans for two residents. One resident's care plan inaccurately documented their mobility needs, while another resident admitted with acute kidney failure and gastrointestinal hemorrhage had no care plan in their clinical record. These deficiencies were confirmed by staff observations and interviews.
A resident with conversion disorder and seizures was discharged without a complete discharge summary. The summary, dated in January, noted the resident's stability and follow-up instructions but lacked documentation of medication reconciliation. The DON confirmed the omission in April.
A resident with hypertension did not receive their prescribed medication, losartan potassium-HCTZ, due to an RN holding the medication for a low pulse, contrary to the physician's order to hold it for low blood pressure. This indicates a misinterpretation of the order, as the RN later mentioned the need to clarify the order with the physician.
The facility failed to document appropriate indications for medications for two residents. A resident with dementia and pain was prescribed Lorazepam for pain, which the DON confirmed was inappropriate. Another resident had orders for Torsemide and Apixaban without documented indications. The DON acknowledged the lack of documentation and planned to seek clarification.
The facility failed to disinfect a glucometer before or after its use on a resident. The Glucometer Disinfection policy requires cleaning after each use, but an RN was observed using the device without disinfecting it. The RN stated that cleaning is done by the night shift, but the log only documented the glucometer's range, not its cleaning.
Infection Control Failures in Respiratory Care, Catheter Care, Laundry Handling, and Water Management
Penalty
Summary
The facility failed to implement adequate infection prevention and control measures in several areas related to respiratory care, urinary catheter care, laundry handling, and water system management. For one resident requiring supplemental oxygen, the oxygen tubing and nasal cannula were observed not labeled with the date of administration and not stored in a bag when not in use, as required by facility policy. The equipment was left exposed, wrapped around a bed bar, and connected to a humidifier, also undated. Staff interviews confirmed that the equipment should have been dated and bagged to prevent contamination, but these procedures were not followed. Another resident with a BIPAP machine and a supra-pubic catheter did not have a physician order or care plan focus for BIPAP therapy, and the BIPAP mask and hose were found with visible moisture, stored in an open drawer and not bagged. During catheter care, staff wore gloves but did not use an isolation gown as required by the resident's care plan and physician orders for enhanced barrier precautions (EBP). The resident confirmed that staff did not consistently use gowns during catheter care, and staff interviews revealed a lack of awareness regarding the EBP requirement for catheter care. Additionally, laundry was observed being delivered to resident rooms uncovered, contrary to facility practice of returning clean clothes in individual bags. The housekeeping supervisor acknowledged the incident. Regarding water management, the maintenance supervisor reported the absence of a facility water flow map, lack of documentation for maintenance activities, and unawareness of the water management or legionella prevention plans, despite facility policies requiring such programs and documentation.
Failure to Provide Baseline Care Plans to Residents and Representatives
Penalty
Summary
The facility failed to provide baseline care plans to the resident and representative for 2 of 23 sampled residents reviewed for baseline care plans. An undated Baseline Care Plan policy stated the facility would develop and implement a baseline care plan within 48 hours of admission, verify within 48 hours that it had been developed, and provide a written summary to the resident and representative in a language they could understand. The supervising nurse or MDS nurse/designee was responsible for providing the written summary and obtaining a signature to verify it was provided. For Resident #76, an undated Baseline Care Preference form showed questions about preferences and assistance needs for activities of daily living and was signed by the resident, but it was not signed or dated by staff who conducted the interview. The resident’s admission MDS, dated 09/07/25, showed a BIMS of 15, indicating cognitive intactness, and diagnoses including dementia, restless leg syndrome, hypertension, and respiratory disorders. The DON stated on 10/02/25 that baseline care plans were completed by MDS and that they were working on that. For Resident #18, an admission assessment dated 09/16/25 showed a BIMS score of 15 and a diagnosis of depression. An undated Baseline Care Preferences form showed the resident’s preferences had been obtained, but the electronic clinical record did not show that the resident or representative had received a copy of the baseline care plan. The resident stated a family member had participated in the admission process and signed paperwork, and the family member stated they had not received a copy of the baseline care plan. The DON stated the care plan/MDS coordinator was responsible for ensuring residents and/or representatives received a copy of baseline care plans.
