Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Norman, Llc during CMS and state inspections, most recent first.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident was not protected from a significant medication error, as required, due to a failure in the medication administration process.
A resident with frequent pain and physician orders for as-needed Tylenol and oxycodone did not receive pain medication when expressing pain during care. Staff delayed administration, incorrectly believing it was too soon for the next dose, resulting in unmanaged pain until the next scheduled medication was given. The DON confirmed that pain management orders were not followed.
Staff failed to follow infection control protocols by placing soiled linens and pads directly on the floor during incontinent care for a resident and by transporting dirty linens without gloves or proper bagging. Multiple CNAs acknowledged not adhering to facility procedures for handling contaminated linens, and the DON confirmed the expected process was not followed.
A resident with rectal cancer and an indwelling catheter did not receive tube feeding as ordered, and the facility failed to document physician notification of the resident's refusal. Additionally, the facility did not remove the Foley catheter for a trial of void as ordered by the physician. The resident was unaware of the voiding trial order, and the catheter remained in place. The LPN and DON confirmed the lack of documentation and adherence to physician orders.
A facility failed to provide a resident with scheduled showers, despite the resident's need for moderate assistance with hygiene due to conditions like spinal stenosis and dementia. The resident did not receive a shower over a five-day period, and the DON confirmed the lack of documentation for a scheduled shower.
A resident, admitted with chronic kidney disease and other conditions, did not receive scheduled showers or baths as required. Despite being cognitively intact and needing substantial assistance, there was no documentation of showers from admission to discharge. The DON confirmed that without documentation, there was no proof of showers being provided.
A resident with a history of femur fracture and dysphasia sustained repeated injuries during transfers due to inadequate documentation and lack of preventive measures. Despite being dependent on assistance, the resident's injuries were not documented in the health records, and no incident reports were completed by the staff, including LPNs and CNAs, as required by the facility's policy.
The facility failed to label and date oxygen tubing for three residents requiring respiratory care. A resident with acute kidney failure and heart failure, another with heart disease and spondylosis, and a third with COPD and a respiratory infection were all observed using oxygen without proper labeling. Staff confirmed the tubing should be changed and dated weekly.
The facility failed to conduct an entrapment risk assessment and obtain a physician order for bed rails for two residents. One resident, with epilepsy and morbid obesity, used bed rails without a documented risk assessment. Another resident, with muscle weakness, also lacked a physician order and risk assessment for bed rail use. The facility's policy required these steps, which were not followed.
The facility failed to administer medications according to physician-ordered parameters for three residents. Medications for hypertension were given despite blood pressure readings being outside the specified limits. Both the CMA and DON acknowledged the oversight, indicating a lapse in following the facility's Pharmacy Services policy.
The facility failed to document appropriate diagnoses for the use of antipsychotic medications in three residents. One resident was prescribed olanzapine without a psychotic disorder diagnosis, another was given aripiprazole without a documented indication, and a third received quetiapine for insomnia without an insomnia diagnosis. The facility's policy requires documented diagnoses for psychotropic drug use, which was not adhered to in these cases.
The facility failed to label food items with the date opened and maintain a clean kitchen, as observed during a survey. Items like cheeses and sour cream lacked proper labeling, and the kitchen had unsanitary conditions, including spilled coffee and food debris. The CDM acknowledged these issues and the potential for cross-contamination.
A facility failed to accurately assess a resident's need for oxygen therapy. Despite having a physician's order for supplemental oxygen and documented use of oxygen, the resident's comprehensive assessment incorrectly indicated no need for oxygen therapy. Interviews with staff revealed discrepancies in the care plan and MDS assessment, with the MDS Coordinator admitting to an error in coding.
A facility failed to follow physician orders for weekly weight monitoring of a resident with chronic kidney disease and fluid overload. Despite orders to report significant weight changes, a weight was missed, and a 28.7-pound gain over 23 days was not documented or reported. Staff interviews revealed a lack of documentation and clarity regarding the resident's weight monitoring.
