Average — CMS composite of the measures below.
The next survey window likely opens around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ignite Medical Resort Okc, Llc during CMS and state inspections, most recent first.
A resident’s baseline care plan was not completed within 48 hours of admission. Record review showed the care plan was started but not finished in the required timeframe, and the MDS coordinator stated it was the admitting nurse’s responsibility to complete it.
Incomplete Comprehensive Care Plan: A resident’s comprehensive care plan was not completed by all departments, and the EHR showed only one activity entry with no other documented care plan entries. The MDS coordinator stated the plan should have been completed by the required timeframe.
Medication administration was not consistent with physician orders for two residents. A CMA documented a MAR code indicating “other/see notes” for several ordered meds for one resident and for escitalopram for another resident, but there was no other documentation for the second resident’s medication. The CMA said the meds were unavailable from the pharmacy, and the DON stated meds should be reordered before they ran out and there should not have been a break in days for these important medications.
A CMA was observed administering medications to multiple residents without performing hand hygiene before, during, or throughout the medication pass. The facility policy required hand-washing or alcohol-based hand rub before and after medication administration, and the CMA stated they had not sanitized at all during the observed med pass.
Unclean Resident Room Floor: A resident’s room floor remained covered with a sticky substance, footprints, paper, tape, and cardboard across multiple observations, despite the resident and family reporting the room had not been cleaned since admission. Housekeeping staff stated rooms were cleaned daily and said the room had been mopped, but later acknowledged the floor was dirty; the DON/maintenance leadership stated resident rooms were expected to be swept or dust mopped and mopped every day.
Failure to monitor and address no bowel elimination: A resident with spinal cord disease, incomplete quadriplegia, cognitive communication deficit, and bowel incontinence had no BM for several days despite orders for bowel/bladder training, Colace BID, and PRN MiraLAX. The chart did not show a constipation care plan, and staff stated the physician should be notified after 2 to 3 days without a BM.
A resident with spinal cord disease, incomplete quadriplegia, and limited mobility was ordered to wear a Miami J cervical collar except during meals and showers. Staff observed the collar padding was soiled, and an LPN and the DON stated the facility only had padding for an Aspen collar and did not have the correct padding for the Miami J collar.
Failure to Address Resident Weight Loss: A resident with quadriplegia, muscle weakness, GERD, and a low BMI had a care plan for nutrition and hydration concerns, along with orders for a regular diet, Ensure with meals, meal assistance, and weekly weights. Despite eating most meals, the resident lost 5.4% of body weight, and the weight loss was flagged without any new intervention being implemented; the DM, DON, physician, and dietitian each described weight monitoring and QA responsibilities, but the weekly QA meeting was cancelled and the dietitian was not in the facility that week.
A resident with a documented acetaminophen allergy had a Tylenol order entered, which was later discontinued without evidence of administration. Additionally, a provider's order for a diuretic to treat leg edema was incorrectly transcribed as a muscle relaxant, and neither medication was documented as administered. Staff interviews revealed confusion about medication orders, allergy verification, and documentation, leading to failures in medication allergy adherence and accurate medication administration.
A resident who required substantial to maximum assistance with personal care did not receive scheduled baths or showers on three occasions, with no documentation to indicate care was provided or refused. Facility staff and the DON confirmed the absence of records for these missed bathing dates.
A resident with a history of diverticulitis experienced prolonged diarrhea, and a physician ordered a stool sample to be collected and sent to the lab. The specimen was never collected or processed, as confirmed by the absence of results in the clinical record and staff and family interviews. The failure occurred during a transition to a new laboratory service, which caused integration issues with the facility's electronic system and disrupted the lab order process.
Two residents identified as exit-seeking or confused did not have appropriate care plans implemented. One resident, with a history of intracerebral hemorrhage and hemiplegia, was noted to be exit-seeking but was not marked as an elopement risk until after an incident where they were found outside the facility. Another resident with dementia had a care plan to disguise exits, but the emergency exit door was not disguised, and facility leadership was unaware of the care plan's interventions.
A resident with a history of exit-seeking behavior eloped from the facility due to inadequate supervision and a malfunctioning emergency exit door that did not latch or alarm. The resident, who was confused and had a history of wandering, was found down the road from the facility after being missing for about 30 minutes. The facility's Elopement Policy was not effectively implemented, contributing to the incident.
A medication cart was found unsecured and unattended, contrary to the facility's policy requiring carts to be locked at all times. This was confirmed by an LPN, a CMA, and the DON. The facility had 69 residents at the time.
A non-diabetic resident was mistakenly given 25 units of Insulin Glargine and had a fingerstick blood sugar test performed, despite having no orders for such interventions. The error was discovered when the resident reported the incident, and an investigation confirmed the mistake. The facility's medication administration protocols were not followed, leading to this significant medication error.