Missing care plan focuses for respiratory and oral care needs
Penalty
Summary
The facility failed to ensure comprehensive care plan focuses were developed for a resident's respiratory needs and another resident's oral care needs. The facility's policy stated that a comprehensive person-centered care plan must include measurable objectives and timeframes to meet each resident's medical, nursing, and psychosocial needs, and that noninvasive ventilation devices such as CPAP, BIPAP, AVAPS, or Trilogy require an order and verification of settings if brought into the facility. For Resident #3, the resident was observed lying in bed with a white BIPAP machine on the bedside dresser, with a mask and hose attached and visible moisture in the mask placed in an open dresser drawer. The resident stated they were admitted with the BIPAP machine and used it nightly to help them breathe. The admission assessment documented intact cognition with a BIMS score of 13, paraplegia, and stage 4 pressure ulcers, but it also indicated the resident did not use a BIPAP or CPAP. The care plan revised 09/22/25 did not include a focus for BIPAP or respiratory needs, and the physician orders did not document an order for BIPAP usage. Staff interviews showed the CNA would ask the nurse about BIPAP needs, and the MDS Coordinator stated they did not interview the resident about BIPAP use and relied on orders and notes. For Resident #5, the resident was observed without teeth and stated they had not seen a dentist and wanted dentures. The resident was cognitively intact with a BIMS score of 15, though the assessment listed dementia. The admission assessment documented no teeth, but the MDS admission assessment and significant change assessment both indicated the resident was not edentulous. The revised care plan did not include a dental or oral care concern. The resident later stated they had told someone they wanted dentures but did not remember who, and had not been asked if they wanted to see a dentist. CNA #2 stated the resident had no teeth or dentures and did not know whether the resident had seen a dentist. The MDS Coordinator stated they did not know why the assessment showed the resident was not edentulous and acknowledged there was nothing on the care plan for oral care.
Care plans not revised for antidepressant use and urinary catheter care
Penalty
Summary
The facility failed to ensure care plans were reviewed and revised for 2 of 23 sampled residents. For Resident #12, an annual assessment dated 08/17/25 showed a BIMS of 14, indicating cognitive intactness for daily decision making, and documented a diagnosis of depression. The assessment also showed an antidepressant was administered during the look-back period, and a physician order dated 09/23/25 directed sertraline HCL 50 mg daily for depression. However, the care plan last revised 08/17/24 focused on trazodone for insomnia, antiplatelet therapy, refusing medications, and pain, and did not include a focus or concern related to antidepressant or psychotropic medications. On 10/01/25, the MDS coordinator stated the care plan did not include antidepressants and that it was an oversight. For Resident #61, an admission assessment dated 09/19/25 showed a BIMS of 13, indicating cognitive intactness for daily decision making, and listed diagnoses including cancer, hypertension, BPH, hyponatremia, hyperlipidemia, malnutrition, depression, asthma, and a wedge compression fracture of L1. On 09/29/25, the resident was observed with a leg bag in place and catheter tubing draped along the leg, and the resident stated they had a catheter. The care plan revised 09/26/25 did not include a focus for a urinary catheter, and review of physician orders showed no orders for catheter care. The MDS coordinator stated the catheter was not on the care plan due to an oversight and said changes were identified through the clinical meeting, physician orders, and a 24-hour report in the system.
