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Ignite Medical Resort Norman, LLC

1050 Rambling Oaks Drive, Norman, OK 73072 · For profit - Limited Liability company · 52 certified beds · (405) 292-2273 Medicare only — no Medicaid

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)2 immediate-jeopardy citations$16,660 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,660 in federal fines (most recent 2025-07-14)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (68%) runs well above the national median (45%)
  • about 20% of its spending goes to commonly-owned related companies
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
1215 Crossroads Blvd · (405) 310-2715 · Call to confirm hours
Pharmacy
1278 N Interstate Dr · (918) 609-5763 · Call to confirm hours
Grocery
1305 36th Ave NW · (405) 329-4613 · Call to confirm hours
Park
1700 Schooner Dr · Typically dawn to dusk
Place of worship
900 24th Ave NW Ste 1 · (405) 701-0100

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Short-stay residents who newly got an antipsychotic medication0.2%1.8%1.4%better
Short-stay residents given the seasonal flu vaccine94.4%74.1%79.4%better
Short-stay residents rehospitalized after admission26.7%27.3%22.6%worse
Short-stay residents with an outpatient ER visit13.5%16.6%12.0%worse

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

65.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 518 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

65.4%U.S. median 51.5%
Got home and stayed home
14.3%U.S. median 10.7%
Went back to hospital
65.1%U.S. median 56.6%
Met the expected recovery
0.84U.S. median 0.31
Therapy hours / resident / day
0.38hours / resident / day
Physical therapy
0.42hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 65.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 215 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.84 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF65.4%CMS range 61.4–69.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF14.3%CMS range 11.5–16.510.7%Oct 2022–Sep 2024worse than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge65.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge76.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge52.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting99.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.5%CMS range 5.3–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.011.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.34
RN hours/ resident / day
1.51
LPN hours/ resident / day
1.50
Aide hours/ resident / day
3.36
Total nurse hours/ resident / day
0.36
RN hoursweekends
68.0%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 52 beds and averages 38.8 residents a day — about 75% occupied, or roughly 13 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.50 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.06 hrs/resident/day on weekends vs 3.47 on weekdays — 12% thinner on weekends. RN hours go from 0.34 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 68% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

