Ignite Medical Resort Adams Parc

Based on records review and interview, the facility failed to:a. report an incident of elopement to the OSDH within 24 hours for 1 (#21) of 4 sampled residents reviewed for accidents; andb. report an allegation of physical abuse to the OSDH and a local law enforcement agency within two hours of the allegation for 1 (#17) of 3 sampled residents reviewed for abuse. The general manager stated two allegations of abuse in the past 12 months and three residents that wandered in the facility.Findings:1. A policy titled Elopement Policy, dated 11/2018, read in part, Upon discovering an unaccountable absence of a resident by a staff member, the staff member will immediately contact a nurse. Record the time that the resident was discovered missing and when and where resident was last seen.The administrator will notify the State Agency to report an unusual occurrence and activation of the facility's Emergency Operations Plan.A behavior narrative note, dated 10/18/25 at 7:04 p.m., showed Res #21 had eloped from the facility and walked to their apartment located approximately 600 feet to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident did not elope from the facility for 1 (#21) of 4 sampled residents reviewed for accident hazards.The general manager stated three residents wandered in the facility.Findings:A Wander/Elopement Risk Evaluation for Res #21, dated 10/17/25, showed the resident had scored 5 on the evaluation. A score of five indicated the resident was not a risk for wandering or elopement. The evaluation showed a score of 6 would have indicated a resident would be at risk for wandering or elopement.A behavior narrative note, dated 10/18/25 at 7:04 p.m., showed Res #21 had eloped from the facility and walked to their apartment located approximately 600 feet to the west on an adjoining property. The note showed Res #21 knocked on the door of their apartment and their family told them to go back to the facility. The note showed facility staff located Res #21 next to their apartment and walked the resident back to the facility. The note showed Res #21 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure restorative therapy was provided to a resident with limited ROM for one (#18) of one sampled resident reviewed for therapy services. The ADON reported 42 residents resided at the facility. Findings: A Restorative Nursing policy dated 12/2019, read in part, the facility believes that each resident will be provided with the opportunity to regain skills and abilities lost due to illness and disability. Therefore, each resident will be evaluated at move in, return from another health care facility, and after a significant change in condition for the potential benefit of participating in a restorative nursing program. Resident #18 had diagnoses which included difficulty walking and muscle weakness. A care plan focus, dated 10/11/21, documented the resident had an ADL self-care performance deficit. An associated care plan intervention, dated 01/03/25, documented the resident was to be in a restorative program for maintenance. A physician order, dated 01/10/25, documented Resident #18 was to continue restorative services…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview the facility failed to ensure entrapment assessments were performed and consents for use of bed rails were obtained prior to the use of bed rails for two (#15 and #23) of two sampled residents reviewed for accidents. The General Manager reported 48 resident had bed rails attached to their beds. Findings: A Side Rails policy, review date of 05/23, read in part, .1. The resident will be assessed for the use of full side rails prior to being used/installed using the device evaluation in [product name withheld]. 2. The resident or responsible party will be informed of the risks and benefits with the use of full side rails and a consent will be obtained . 1. Resident #15 had diagnoses which included dementia and generalized muscle weakness. An annual assessment, dated 10/13/23, documented Resident #15's cognition was severly impaired and they were dependent of staff for activities of daily living. A review of Resident #15's medical records found no documentation of an entrapment assessment or consent for the use of bed rails. 2. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to monitor food cooking and holding temperatures to ensure safe temperatures were maintained in the kitchen and on the steam table during meal service. The General Manager reported 48 residents resided in the facility. Findings: A facility policy titled Food, Revised 04/23, read in part, .The temperatures of food items served to elders will be tested and recorded before the delivery of food to the units/neighborhoods, at the time serving begins, at least once during serving if serving lasts longer than thirty (30) minutes, and at the conclusion of serving . The lunch temperature log, dated 10/23, did not document any food temperatures had been recorded between 10/18/23 and 10/24/23. The dinner temperature log, dated 10/23, did not document any food temperatures had been recorded between 10/18/23 and 10/24/23. On 10/24/23 at 12:00 p.m., [NAME] #2 was asked why no temperatures were documented between 10/18/23 and 10/24/23 they stated temperatures were not done. They also stated the chef on duty for the meal was responsible for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a discharge summary was completed for one (#40) of one resident reviewed for discharge. The General Manager reported 48 residents resided in the facility. Findings: A facility policy titled discharges, revised 4/23, read in part, .Document in nursing notes time of transfer, where resident is going, condition of resident, method of transportation, disposition of all belongings and medications and that all parties are aware of the discharge . Resident #40 had diagnoses which included fracture of the third lumbar vertebra and hypertension. A 5-Day PPS assessment, dated 10/06/23, documented the resident was admitted on [DATE] and was discharged on 10/06/23. On 10/25/23 at 1:30 p.m., Resident #40's electronic health record was reviewed, a discharge summary was not located. On 10/25/23 at 1:40 p.m., the Director of Hospitality reported they did not work on 10/06/23 and they were unsure if a discharge summary was completed. On 10/26/23 at 9:20 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure medications were available for three (#42, #35 and #153) of nine sampled residents who were reviewed for medication availability. The DON identified 50 residents who received medications in the facility. Findings: 1. Resident #42 had diagnoses which included neuropathy, hyperlipidemia, mild pain, anxiety, hypertension, and depression. Physician's orders, dated April 2022, documented the resident was ordered the following medications: ~ Atorvastatin 20 mg by mouth at bedtime for hyperlipidemia, ~ Duloxetine 60 mg by mouth daily for depression, ~ Losartan 25 mg by mouth daily for hypertension, ~ Olanzapine 2.5 mg by mouth at bedtime for anxiety, ~ Tylenol 650 mg three times a day for mild pain, and ~ Gabapentin 300 mg by mouth four times a day for neuropathy. Review of the MAR, dated April 2022, documented the resident was not administered Atorvastatin from 04/02/22 through 04/05/22, Duloxetine on 04/02/22, Losartan on 04/04/22, Olanzapine on 04/02/22, Tylenol on 04/02/22 at 8:00 a.m. and 2:00 p.m., and Gabapentin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and record review, the facility failed to ensure medication error rate of less than 5% during medication administration for two (#153 and #35) of three sampled residents observed during medication pass. The facility had two errors out of 35 opportunities, resulting in a 5.71% medication error rate. The DON identified 50 residents received medications. Findings: 1. Resident #153 had a physician's order for aspirin 81 mg to be administered daily. 2. Resident #35 had a physician's order for Invokana 100 mg two tablets one time a day. On 04/06/22 at 7:27 a.m., LPN #1 was observed to prepare medication for resident #153. She stated that the aspirin was not in the facility. At 7:43 a.m., LPN #1 was observed to prepare medication for resident #35. She was observed to administer Invokana one tablet to the resident. The medication administration observation error rate was calculated to be 5.71%.