Respiratory Treatments Not Monitored and Equipment Not Properly Labeled or Stored
Penalty
Summary
Safe and appropriate respiratory care was not provided when a resident receiving a nebulizer treatment was observed with the mask on and the machine no longer producing steam, while no staff were present in the room. The mask was later removed, the machine was turned off, and the mask was placed in a baggie next to the bed. The resident’s order required nebulizer treatment as needed and assessment before, during, and after treatment, including education to participate in medication delivery. The resident was cognitively intact, had diagnoses including heart failure, coronary artery disease, Parkinson’s disease, and asthma, and stated the nurse did not listen to their lungs before or after the treatment and left the room after placing the mask on them. The facility also failed to ensure oxygen equipment and BIPAP equipment were labeled and stored appropriately when not in use. One resident’s oxygen tubing and nasal cannula were observed wrapped around the bed repositioning bar and connected to a humidifier at the wall, with no date on the tubing, cannula, or humidifier and no bag used for storage. The resident had moderate cognitive impairment, acute respiratory failure, and cerebrovascular disease, and stated they used oxygen as needed. A CNA and RN both confirmed the tubing, cannula, and humidifier were not labeled with the date they were administered and were not bagged when not in use. A second resident’s BIPAP machine was observed on the bedside dresser with the mask and hose attached, and visible moisture in the mask, with the mask lying in an open dresser drawer rather than in a bag. The resident stated they were admitted with the BIPAP machine and used it nightly to help them breathe, but the record contained no physician order or care plan focus for BIPAP use. The CNA and IP both observed the BIPAP equipment stored in the open drawer and stated the mask should be bagged when not in use to prevent germs and spread of infection.
Missed Dialysis Monitoring Assessments
Penalty
Summary
The facility failed to complete pre- and post-dialysis assessments for a resident who required outpatient hemodialysis. Resident #7 had end stage renal disease, DMII, and an arteriovenous fistula, and the quarterly assessment documented a BIMS of 15, indicating the resident was cognitively intact for daily decision making. The care plan addressed renal failure related to chronic kidney disease stage five and included monitoring for dehydration, fluid overload, infection at the dialysis site, and lab reports of electrolytes, as well as checking the fistula/graft for bruits and thrills and avoiding blood pressures or blood draws in the fistula arm. Review of the dialysis monitoring forms showed multiple missed and partially incomplete dialysis monitoring opportunities in August and September 2025. The facility had discontinued the electronic dialysis monitoring assessments and began using paper forms, and the physician’s order required the dialysis patient monitoring form to be completed one time a day every Monday, Wednesday, and Friday. LPN #1 stated the resident took the pre-dialysis sheet to the dialysis center, where it was completed during treatment and returned for the facility nurse to finish the post-dialysis assessment. The DON stated the forms were scanned into the record and that if a form was not returned, the dialysis center was contacted and the physician notified, but the progress notes showed no documentation of physician notification regarding missing dialysis assessment forms. When given a list of missing assessments, the DON stated they were not documented on those dates.
Kitchen Sanitation and Dish Machine Temperature Deficiencies
Penalty
Summary
The facility failed to maintain a clean ice machine, wash and sanitize hands before handling clean dishes, and meet the minimum hot water temperatures required for sanitizing dishes in the dish machine. During observation of the main kitchen ice machine, the plastic cover was removed and black substance was seen along the edges of the molded cover, on the plastic framing the evaporator, around the water reservoir tray, and around the pump and other components above the reservoir. The Director of Nursing identified that 72 residents ate meals prepared in the kitchen. During dish room observations, the dietary manager and cook #1 loaded dirty dishes into the dish machine, removed clean dishes from the clean side, and stored clean dishes to air dry without sanitizing their hands between handling dirty and clean items. The dish machine initially showed wash and rinse temperatures of 88 degrees Fahrenheit and 84 degrees Fahrenheit, and later temperatures reached 120 degrees Fahrenheit for wash and 116 degrees Fahrenheit for rinse. The machine’s front screen indicated minimum temperatures of 150 degrees Fahrenheit for wash and 180 degrees Fahrenheit for rinse for hot water sanitization, while a sealed chemical sanitizer bottle under the clean side was not connected to the machine. The dietary manager gave mixed statements about whether the machine used hot water or chemical sanitization and stated they did not know why the sanitizer was not connected or how to connect it.