Baseline Care Plan Not Completed Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure a baseline care plan was developed within 48 hours of admission for Resident #62. Record review showed Resident #62 was admitted on [DATE], and the electronic health record did not show that a baseline care plan had been completed. The facility’s Care Plan policy, revised 04/2025, stated that a baseline care plan is developed for each resident upon admission, but no later than 48 hours after admission, and includes the minimum health care information necessary to properly care for the resident. During interview on 09/10/25 at 3:03 p.m., the MDS coordinator stated the facility had 48 hours to complete a baseline care plan, that it was to be completed by the admitting nurse, and that Resident #62’s baseline care plan had been started but not completed within the required timeframe.
Incomplete Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan was completed for Resident #62. The resident’s Care Plan Report, dated 08/28/25, showed the resident was admitted on [DATE], and review of the electronic health record showed only 1 activity entry in the care plan with no other documented entries. The facility’s Care Plan policy, revised 04/2025, stated that the comprehensive care plan is developed within 7 days of CAA completion and is developed by interdisciplinary team members based on their assessments and interaction with the resident and/or the resident’s significant others. On 09/10/25 at 3:04 p.m., the MDS coordinator stated the comprehensive care plan had not been completed by all departments and should have been completed on 09/03/25.
Medication Administration Not Consistent With Physician Orders
Penalty
Summary
The facility failed to ensure medications were administered according to physicians’ orders for 2 residents reviewed for medication administration. The facility’s Medication Orders policy, dated 01/2023, stated that if a medication is ordered but not available, staff should check whether it was misplaced and then call the pharmacy to obtain it. Resident #32’s order summary showed diagnoses including atherosclerosis of coronary artery bypass graft without angina pectoris, major depressive disorder, and overactive bladder, with orders for clopidogrel bisulfate 75 mg, lamotrigine 25 mg, and oxybutynin 15 mg. On 09/11/25, a number 9 was documented on the MAR for each of these medications, indicating “other/see nurses note.” Resident #69’s order summary showed a diagnosis of major depressive disorder and an order for escitalopram oxalate 20 mg. On 09/11/25, a number 9 was documented on the MAR for this medication, and no other documentation was found in the resident’s health record for it. CMA #1 stated that number 9 meant see other/notes and that she marked the medications because they were waiting on the pharmacy and the medication was unavailable. She also stated the policy was to order medications before they ran out. The DON stated medications should be reordered when down to about three days’ worth, that if medications were in within 24 hours staff should be notified, and that there should not have been a break in days on those medications because they were important medications.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during medication administration observations for 4 of 6 sampled residents reviewed for medication administration, including Residents #32, #53, #69, and #81. On 09/11/25, CMA #1 was observed preparing and administering medications to each of these residents without washing or sanitizing hands before, during, or throughout the medication administration process. The facility’s Hand Hygiene policy, revised 04/2025, states that staff members will comply with current CDC hand hygiene guidelines and that hand-washing or alcohol-based hand rub is indicated before and after medication administration. During interview on 09/11/25, CMA #1 stated the policy for hand hygiene during medication administration was to either wash or sanitize hands before and after each resident, and stated they had not sanitized during the observed medication administration observation at all.
Unclean Resident Room Floor
Penalty
Summary
The facility failed to ensure a homelike environment for 1 of 5 sampled resident rooms reviewed for cleanliness. Resident #16’s room floor was observed on multiple occasions to have a clear-to-white sticky substance throughout the room, with footprints in several areas, along with small pieces of paper, white tape, and two large pieces of black cardboard on the floor by the bed. These conditions were observed at 9:50 a.m., again at 10:59 a.m., and still present at 5:22 p.m., showing the room remained unclean over the course of the day. Resident #16 stated the room was dirty and said a family member had told staff to clean it, but it still had not been done. The family member stated they had asked multiple staff members to have the room cleaned since the resident’s admission, but it remained dirty. Housekeeper #1 stated resident rooms were cleaned every day and said Resident #16’s room had been cleaned and mopped, but when shown the floor they acknowledged it was dirty. The maintenance director stated housekeepers were expected to sweep or dust mop first and then mop resident rooms every day.