10
deficiencies at the latest standard inspection (2024-08-15)
5
at the previous standard inspection (2023-07-17)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-07-14 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 07/11/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to prevent a significant medication error by administering the wrong dose of morphine (an opioid) to Resident #3.On 07/11/25 at 12:34 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 07/11/25 at 2:23 p.m., the administrator and the general manager were notified of the IJ situation and the IJ template was provided.On 07/14/25 at 2:00 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,IJ removal Plan - Ignite Medical Resort [NAME].Ignite Medical Resort [NAME] is committed to ensuring the safety and well-being of all residents and operates in substantial compliance with Federal and State laws and regulations. This removal plan constitutes Ignite Medical Resort [NAME]'s written credible allegation of compliance for the immediate jeopardy noted. Facility will be in compliance on…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2025-07-14 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 07/11/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to prevent a significant medication error for Resident #3. On 07/11/25 at 12:34 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 07/11/25 at 2:23 p.m., the administrator and the general manager were notified of the IJ situation and the IJ template was provided.On 07/14/25 at 2:00 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,IJ removal Plan - Ignite Medical Resort [NAME].Ignite Medical Resort [NAME] is committed to ensuring the safety and well-being of all residents and operates in substantial compliance with Federal and State laws and regulations. This removal plan constitutes Ignite Medical Resort [NAME]'s written credible allegation of compliance for the immediate jeopardy noted. It is the facility's policy to ensure that residents are free of any significant…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-14 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to provide pain medication to a resident as ordered for 1 (#1) of 3 sampled residents reviewed for medication as ordered. The general manager identified 36 residents resided in the facility. Findings:On 07/09/25 at 12:01 p.m., CNA #1 and CNA #2 were providing incontinent care on Resident #1. The resident informed CNA #1 and CNA #2 they were in pain. Resident #1 was groaning holding their left hip. On 07/09/25 at 12:10 p.m., Resident #1 groaned in pain as they were turned to their left side. On 07/9/25 at 12:22 p.m., CNA #2 was observed speaking with CMA #3. A physician's order, dated 04/15/25, showed Tylenol (pain medication) 325 mg give two tablets by mouth every six hours as needed for pain.A Pain Management policy, dated 04/17/25, read in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.Physician's orders, dated…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure dirty linens were handled in a manner to prevent cross contamination during:a. incontinent care for 1 (#1) of 3 sampled residents observed for incontinent care; and b. a hall observation. The general manager identified 36 residents resided in the facility. Findings:On 07/09/25 at 12:01 p.m., CNA #1 and CNA #2 was observed to provide incontinent care on Resident #1. Both CNAs had on gloves and provided privacy. On 07/09/25 at 12:05 p.m., Resident #1's brief was observed soiled. CNA #2 wiped the resident's genitalia.On 07/09/25 at 12:10 p.m., Resident #1 was observed rolled to their left side. CNA #1 removed the resident's soiled pad and placed on the floor next to a white sheet. On 07/09/25 at 12:12 p.m., CNA #1 was observed to wipe the Resident #1's buttocks and anal area. CNA #1 changed their gloves and put a new brief on the resident. On 07/09/25 at 12:14 p.m., CNA #1 and CNA #2 completed incontinent care on Resident #1. They adjusted 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-02 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure physician orders were followed for tube feeding administration and removal of a Foley catheter for one (#4) of three sampled residents reviewed for physician orders. The administrator identified 39 residents resided in the facility. Findings: A facility TUBE FEEDING policy, revised 04/2024, read in part, The physician or nurse practitioner should be notified if tube feeding amount not infused as ordered. Res #4 admitted to the facility on [DATE] with diagnoses which included rectal cancer. A physician order, dated 11/15/24, documented to provide catheter care every shift and PRN. A physician order, dated 11/17/24, documented to administer Jevity 1.5 Cal at 65 ml/hr via g-tube every shift for feeding. An admission MDS, dated [DATE], documented Res #4 was moderately cognitively impaired, had an indwelling catheter, and received greater than half of nutritional intake through a feeding tube. An office visit physician note, dated…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure dependent residents were showered for one (#3) of three sampled residents reviewed for ADLs. The administrator identified 39 residents resided in the facility. Findings: Res #3 admitted to the facility on [DATE] with diagnoses which included spinal stenosis, back pain, and dementia. Record review documented Res #3 did not receive a shower from 09/12/24 to 09/17/24. An admission MDS, dated [DATE], documented Res #3 was cognitively intact and required moderate assistance with hygiene/bathing. On 12/02/24 at 11:30 a.m., the DON stated Res #3 was to receive their showers on Tuesdays, Thursdays, and Saturdays. On 12/02/24 at 2:02 p.m., the DON stated they were unable to locate documentation Res #3 received a shower on 09/14/24. On 12/02/24 at 3:07 p.m., the DON stated Res #3 should have received their shower on 09/14/24.