A facility failed to follow infection control practices by not covering a resident's nebulizer mask when not in use. A resident with a cognitive communication deficit had their nebulizer mask left uncovered on a paper towel in the window sill next to food and drinks. A CNA and an LPN confirmed that the mask should have been bagged according to facility policy, which was not followed in this instance.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or omissions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide Timely Pain Management as Ordered
Penalty
Summary
A deficiency occurred when a resident who was frequently in pain and had physician orders for as-needed pain medications did not receive pain management as ordered. During incontinent care, the resident expressed pain, was observed groaning, and reported discomfort to the CNAs. The resident's orders included Tylenol 325 mg two tablets by mouth every six hours as needed and oxycodone HCl 5 mg, with specific dosing based on pain level. The medication administration record showed the last dose of oxycodone was given at 5:06 a.m., and the next dose was not administered until 1:07 p.m., despite the resident expressing pain around noon. Tylenol was not administered during this period. CNA staff reported the resident's pain to the CMA, who stated it was too early to administer additional pain medication and that the resident had already received all available pain relief. However, upon review, the CMA acknowledged a miscalculation and that the resident should have received pain medication when they complained. The DON confirmed that the CMA did not follow the resident's pain management orders. The failure to provide timely pain medication as ordered resulted in the resident experiencing unmanaged pain during the observed period.
Improper Handling of Dirty Linens During Care and Transport
Penalty
Summary
The facility failed to ensure proper handling of dirty linens to prevent cross-contamination during incontinent care and general linen management. During an observation of incontinent care provided to a resident, two CNAs were seen placing soiled pads and a pillowcase directly on the floor instead of immediately bagging them as required by facility protocol. The soiled items remained on the floor next to other linens before being bagged and removed from the room. Both CNAs later acknowledged in interviews that they did not follow the facility's process for handling dirty linens during the care episode. In a separate observation, another CNA was seen picking up dirty linens and a pad from the floor near a resident's room without wearing gloves and holding the items close to their upper body while transporting them to the designated environment room. This CNA also confirmed in an interview that the linens were dirty and that the facility's process was to bag dirty linens before transport, which was not followed. The Director of Nursing confirmed that staff are expected to bag dirty linens during care and transportation.
Failure to Follow Physician Orders for Tube Feeding and Catheter Management
Penalty
Summary
The facility failed to follow physician orders for a resident who was admitted with rectal cancer and had an indwelling catheter and a feeding tube. The physician had ordered catheter care every shift and the administration of Jevity 1.5 Cal at 65 ml/hr via g-tube every night shift for feeding. However, the facility did not administer the tube feeding as ordered on 11/27/24, and the resident refused the feeding on subsequent days without proper documentation of physician notification. Additionally, the resident was observed with a full bag of tube feeding formula that was not labeled or dated, and the connection end had dried and crusted formula, indicating neglect in tube feeding management. Furthermore, the facility did not follow the physician's order for a trial of void by removing the Foley catheter. The resident was unaware of the order for the voiding trial, and the catheter remained in place without any attempt to remove it for the trial. The LPN confirmed that there was no documentation of physician notification regarding the refusal of tube feeding, and the DON acknowledged that the blank on the MAR/TAR indicated the tube feeding was not done. The failure to follow physician orders for both tube feeding and catheter management resulted in a deficiency in the care provided to the resident.
Failure to Provide Scheduled Showers to a Resident
Penalty
Summary
The facility failed to ensure that a dependent resident received the necessary assistance with activities of daily living, specifically showering. The resident, who was admitted with diagnoses including spinal stenosis, back pain, and dementia, was documented as cognitively intact and requiring moderate assistance with hygiene and bathing. Despite the facility's schedule indicating that the resident was to receive showers on Tuesdays, Thursdays, and Saturdays, records showed that the resident did not receive a shower from September 12 to September 17, 2024. The Director of Nursing (DON) confirmed the absence of documentation for a shower on September 14, 2024, acknowledging that the resident should have received their shower on that date.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide scheduled baths or showers for a resident who was unable to perform activities of daily living independently. The resident, who was cognitively intact and required substantial to maximal assistance with bathing, was admitted with diagnoses including chronic kidney disease, pleural effusion, and fluid overload. Despite being scheduled to receive showers every Tuesday and Friday, there was no documentation in the medical record indicating that the resident received any showers or baths from admission until discharge. A grievance form dated July 7, 2024, documented the resident's request for a shower over several days. The Director of Nursing (DON) confirmed that completed baths should have been documented in the electronic health record (EHR) or under tasks in the resident's medical record, and acknowledged that without such documentation, there was no proof that the resident received a shower during their stay.