Failure to Monitor and Address No Bowel Elimination
Penalty
Summary
The facility failed to assess, monitor, and intervene for no bowel elimination from 09/02/25 to 09/07/25 for Resident #48. The resident had disease of the spinal cord, quadriplegia C5-C7 incomplete, cognitive communication deficit, and needed assistance with personal care. The resident’s admission assessment showed a BIMS of 10, indicating moderate impairment for daily decision making, and the resident was incontinent of bowel. The resident’s care plan dated 08/16/25 did not include a care plan for constipation. Physician orders dated 08/22/25 directed bowel and bladder training every two hours, including offering the bedpan and urinal every two hours, and Colace 100 mg twice daily for constipation. A physician order dated 08/23/25 also included MiraLAX 17 GM every 24 hours as needed for constipation. The medical record showed no bowel movement from 09/02/25 through 09/07/25. On 09/11/25, RN #1 stated that if a resident had not had a bowel movement within two days, the physician would be notified and PRN constipation medication would be checked, and the DON stated that if a resident had not had a bowel movement within three days, the nurse would be expected to notify the physician.
Incorrect Cervical Collar Padding
Penalty
Summary
The facility failed to ensure a resident with limited mobility was provided the appropriate padding for a Miami J cervical collar. Resident #48 had diagnoses including disease of the spinal cord, quadriplegia C5-C7 incomplete, and falls, and the care plan identified an ADL self-care performance deficit and limitations in physical mobility. A physician order directed the resident to always wear the Miami J cervical collar except during meals and showers until follow-up in six weeks. The resident's admission assessment showed a BIMS of 10, indicating moderate impairment for daily decision making, and the resident was dependent with bathing and required assistance with eating. During observation, the resident was seen wearing the Miami J cervical collar while lying in bed and later sitting in a wheelchair eating breakfast with assistance from a private sitter. The collar was later observed lying on the bed, and its padding was soiled. Staff stated the facility only had padding for an Aspen cervical collar and did not have the correct padding for the resident's Miami J collar. The DON confirmed the facility did not have the correct padding for the collar and stated there had been miscommunication regarding its availability.
Failure to Address Resident Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for Resident #48, who had diagnoses including quadriplegia, muscle weakness, need for assistance with personal care, GERD, and a BMI of 19.9 or less. The resident had a care plan for potential alterations in nutrition and hydration, with interventions to evaluate weight changes and follow facility protocol for weight change. Physician orders directed a regular diet, Ensure one can with meals, assistance with every meal, and weekly weights for four weeks then monthly. Although the resident was observed eating breakfast with help from a private sitter and the electronic record showed meals eaten at 76% to 100%, the weight record showed a weight of 137.5 pounds on 09/04/25, reflecting a 5.4% loss from 145.4 pounds on 08/16/25. The record and interviews showed the weight loss was identified, but no new intervention had been implemented after the 09/04/25 weight loss was flagged in the computer. The DM stated the dietitian was responsible for monitoring resident weights, and the DON stated the dietitian was responsible for monitoring weights and notifying the physician. The physician stated the facility had weekly QA meetings and weight loss was one of the topics, but also stated there was no QA meeting last week. The dietitian stated they were not in the facility last week and the weekly QA meeting was cancelled, and they would have been aware of the resident's weight loss this week.
Failure to Ensure Medication Allergy Adherence and Accurate Medication Administration
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for a resident, specifically regarding medication allergy adherence, accurate transcription of medication orders, and administration of medications as ordered. A resident with a documented allergy to acetaminophen was admitted and subsequently had a physician order for Tylenol (acetaminophen) entered, despite the known allergy. The order was discontinued after two days, and there was no documentation that the medication was administered. Staff interviews confirmed awareness of the allergy but could not explain why the order was placed or provide details about the resident's reaction to acetaminophen. Additionally, there were discrepancies in the transcription and administration of other medications. A provider ordered metolazone, a diuretic, for the resident's bilateral leg edema, but the order was incorrectly entered as metaxalone, a muscle relaxant, in the system. The metaxalone order was later discontinued with a note indicating it was entered in error. Neither metaxalone nor metolazone was documented as administered to the resident, and staff were unable to determine if the medications were ever received or given. Interviews with staff, including CMAs, LPNs, and the DON, revealed confusion regarding the medication orders, the process for verifying allergies, and the handling of new medication orders. Staff described procedures for checking allergies and communicating with the pharmacy, but in this case, these procedures were not effectively followed, resulting in medication orders that did not align with the resident's documented allergies and needs, and a lack of documentation regarding medication administration.
Failure to Provide Scheduled Bathing for Dependent Resident
Penalty
Summary
The facility failed to provide scheduled bathing for one resident who required substantial to maximum assistance with personal care due to muscle weakness and unsteadiness. According to the facility's policy, residents are to be offered a bath or shower twice per week if no preference is stated. Documentation and interviews revealed that the resident was scheduled for showers on Tuesdays and Fridays, but there was no record of bathing provided on three scheduled dates during the resident's admission. Certified nurse aide staff confirmed that showers are scheduled based on room numbers and refusals are documented, but there was no documentation of refusals or completed baths for the missed dates. The DON was unable to locate any documentation to confirm that bathing was provided on those dates.