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-15 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide baths/showers as scheduled for one (#36) of three sampled residents reviewed for activities of daily living. The DON identified 47 residents who resided in the facility. Findings: A Bathing policy, dated 05/24, read in part, .All residents are given a bath or shower in accordance with their preferences. If no preferences on a bath is voiced, a bath or shower will be offered twice per week . Res #36 was admitted [DATE] with diagnoses which included chronic kidney disease, pleural effusion, and fluid overload. The resident was discharged [DATE]. A facility shower schedule documented Res #36 was to receive a shower every Tuesday and Friday. An admission assessment, dated 06/14/24, documented Res #36 was cognitively intact and required substantial to maximal assistance with bathing. A Resident Grievance form, dated 07/07/24, documented the resident had requested a shower for days. Res #36's medical record had no documentation the resident received…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to prevent an injury to a resident during transfers for one (#29) of two residents sampled for accidents and hazards. The Administrator identified 47 residents resided in the facility. Findings: The facility's Incident and-Accidents policy, dated 11/2018, read in part, If an accident occurs, a full investigation will be initiated, including staff, interviews, equipment, checks, and follow through on policy and procedures. The policy also read, Facility will monitor the effectiveness of the interventions, including adequate supervision consistent with the residents needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident. The policy also read, The facility shall maintain a file of all written reports of each incident and accident affecting the resident that is not a expected outcome of a residence condition or disease process. Resident #29 was admitted on [DATE] with diagnoses which included…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure oxygen tubing was labeled and dated, per professional standards of care for three (#4,26, and #93) of three resident sampled for respiratory care. The DON identified 5 residents had orders for oxygen therapy. Findings: 1. Resident #4 was admitted on [DATE] with diagnoses which included acute kidney failure and systolic heart failure. Resident #4's physician orders, dated 8/04/24, read in part, May administer supplemental Oxygen as needed. On 08/11/24 at 9:05 a.m., Resident #4 was observed wearing oxygen via a nasal cannula. The tubing was attached to an oxygen saturator. There was no date observed on the humidifier or oxygen tubing indicating when the tubing was last changed. On 08/11/24 at 9:06 a.m., CNA #3 was asked what the date was on the oxygen tubing and/or humidifier. They stated there was not a date on the oxygen tubing or humidifier. On 08/11/24 at 9:11 a.m., RN #1 was taken to resident #4's room and asked if the oxygen tubing and…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-15 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to perform an entrapment risk assessment prior to installing bed or side rails for two (#2 and #86) of two residents and failed to obtain a physician order for the medical rationale and use of bed rails prior to installation for one (#86) of two sample residents reviewed for accident hazards. The DON identified 44 residents whose beds were equipped with a bed rail of any type. Findings: An admission Packet excerpt, undated, read in part, .The grab bars/side rails are/will be implemented for positioning only after a licensed nursing assessment. FULL SIDE RAILS WILL NOT BE UTILIZED. Responsible Party and/or Guest have been advised that bed/side rails may be installed. The risks and alternatives to using bed/side rails, as they apply to Guest's particular condition and circumstances have been clearly explained. A written order from the Guest's attending physician, specifying the medical rational and circumstances for use will be obtained prior to the installation of this medical treatment device. Facility will…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-15 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident medications were administered according to physician ordered parameters for three (#12, 88, and #89) of five sampled residents reviewed for unnecessary medications. The DON identified 47 residents who resided in the facility. Findings: A Pharmacy Services policy, dated 05/24, read in part, .Provide continuity of staff to ensure that medications are administered without unnecessary interruptions through: following specific monitoring related to medications, when ordered or indicated, including specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), and parameters for notifying the prescriber . 1. Res #12 was admitted [DATE] with diagnoses which included dementia and hypertension. A physician order, dated 07/22/24, documented amlodipine 10 mg one time a day for hypertension. The order documented to hold the medication for a systolic blood pressure less than 110 or a diastolic blood pressure less than 70. A…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-15 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident who received psychotropic medications had an acceptable diagnoses/indication for the use of an antipsychotic medication for three (#12, 88, and #89) of five sampled residents reviewed for unnecessary medications. The ADON identified 21 residents who received psychotropic medications. Findings: A Medication Monitoring policy, dated 01/24, read in parts, .Based on a comprehensive assessment of a resident, the facility must ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record .The attending physician in collaboration with the consultant pharmacist must re-evaluate the use of the psychotropic medication and consider whether or not the medication can be reduced or discontinued upon admission or soon after admission . 