Failure to Document and Prevent Repeated Resident Injuries During Transfers
Penalty
Summary
The facility failed to prevent an injury to a resident during transfers, as evidenced by multiple incidents involving Resident #29. The resident, who was admitted with a fracture of the right femur and dysphasia, was dependent on assistance for transfers. Despite this, the resident sustained a laceration on the left leg during transfers from the bed to a wheelchair on multiple occasions. The resident reported these injuries to staff, but there was no documentation of the incidents or any interventions to prevent further injuries in the electronic health records. The facility's staff, including LPNs and CNAs, were aware of the injuries but failed to document them or complete incident reports as required by the facility's policy. The Director of Nursing and the Corporate Administrator acknowledged the lack of documentation and investigation into the incidents. The facility's policy mandates a full investigation and documentation of any accidents, but this was not followed, leading to repeated injuries to the resident without any preventive measures being implemented.
Failure to Label and Date Oxygen Tubing
Penalty
Summary
The facility failed to ensure that oxygen tubing was labeled and dated according to professional standards of care for three residents who required respiratory care. Resident #4, admitted with acute kidney failure and systolic heart failure, was observed using oxygen via a nasal cannula without any date on the tubing or humidifier to indicate when it was last changed. Both a CNA and an RN confirmed the absence of labeling, with the RN acknowledging that the tubing should be changed and dated every seven days. Similarly, Resident #26, with diagnoses including atherosclerotic heart disease and spondylosis, was found using oxygen without the tubing or humidifier being labeled with a date. An RN confirmed the lack of labeling and stated the tubing should be changed weekly. Resident #93, who had chronic obstructive pulmonary disease and a lower respiratory infection, was also observed using oxygen without any date on the tubing or humidifier. The ADON confirmed the absence of labeling and reiterated that it is a nursing standard to change and label the tubing weekly.
Failure to Conduct Entrapment Risk Assessment and Obtain Physician Order for Bed Rails
Penalty
Summary
The facility failed to perform an entrapment risk assessment prior to installing bed or side rails for two residents and did not obtain a physician order for the medical rationale and use of bed rails for one of these residents. Resident #2, who had diagnoses including epilepsy, muscle wasting, and morbid obesity, had a physician order for quarter bed rails for turning and positioning. However, there was no documentation of an entrapment risk assessment in the medical record. The resident was observed using the bed rails for turning and positioning, and the facility administrator confirmed that the required assessment was not completed. Resident #86, admitted with diagnoses such as muscle weakness and peripheral vascular disease, also lacked documentation of a physician order and an entrapment risk assessment for the use of bed rails. The resident was observed using the rails to assist in turning, and the facility administrator acknowledged the absence of the necessary physician order and assessment. The facility's admission packet indicated that bed rails should only be implemented after a licensed nursing assessment and with a physician's written order, which was not adhered to in these cases.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that medications were administered according to physician-ordered parameters for three residents. Resident #12, who was admitted with dementia and hypertension, had orders for amlodipine and losartan to be held if the diastolic blood pressure was less than 70. However, the July and August 2024 Medication Administration Records (MAR) documented that these medications were administered on multiple occasions when the diastolic blood pressure was below the specified threshold. Resident #88, with diagnoses including dementia and chronic kidney disease, had an order for carvedilol to be held under similar blood pressure conditions, yet it was administered twice when the diastolic blood pressure was below 70. Resident #89, with chronic respiratory failure and hypertension, had an order for metoprolol to be held if the systolic blood pressure was less than 110 or diastolic less than 60, but it was administered twice under these conditions. The Certified Medication Aide (CMA) #1 and the Director of Nursing (DON) were informed of these discrepancies. CMA #1 acknowledged that the medications should have been held according to the physician's parameters. The DON also recognized that the medication staff should have been more attentive and not administered the medications when the blood pressure readings were outside the ordered parameters. This oversight in medication administration indicates a failure to adhere to the facility's Pharmacy Services policy, which emphasizes the importance of monitoring specific parameters related to medications to avoid unnecessary interruptions.
Inadequate Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had appropriate diagnoses or indications for their use. Specifically, three residents were identified as receiving antipsychotic medications without documented diagnoses to justify their use. Resident #12 was admitted with dementia, anxiety, and depression, and was prescribed olanzapine for a psychotic disorder, yet no diagnosis of a psychotic disorder was found in their medical record. Similarly, Resident #88, who was severely cognitively impaired and had moderate depression symptoms, was prescribed aripiprazole without a documented diagnosis in the physician order to support its use. Additionally, Resident #89, who had chronic respiratory failure, chronic kidney disease, and hypertension, was prescribed quetiapine for insomnia, but there was no documentation of an insomnia diagnosis in their medical record. The facility's Medication Monitoring policy requires that psychotropic drugs are only given when necessary to treat a specific condition as diagnosed and documented in the clinical record. The administrator acknowledged the lack of appropriate diagnoses for the use of antipsychotic medications for these residents.