Failure to Provide Bariatric Bed Accommodation
Penalty
Summary
The facility failed to reasonably accommodate Resident #3’s need for a bariatric bed. Resident #3 was observed on an air mattress and was described as tall, big built/obese, with shoulders near each side of the bed. The resident was paraplegic and required assistance to turn hips, but did not have room to turn. The admission assessment dated 09/19/25 showed diagnoses including peripheral vascular disease, diabetes mellitus, paraplegia, depression, and pressure ulcers, with a BIMS of 13 indicating cognitive intactness for daily decision making. The assessment also showed a weight of 295 pounds and a height of 75 inches on admission. The care plan revised 09/22/25 showed no concern for a bariatric sized bed, and physician orders for October 2025 showed no order for a bariatric bed. A progress note dated 10/02/25 documented nursing discussion with the resident about the mattress for pressure relief; the resident voiced concern that the air loss mattress felt like it would force them to fall off the bed, and therapy had them sitting up on the side of the bed. The resident agreed to try a Roho mattress and the mattress was changed, but the note did not mention the need for a bariatric bed. The resident stated the facility was to get them a larger bed on admission, but they had not heard anything more about it. The administrator stated the admissions coordinator usually had equipment delivered before admission, that the bed frame was adjustable and large enough, that the resident needed a larger mattress and the facility did not have the right size available, and that staff could have notified/requested a larger bed; the administrator also stated they were not aware the resident needed a larger mattress until the day before the interview.
PRN Lorazepam Order Exceeded 14-Day Limit
Penalty
Summary
The facility failed to limit a physician’s PRN anti-anxiety medication order to 14 days for Resident #4. Record review showed the resident received PRN lorazepam 11 times in July 2025, no PRN doses in August 2025, and one PRN dose in September 2025. The order summary dated 09/30/25 showed active orders for lorazepam 0.5 mg orally every 6 hours PRN for restlessness or agitation, written on 07/13/25, and lorazepam 0.5 mg liquid sublingually every 2 hours PRN for restlessness or agitation, written on 07/15/25. Resident #4’s diagnoses included chronic pulmonary embolism, pneumonia, heart failure, atrial fibrillation, and shortness of breath. On 10/02/25, the DON stated the facility policy limited PRN anxiety medication to 14 days and that floor nurses were expected to write all PRN anxiety medications with a 14-day stop date. The DON stated the orders were reviewed in morning meetings and that the resident’s PRN anxiety medication order was missed because it did not have the 14-day limit. By the end of survey, the facility had not provided documented rationale for extending the PRN lorazepam order past 14 days.
Missing Physician Discharge Order for Planned Resident Discharge
Penalty
Summary
The facility failed to ensure a physician discharge order was obtained for one sampled resident who was planned for discharge. Resident #78 was admitted for a short-term stay, had a BIMS score of 15 indicating cognitive intactness for daily decision making, and had a diagnosis of dementia. The resident’s care plan identified a need for assistance with discharge planning, and the admission assessment showed the resident’s goal was to discharge to the community with active discharge planning already occurring. The record showed the resident was planned to discharge to an assisted living facility, and a care plan meeting was held with the resident, the resident’s POA, and the interdisciplinary team. The resident was discharged and transported by family, and the discharge summary and return-not-anticipated assessment documented a planned discharge to the community. However, the order summary report did not show a discharge order, and the DON stated the electronic clinical record did not show that a physician order had been obtained for the discharge. The social services director stated the clinical team was responsible for obtaining the physician order, and the administrator stated the facility had failed to ensure the physician order had been documented.