1. Res #12 was admitted [DATE] with diagnoses which included dementia, anxiety, and…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · Ecited before2024-08-15 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure food items were labeled with the date opened in the refrigerators, maintain a clean and sanitary kitchen during two of two kitchen observations. The DON identified 47 residents received nutrition form the kitchen. Findings: The facility's Food & Nutrition Services Sanitation & Food Safety policy, revised 2017, read in part, Refrigerated Potentially Hazardous Food or Time/Temperature Controlled for Safety foods are labeled with the date received. The policy also read, If opened, the cold food item is labeled with the date opened and the date which to discard by. The facility's Dietary Cleaning Policy policy, dated December 2020, read in part, This facility will store, prepare, distribute and serve food under sanitary conditions to ensure that proper sanitation and food handling practices to prevent the outbreak of foodborne illness is attained continuously. On 08/11/24 at 7:26 a.m., the following items were observed in the kitchen refrigerators: a. opened cubed pears were in a round plastic contained…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-15 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident assessments were accurately coded for one (#4) of 12 sampled residents reviewed for accurate assessments. The administrator identified 47 Residents resided in the facility. Findings: The facility's Coordination of certification of Assessments policy, revised April 2024, read in part, To ensure each resident assessment will be coordinated by and certified as complete by a registered nurse, and all individuals who complete a portion of the assessment will sign and certify to the accuracy of the portion of their assessment. The policy also read, All information recorded within the MDS assessment reflect the resident status at the time of the assessment reference date. Resident #4 was admitted on [DATE] with diagnoses which included systolic heart failure and depression. A physician order, dated 08/04/24, documented, may administer supplemental oxygen as needed. A comprehensive assessment, dated 08/11/24, documented in section O, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure physician orders were followed for obtaining weekly weights for one (#36) of one sampled resident reviewed for weights. The DON identified 47 residents who resided in the facility. Findings: Res #36 was admitted [DATE] with diagnoses which included chronic kidney disease, pleural effusion, and fluid overload. The resident was discharged [DATE]. A physician order, dated 06/08/24, documented weekly weights every Thursday. A physician order, dated 06/08/24, documented weights taken as prescribed by the physician. Weight differences of greater than 3 pounds in two days or 5 pounds in one week will be communicated to the physician. Weights will be taken using the same scale or other as appropriate based on mobility. A care plan, dated 06/11/24, documented the resident had the potential for alterations in nutrition and hydration related to recent fluid overload with an intervention to obtain and document weights per physician orders. An admission…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to cover a residents nebulizer mask when not in in use to prevent the spread of infection for one (#35) of three residents sampled for infection control practices for nebulizer mask. The DON identified 14 residents used nebulizer's. Findings: Resident #35 was admitted on [DATE] with diagnoses which included fracture of the right lower leg and cognitive communication deficit. Resident #35's physician orders, dated 07/24/24. read in part, Ipratropium Bromide Inhalation Solution 0.02 % (Ipratropium Bromide) 1 application inhale orally every 4 hours as needed for SOB. On 08/11/24 at 12:22 p.m., Resident #35's nebulizer mask and machine was observed in the window next to the bed the residents bed. The nebulizer mask was not in a bag and was laying in the window seal on a paper towel next to some food and drinks. 08/11/24 at 12:50 p.m., CNA #4 was taken into Resident #35's room. CNA # 4 was asked to identify what was in Resident #35's window sill.…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-17 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents were bathed as scheduled for nine (#12, 21, 24, 25, 30, 32, 42, 54, and #55) of sixteen sampled residents reviewed for bathing. The Resident Census and Conditions of Residents form documented 39 residents resided in the facility. Findings: 1. Res #12 was admitted with diagnoses which included fracture of superior rim of left pubis, abnormalities of gait and mobility, lack of coordination, and cognitive communication deficit. A physician order, dated 06/30/23, documented a shower or bath twice a week and prn personal care. An admission assessment, dated 07/05/23, documented the resident was moderately impaired in cognition and required extensive one person physical assistance with bathing. The July 2023 bathing record documented Res #12 was bathed one out of four opportunities from 07/01/23 through 07/12/23. On 07/12/23 at 10:39 a.m., Res #12 stated they had only received one shower since admission. Res #12 stated they had…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-17 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 (#38) of three sampled residents