Failure to Obtain Physician-Ordered Lab Specimen Due to Lab Service Transition
Penalty
Summary
The facility failed to ensure that a physician-ordered laboratory test was obtained for one resident who had a diagnosis including diverticulitis of the intestine. A physician ordered a stool sample to be collected and sent to the lab, with instructions to leave the order active until the specimen was collected and to call the lab for pickup. Documentation in the resident's clinical record did not show any results for the ordered stool specimen, and interviews with staff and the resident's family confirmed that the specimen was likely never collected. The resident had experienced ongoing diarrhea for an extended period, and the family expressed concern that the necessary laboratory testing was not completed. Staff interviews revealed that there was a process in place for handling lab orders, including entering orders into the electronic system, collecting specimens, labeling them, and notifying the lab for pickup. However, during the time in question, the facility had changed laboratory service providers and experienced difficulties integrating the new lab into their electronic system. This disruption contributed to the failure to collect and process the ordered specimen as required by the physician's order.
Failure to Implement Comprehensive Care Plans for Exit-Seeking Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents identified as exit-seeking or confused. Resident #2, admitted with diagnoses including nontraumatic intracerebral hemorrhage and hemiplegia, was noted to be confused and exit-seeking but easily redirected. Despite these observations, the care plan did not indicate the resident was an elopement risk. On one occasion, the resident was found missing and later located by staff heading towards a nearby store. The care plan was only updated to reflect the elopement risk after this incident. Resident #3, admitted with dementia, had a care plan that included interventions for elopement risk, such as disguising exits and decorating doors. However, during an observation, the emergency exit door on the resident's hall was not disguised or decorated, contradicting the care plan. The administrator and CNO were unaware of why these interventions were included in the care plan and stated they would investigate further.
Resident Elopement Due to Inadequate Supervision and Door Malfunction
Penalty
Summary
The facility failed to adequately supervise and prevent a resident from eloping, which resulted in a resident with a history of exit-seeking behavior leaving the premises unsupervised. The resident, who was admitted with diagnoses including nontraumatic intracerebral hemorrhage and hemiplegia, was noted to be confused and confabulating, with a documented history of exit-seeking behavior. Despite being stationed at the nurses' station for monitoring, the resident managed to leave the facility through an emergency exit door that did not latch properly, and the alarm did not sound. The resident was found down the road from the facility approximately 30 minutes after being noticed missing. The facility's Elopement Policy required that residents identified with wandering or exit-seeking behavior be assessed and have appropriate interventions included in their care plan. However, the resident's exit-seeking behavior was known to staff, and the door's malfunction was not addressed in a timely manner, leading to the resident's elopement. The facility's failure to ensure the door was functioning properly and to provide adequate supervision contributed to the incident. The facility's administrator later acknowledged that the exit doors were checked monthly, but the door in question had not been checked since earlier in the month, and the facility was not equipped to handle residents with such behaviors as they were not a memory care facility.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that a medication cart was securely locked according to company policy and procedure. On November 26, 2024, at 4:03 p.m., medication cart #1 on hall 400 was observed to be unsecured and unattended. This was confirmed by LPN #1 and CMA #1, who both reported that the medication cart was supposed to be locked. The following day, on November 27, 2024, at 11:25 a.m., the Director of Nursing (DON) reiterated that according to company policy, medication carts were required to be locked at all times. The facility housed 69 residents at the time of the observation.
Medication Error Involving Non-Diabetic Resident
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who was not diabetic and had no orders for insulin administration. Despite this, the resident was mistakenly given 25 units of Insulin Glargine and had a fingerstick blood sugar test performed. The incident was reported by the resident, who was confused about the procedures performed on them, as they were not diabetic and had no orders for such interventions. The resident's medical history included acute kidney failure, seizure, sepsis, and acute cystitis, but did not include diabetes or any indication for insulin use. The error was discovered when the resident reported the incident to the charge nurse, who then initiated an investigation. The investigation confirmed that the resident had been given insulin and had a fingerstick blood sugar test, which were not part of their prescribed care plan. The facility's medication administration policy requires verification of the right medication, dose, route, patient, and time, as well as proper identification of the resident before administering medication. However, these protocols were not followed, leading to the administration of insulin to a non-diabetic resident.
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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.
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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) |
|---|---|---|---|---|
| Bellevue Health & Rehabilitation Center | 0.1 mi | ★★★★★ | 3 | 0 |
| Northwest Nursing Center | 1.1 mi | ★★★★★ | 20 | 0 |
| The Lodge At Brookline | 1.2 mi | ★★★★★ | 0 | 0 |
| North Winds Living Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Warr Acres Nursing Center | 2 mi | ★★★★★ | 0 | 0 |
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