Failure to Provide Bed Hold Policy and Discharge Notice
Penalty
Summary
The facility failed to provide a bed hold policy and discharge notice to the resident representative for 2 of 2 sampled residents reviewed for bed hold policies. The facility’s undated bed hold notice policy stated that written information regarding bed hold practices should be provided to the resident and/or resident representative well in advance of, and at the time of, a transfer for hospitalization or therapeutic leave, and within 24 hours in the event of an emergency transfer. The DON identified that 162 residents had been discharged from the facility in the last six months. Resident #76 had an admission MDS assessment showing a BIMS score of 15, indicating cognitive intactness for daily decision making, and diagnoses including dementia, restless leg syndrome, hypertension, and respiratory disorders. The resident was sent to the hospital per representative request due to sleeping a lot and being very lethargic, and the discharge assessment showed the resident was anticipated to return. The DON and administrator stated there was no bed hold policy or discharge notice in the record for Resident #76, and the administrator stated the bed hold policy was not issued. Resident #9 also had a BIMS score of 15 and diagnoses including acute diastolic heart failure and acute kidney failure. The resident was sent to the hospital per physician request due to vomiting blood and did not return to the facility, and the discharge assessment showed the resident was anticipated to return. The DON stated there was no documentation that Resident #9 or the family representative received a bed hold policy when the resident was sent to the hospital, and stated the facility was non-compliant with the bed hold regulations.
MDS Assessments Not Accurately Coded for Respiratory Device Use and Dentition
Penalty
Summary
The facility failed to ensure MDS assessments were accurately coded to reflect resident status for 2 of 23 sampled residents. For one resident, the admission assessment dated 09/19/25 indicated the resident did not use BIPAP or CPAP, even though the resident was observed with a white BIPAP machine at the bedside, with a mask and hose attached and visible moisture in the mask stored in the bedside drawer. The resident stated they had been admitted with the BIPAP machine and used it nightly to help them breathe. Review of the medical record found no physician order or care plan focus for BIPAP use, and the MDS coordinator stated they selected “No” because they did not see an order and did not interview the resident about BIPAP use. For another resident, the assessment coding was inconsistent regarding dentition. The resident was observed to have no teeth, and prior admission assessments had documented the resident as having no teeth, but a later admission assessment and a significant change assessment both indicated the resident was not edentulous. The resident stated they had not seen a dentist, did not have teeth, and wanted dentures. Staff interviews confirmed the resident did not have teeth, while the MDS coordinator stated they did not know why the assessment showed the resident was not edentulous and acknowledged it might affect the care plan. The care plan contained no concern for dental care.
Missed Showers for Dependent Resident
Penalty
Summary
The facility failed to ensure showers were provided for a dependent resident who required staff assistance with showering/bathing. Resident #15 had a BIMS score of 15, was cognitively intact for daily decision making, had a diagnosis of depression, and was documented on the admission assessment and care plan as dependent on staff for showering/bathing. The facility policy stated residents would be provided showers as requested or according to the facility schedule and resident safety. Review of the electronic clinical record and shower sheets from 09/09/25 through 09/30/25 showed the resident received a shower or bath 6 out of 8 opportunities, but did not receive one on 09/16/25 or 09/20/25. The resident stated they had asked for a shower in the past but staff never assisted them, and said they had received a shower on 09/30/25. CNA #4 stated showers were documented in the electronic clinical record and on shower sheets, and RN #1 stated completed shower sheets were reviewed and placed in a box to be filed. The DON stated the electronic clinical record sent alerts that were reviewed daily if residents had not received a shower or bath in 72 hours, and did not know why the resident missed the scheduled shower/bath dates.
Failure to Complete Safe Smoking Assessment
Penalty
Summary
The facility failed to ensure a safe smoking assessment was completed for Resident #10, a resident with moderately impaired cognition and a BIMS score of 9 who was identified in the admission assessment as a tobacco user. The resident’s care plan, revised 09/09/25, documented behaviors of smoking outside and refusing lactulose, and included interventions stating the resident had been educated on the non-smoking policy and the health risks involved with smoking. However, the resident’s medical record did not document that a safe smoking assessment had been completed. On 10/02/25, Resident #10 was observed ambulating with a walker, entering the east exit door code, going outside, and sitting less than 15 feet from the door with a lighter and cigarette in possession. The resident lit a cigarette and smoked unsupervised near the facility entrance. During interview, the resident stated they went outside to smoke whenever they wanted and said the facility had never spoken to them about it. Staff interviews confirmed the facility was a non-smoking facility and that staff had seen the resident smoke outside; RN #2 stated the resident could open the door and go outside to the parking area to smoke. The IP also observed the resident smoking with a lighter and cigarettes in possession and stated the resident was smoking within 10 feet of the facility entrance and exit.