reviewed for discharge summaries. The Resident Census and Conditions of Residents form documented 39 residents resided in the facility. Findings: Res #38 was admitted [DATE] with diagnoses which included multiple fractures of pelvis, muscle weakness, and hypertension. A 5-Day PPS assessment, dated 06/15/23, documented an unplanned discharge to an acute hospital with return not anticipated. A progress note, dated 07/17/23 at 3:01 p.m., documented a late entry for 06/15/23. The note documented the resident was discharged on 06/15/23 after a follow-up care appointment. The note documented the resident was sent to the ER to follow up for continuing hip pain. They were not admitted and no further fracture/injury was noted. The note documented the resident transferred to another facility for long term care. There was no documentation a discharge summary had been completed. On…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a multi podus boot was in place per physician order for one (#28) of one sampled resident reviewed for multipodis boots. The Resident Census and Conditions of Residents form documented 39 residents resided in the facility. Findings: Res #28 was admitted to the facility with diagnoses of peripheral vascular disease, embolism and thrombosis of the arteries of the lower extremities, and congestive heart failure. A physician order, dated 05/06/23, documented multi podus boot to left foot while in bed. On 07/13/23 at 12:48 p.m., the resident was observed resting in bed watching television. The resident has a strengthening band attached to the left foot. They reported it helped to be able to move their leg easier. On 07/17/23 at 10:51 a.m., the resident was observed resting in bed watching television. No multipodis boot was observed on the left foot. On 07/17/23 at 3:00 p.m., the administrator reported the resident should have had the boot in place to the left foot.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-17 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care to assure safety related to the administration of injections for one (#42) of two residents reviewed for medication administration. The Resident Census and Conditions of Residents form documented 12 residents received injections. Findings: A NIOSH-How to Prevent Needlestick and Sharps Injuries guideline, dated February 2012, documented the following: Needlestick and other sharps injuries are a serious hazard in any healthcare setting. Contact with contaminated needles and other sharps may expose healthcare workers to blood that contains pathogens which pose a grave, potentially lethal risk. Healthcare workers can be at risk for needlestick and sharps injuries when they recap a needle. Healthcare staff should plan for the safe handling and disposal of needles before use and avoid recapping or bending needles that might be contaminated. Res #42 was admitted with diagnoses which included central cord syndrome, diabetes…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-17 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to post nurse staffing information, which included all the required components, in an area where it could be reviewed by all residents and visitors. The Resident Census and Conditions of Residents form documented 39 residents resided in the facility. Findings: On 07/12/23 at 10:00 a.m., no nurse staffing information was posted. On 07/13/23 at 3:00 p.m., no nurse staffing information was posted. On 07/17/23 at 1:30 p.m., no nurse staffing information was posted. On 07/17/23 at 1:50 p.m., the DON reported there was not daily nurse staffing information posted.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-05-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner. The facility failed to: a. clean the oven and hand washing sinks. b. wear hair restraints when in the kitchen. c. perform hand hygiene after touching unclean surfaces during meal service and meal pass. The Census and Conditions of Residents form documented 36 residents lived in the facility. Findings: The DIETARY SERVICES POLICY, revised 07/05/06, read in parts .All dietary services personnel shall at all times wear clean, washable clothes and hair nets or clean caps .Effective procedures are established for the cleaning of all equipment and work areas .personnel entering the dietary area will be responsible for the same standards of cleanliness as those required of the dietary staff . The Ignite [NAME] Dining Dept. Cleaning Assignments read in parts .Prep [NAME] Weekly Duties .Sunday - clean gas range inside and out. Daily Duties .Proper hand washing & glove usage .Clean…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, it was determined the facility failed to provide baths/showers as scheduled for two (#30 and #38) of two sampled residents. The Census and Conditions of Residents form documented 36 residents lived in the facility. Findings: 1. Res #30 was admitted , on 04/30/22, with diagnoses which included other recurrent depressive disorders, muscle weakness, unspecified abnormalities of gait and mobility, unspecified lack of coordination, and need for assistance with personal care. A physician order, dated 04/30/22 documented the resident was to receive showers three times a week, every Tuesday, Thursday, Saturday, and PRN. An admission assessment, dated 05/02/22, documented the resident was cognitively intact and required one person physical assist for bathing. The resident's record had no documentation the resident had a shower/bed bath since admission. 2. Resident #38 was admitted , on 04/26/22, with diagnoses of diabetes mellitus, muscle weakness, and morbid obesity. A physician order, dated 04/26/22, documented the resident was to receive…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$16,660 in federal fines across 1 penalty.