Deficiencies in Food Labeling and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to its Food & Nutrition Services Sanitation & Food Safety policy by not labeling food items with the date they were opened in the kitchen refrigerators. During observations, several food items, including cubed pears, various cheeses, sour cream, and watermelon cups, were found without labels indicating when they were opened. Staff members acknowledged the lack of labeling and sealing of food items, which is against the facility's policy that requires all refrigerated potentially hazardous foods to be labeled with the date received and opened. Additionally, the facility did not maintain a clean and sanitary kitchen environment. Observations revealed spilled coffee on the ice and coffee machines, watermelon juice on various surfaces, and food debris on shelf liners and clean containers. Clean pans and coffee thermos servers were improperly stored, and some items in the freezer were not labeled or sealed. The Certified Dietary Manager (CDM) admitted to being unsure of the policy for maintaining a clean kitchen and acknowledged the potential for cross-contamination due to the unsanitary conditions. The CDM also noted that the cleaning schedule was not being properly followed.
Inaccurate Resident Assessment for Oxygen Therapy
Penalty
Summary
The facility failed to ensure accurate resident assessments for one of the sampled residents, specifically regarding the use of oxygen therapy. Resident #4, who was admitted with diagnoses including systolic heart failure and depression, had a physician's order for supplemental oxygen as needed. However, the comprehensive assessment dated 08/11/24 incorrectly documented that the resident did not require oxygen therapy, despite evidence from an O2 Sats Summary document indicating that the resident received oxygen on that date. Interviews with facility staff revealed discrepancies in the documentation of Resident #4's care plan and MDS assessment. LPN #1 confirmed that the resident was on oxygen and had an order for supplemental oxygen as needed, while the DON acknowledged that the resident's care plan did not reflect their oxygen care needs, even though the resident wore oxygen at night. The MDS Coordinator admitted to incorrectly coding the MDS assessment by selecting 'no' for oxygen therapy, despite the resident's use of oxygen on 08/11/24, resulting in an inaccurate assessment.
Failure to Follow Physician Orders for Resident Weight Monitoring
Penalty
Summary
The facility failed to follow physician orders for obtaining weekly weights for a resident with chronic kidney disease, pleural effusion, and fluid overload. The physician had ordered weekly weights every Thursday, with specific instructions to report any weight differences of greater than 3 pounds in two days or 5 pounds in one week. Despite these orders, the resident's medical record showed weights were not consistently documented, with a missing weight entry on June 20, 2024. Additionally, there was no documentation that the significant weight gain of 28.7 pounds over 23 days was reported to the physician, nor were any interventions implemented to address this weight gain. Interviews with facility staff revealed a lack of clarity and documentation regarding the resident's weight monitoring. An LPN stated uncertainty about why the weight was not obtained on the specified date and believed they had notified the physician about the weight gain but failed to document it. The DON confirmed the absence of documentation for the weight on June 20, 2024, and acknowledged the resident was supposed to be weighed weekly. The physician did not recall being notified of the significant weight gain, although they noted the resident was in good spirits upon discharge and had voiced no concerns.
Infection Control Deficiency: Uncovered Nebulizer Mask
Penalty
Summary
The facility failed to adhere to infection prevention and control practices by not covering a resident's nebulizer mask when not in use. Resident #35, who was admitted with a fracture of the right lower leg and cognitive communication deficit, had a physician's order for Ipratropium Bromide Inhalation Solution to be used as needed for shortness of breath. On observation, the resident's nebulizer mask was found uncovered and placed on a paper towel in the window sill next to food and drinks. A CNA confirmed that the mask was not bagged as required, and an LPN stated that the facility's policy mandates that nebulizer masks should be bagged and changed weekly. However, the mask was observed to be improperly stored, indicating a lapse in following the facility's infection control policy.
What surveyors are citing around you — mapped
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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 193 citations issued within 25 miles in the last 12 months — including the 7 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 Norman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medical Park West Rehabilitation & Skilled Care | 0.8 mi | ★★★★★ | 1 | 0 |
| Grace Skilled And Nursing Therapy Norman | 1.3 mi | ★★★★★ | 3 | 0 |
| 24th Place | 1.6 mi | ★★★★★ | 13 | 1 |
| Holiday Heights Healthcare | 2.7 mi | ★★★★★ | 0 | 0 |
| Noble Health Care Center | 7.7 mi | ★★★★★ | 2 | 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.