Unsecured Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter was secured for Resident #1, one of four sampled residents with urinary catheters. Resident #1 had an indwelling urinary catheter for urinary retention, and a quarterly assessment dated 07/23/25 showed a BIMS score of four, indicating severe cognitive impairment for daily decision making. On 10/01/25 at 10:23 a.m., CNA #1 and CNA #3 were observed providing catheter care, but the catheter was not observed to be secured before or after the care was provided. On 10/02/25, CNA #3 stated they typically used a device to secure indwelling urinary catheters but did not know why Resident #1's catheter was not secured, and stated they did not know why it had not been secured after catheter care. Resident #1 stated that if they or staff were not careful, the catheter would pull against them at the insertion site. LPN #3 stated indwelling urinary catheters were to be secured but had not yet assessed or secured Resident #1's catheter, and the DON stated the catheter was supposed to be secured but did not know why it was not secured.
Missing Clinical Rationale for Declined GDRs
Penalty
Summary
The facility failed to ensure that a clinical rationale was documented when gradual dose reductions were declined for two residents reviewed for unnecessary medications. For one resident, the record showed fluoxetine 40 mg daily was ordered for depression, and a Pharmaceutical Consultant Report recommended a gradual dose reduction, but the physician only checked a box indicating the minimal effective dose and left the clinical rationale section blank. The resident’s annual assessment showed a BIMS score of 14, indicating cognitive intactness for daily decision making, and the care plan directed monitoring for effectiveness and continued need while maintaining the lowest possible effective dose. For another resident, the record included a pharmacist letter requesting gradual dose reduction for Abilify 5 mg at bedtime and hydroxyzine 50 mg every 8 hours as needed, along with monitoring for venlafaxine 75 mg twice daily, but the document was not signed by the physician. The resident’s physician order showed venlafaxine 37.5 mg twice daily via PEG, and the significant change assessment showed a BIMS score of 11 with diagnoses including dementia, diabetes, depression, and psychotic disorder with delusions. Review of medication regimen reviews and gradual dose reductions from August 2024 through August 2025 showed no GDRs were requested by the pharmacist for this resident, and the DON stated the pharmacist completed the medication review monthly.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure monitoring for anticoagulants for Resident #11, who was ordered Xarelto 10 mg daily for quadriplegia. The resident’s annual assessment showed a BIMS score of 14, indicating cognitive intactness for daily decision making, along with a diagnosis of multiple sclerosis and receipt of an anticoagulant during the look-back period. The care plan directed staff to monitor, document, and report signs or symptoms of anticoagulant complications, but on review of the electronic clinical record, an LPN stated the resident received Xarelto daily and could not identify the side effects monitored for residents receiving anticoagulants. The DON stated the resident had not been monitored for side effects related to anticoagulant medication and that this monitoring should have populated onto the treatment record.
Unsecured Treatment Cart
Penalty
Summary
The facility failed to ensure treatment carts were secured when unattended. During observation on 10/01/25 at 1:55 p.m., the 400-hall treatment cart was found unlocked and unattended by room [ROOM NUMBER]. The cart contained insulin, heparin, medicated ointments, and wound cleanser/wound care supplies. At 1:57 p.m., RN #1 was observed locking the cart. An undated facility policy titled Medication Storage stated that during a medication pass, medications must be under the direct observation of the person administering them or locked in the medication storage area/cart. RN #1 stated the treatment cart was to be locked when unattended, and the DON stated treatment carts were to be kept locked when unattended to ensure medications were secured.