  • $16,660 — penalty dated 2025-07-14

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to IGNITE MEDICAL RESORTS — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.7-1.7 vs chain
Health inspection 2 of 52.4-0.4 vs chain
Staffing 1 of 51.9-0.9 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 21 homes this chain runs (chain average 2.7★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
IGNITE OKLAHOMA JV, LLCOrganizationDIRECT OWNERSHIP INTERESTsince 03/01/2020
IGNITE-VILLA HOLDCO LLCOrganizationDIRECT OWNERSHIP INTERESTsince 03/01/2020
BERGER FAM TR UA 06252014OrganizationINDIRECT OWNERSHIP INTERESTsince 03/01/2020
BLUE PEARL FINANCIAL LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 03/01/2020
GOLD PEARL, LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 01/03/2022
IGNITE POST ACUTE SOLUTIONS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 03/01/2020
ISRAEL FAMILY INVESTMENT TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 03/01/2020
ISRAEL INVESTMENT TROrganizationINDIRECT OWNERSHIP INTERESTsince 03/01/2020
PRESTIGE WORLDWIDE OKLAHOMA, LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 03/01/2020
STERN FAMILY INVESTMENT TROrganizationINDIRECT OWNERSHIP INTERESTsince 03/01/2020
CARR, JAREDIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
CASTILLO-SIMON, REVELIndividualINDIRECT OWNERSHIP INTERESTsince 01/01/2023
GOBST, RYANIndividualINDIRECT OWNERSHIP INTERESTsince 03/01/2020
JABLONSKI, NICOLEIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
MCFARLANE, JOHNIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
ROLF, CHELSEYIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2024
ROSE, MARCIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/20/2020
SHEARER, RACHELIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
SKELTON, MEAGHANIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2022
THENGIL, MATHEWIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
WHITE, JIMIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
BERGER, MENACHEMIndividualMANAGING CONTROL - GOVERNING BODYsince 03/01/2020
CARR, BARRYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
FIELDS, TIMOTHYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
ISRAEL, BENJAMINIndividualMANAGING CONTROL - GOVERNING BODYsince 03/01/2020
STERN, TODDIndividualMANAGING CONTROL - GOVERNING BODYsince 03/01/2020
IGNITE TEAM PARTNERS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
SPARK THERAPY LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
PLUSQUELLEC, PAULIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
BERGER, AVIVAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/14/2025
ISRAEL, YEHUDISIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/14/2025
LUXE STAFFING LLCOrganizationADP OF THE SNFsince 01/04/2021
SABRA HEALTH CARE REIT INCOrganizationADP OF THE SNFsince 01/01/2020

CMS files one row per role, so the 58 rows in the source record cover these 33 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

14 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$8.0M
Net patient revenuemost recent cost report
-0.2%
Operating marginrevenue minus expenses
$1.6M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 56%Other / private 44%

This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$552per resident / day
operating cost
$16,783per month
≈ monthly operating cost
$551per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OK

Paying with Medicaid

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Oklahoma Medicaid page for homes that do.

Typical monthly cost in Oklahoma
$7,026/mo
Nursing home (semi-private)
$7,756/mo
Nursing home (private)
$6,150/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 375461. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-15, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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