Failure to Complete Ordered Radiology Services
Penalty
Summary
The facility failed to ensure radiology services were provided for one resident who had physician-ordered x-rays of the left humerus and elbow. The resident’s care plan identified pain related to osteoarthritis and chronic pain, and a physician visit note documented left upper arm pain with an order to obtain x-rays and then escalate to MRI evaluation. A later physician visit note repeated the same assessment and treatment plan, and a quarterly assessment showed the resident had a BIMS score of five, indicating severe cognitive impairment, along with diagnoses of osteoporosis and osteoarthritis and use of scheduled and as-needed pain medications. During interviews, the ADON stated physician visit notes were faxed to the facility and uploaded into the electronic record, and that any written orders were typically left with charge nurses for entry and review. The ADON later acknowledged missing the physician visit notes that contained the x-ray order and stated the notes had not been reviewed after being provided to the facility. The DON stated the physician visit notes were sent to the facility and confirmed the x-ray indicated in the notes had not been completed. The resident stated they had chronic bilateral shoulder pain managed with their current medication regimen and reported they had not had any radiologic or diagnostic testing while at the facility.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical abuse, as evidenced by incidents involving two residents. One resident, diagnosed with anxiety disorder and depression, reported that a CNA was rough during care and made an inappropriate comment, suggesting the resident should be in a bubble. The CNA admitted to making the statement, and the incident caused anxiety for both the resident and the CNA, who was new to the unit. Another resident, with diagnoses including epileptic seizures and muscle wasting, reported that the same CNA had an unprofessional attitude and made a threatening comment about getting the resident kicked out. The resident was unable to comply with the CNA's care method due to physical limitations from a stroke. Other residents also reported feeling uncomfortable with the CNA's demeanor, leading to fear of using the call light for assistance. The CNA was placed on suspension pending investigation and eventually left the facility.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety and handling protocols, as observed during a survey. Several deficiencies were noted, including improperly labeled and expired food items in the refrigerator, such as a jar of grape jelly opened and dated months prior, and various dairy products with expired use-by dates. Additionally, thawed chicken pieces and other food items lacked proper labeling and use-by dates. The facility's walk-in cooler and large refrigerator contained items that were either expired or not properly dated, indicating a lack of compliance with the facility's 'Date Marking for Food Safety' policy. Further observations revealed unsanitary conditions in the kitchen, such as the use of dirty and greasy bins for storing bulk foods and the absence of beard restraints for staff with facial hair. The dishwashing process was also found to be inadequate, with clean dishware exposed to splash from soiled dishes and a lack of routine testing for proper chemical sanitization in the dishwasher rinse cycles. The facility's 'Dishwashing Machine Use' policy was not followed, as there were no documented sanitizer levels for the dishwasher, and staff were unaware of how to check these levels. These findings were acknowledged by the Certified Dietary Manager, who confirmed that proper procedures for food handling and storage had not been followed.
Failure to Conduct Annual CNA Competency Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for two certified nurse aides (CNAs) as required by their Competency Evaluation policy. The policy mandates that subsequent and/or annual competency evaluations be conducted based on the facility assessment, training program evaluation, and job performance evaluations. However, upon review, it was found that there were no annual competency reviews in the personnel files of two CNAs, one hired in November 2021 and the other in July 2022. The Director of Nursing (DON) and Executive Director confirmed that while competency reviews are supposed to be completed upon hire and annually, the reviews from the previous year could not be located, and skills checks were scheduled for May.
Failure to Offer Advanced Directives
Penalty
Summary
The facility failed to ensure that residents were offered the choice to formulate advanced directives, as required. This deficiency was identified during a review of the clinical records and interviews with facility staff. Specifically, two residents, one with a diagnosis of a displaced comminuted fracture of the right arm and another following joint replacement surgery of the left knee, were not documented as having been offered the choice to formulate an advanced directive. The Admissions Coordinator confirmed that these residents had not been offered this choice because they had not yet completed the admission contract signing process.
Failure to Obtain Discharge Order
Penalty
Summary
The facility failed to obtain a discharge order for a resident diagnosed with conversion disorder with seizures. The facility's policy, revised in 2023, requires obtaining a physician's order for transfer or discharge. However, a progress note dated January 25, 2024, indicated the date and time of discharge without a corresponding physician's order. During an interview on April 23, 2024, the Director of Nursing confirmed the absence of a physician's order for the discharge of the resident.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure a baseline care plan was completed within 48 hours for a resident admitted with acute kidney failure and gastrointestinal hemorrhage. The facility's policy, dated 2023, mandates that a baseline care plan be developed within 48 hours of a resident's admission. However, upon review, there was no baseline care plan found in the clinical record of the resident in question. This deficiency was confirmed during an interview with MDS Coordinator #2, who acknowledged that the baseline care plan had not been developed.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in meeting their care needs. Resident #9's care plan, initiated in February 2024, inaccurately documented the resident's ability to walk with assistance, despite an admission assessment indicating the need for substantial assistance with bed mobility and no attempts to transfer or walk due to medical or safety concerns. This discrepancy was confirmed by a nurse and the MDS Coordinator, and a physical therapist was observed assisting the resident with a stand pivot transfer using a gait belt. Additionally, Resident #28, admitted with acute kidney failure and gastrointestinal hemorrhage, did not have a comprehensive care plan in their clinical record, as confirmed by the MDS Coordinator.
Incomplete Discharge Summary for a Resident
Penalty
Summary
The facility failed to ensure a complete discharge summary for a resident diagnosed with conversion disorder with seizures. The discharge summary, dated January 25, 2024, indicated that the resident received skilled nursing and therapy services and was stable at the time of discharge. It also noted that the resident and their representative were instructed to follow up with the primary care provider after discharge. However, the Clinical Discharge Instruction Form, which should have included a section for medications sent home, was found to be incomplete. On April 23, 2024, the Director of Nursing confirmed that medication reconciliation was not documented.
Medication Administration Error Due to Misinterpretation of Physician's Order
Penalty
Summary
The facility failed to administer medications as ordered for a resident diagnosed with hypertension. The resident had a physician's order for losartan potassium-HCTZ to be given daily, with instructions to hold the medication if the systolic blood pressure was less than 105 or the diastolic was less than 65, and to notify the physician. On the specified date, an RN documented holding the medication due to a low pulse, which was not in accordance with the physician's order. The RN later stated the order was to hold the medication if the blood pressure was low and to notify the physician, indicating a misunderstanding or miscommunication regarding the order.
Failure to Document Appropriate Indications for Medications
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary medications, as evidenced by the lack of proper indications for the use of certain medications for two residents. Resident #4, who had diagnoses including dementia and pain, was prescribed Lorazepam, an antianxiety medication, for pain management. However, the Director of Nursing (DON) confirmed that pain was not an appropriate indication for Lorazepam use. Additionally, Resident #262 had physician orders for Torsemide, a diuretic, and Apixaban, an anticoagulant, but neither medication had an appropriate indication for use documented. The DON acknowledged this oversight and indicated they would seek clarification from the physician.
Failure to Disinfect Glucometer
Penalty
Summary
The facility failed to disinfect a glucometer before or after its use on a resident, as observed during a survey. The facility's Glucometer Disinfection policy, dated 2023, mandates that blood glucometers be cleaned and disinfected after each use and according to the manufacturer's instructions for multi-resident use. On April 23, 2024, at 11:30 a.m., RN #2 was observed performing glucose monitoring with a glucometer without disinfecting it before or after use. RN #2 stated that the glucometer is cleaned by the night shift, but the provided Glucometer Control Log only documented that the glucometer was in range, with no record of any cleanings.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 200 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oklahoma City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edmond Health Care Center | 1 mi | ★★★★★ | 10 | 0 |
| The Timbers Skilled Nursing And Therapy | 1.6 mi | ★★★★★ | 6 | 2 |
| Epworth Villa Health Services | 3.4 mi | ★★★★★ | 0 | 0 |
| The Wilshire Skilled Nursing And Therapy | 4.1 mi | ★★★★★ | 0 | 0 |
| Tuscany Village Nursing Center | 4.5 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.