Inspection Reports for
Ignite Medical Resort Blue Springs

The complaint investigation found that Resident #2 was given another resident's medications due to interruptions and distraction during medication pass. Resident #3 experienced an unwitnessed fall related to the bathroom track door coming off, resulting in a femoral neck fracture. The fall was accidental and not due to neglect or abuse.

The facility failed to prevent a medication error where Resident #2 received Resident #14's medications, resulting in minimal harm. Additionally, the facility failed to ensure a safe environment when Resident #3 fell and was found with the bathroom track door on the floor, sustaining a femoral neck fracture. Both incidents were investigated, and corrective actions were initiated.

The facility failed to maintain resident rooms free from cobwebs and dust buildup behind beds and furniture, potentially affecting at least 23 residents. Observations and interviews confirmed the presence of dust and cobwebs in multiple rooms, indicating inadequate cleaning practices.

The facility was found deficient in multiple areas including failure to obtain physician orders and perform assessments for medication self-administration and colostomy care, inadequate room cleaning with dust and cobweb buildup, failure to properly assess and document wound care, failure to ensure ordered splint use for mobility, lack of physician orders and care plans for CPAP use, and failure to follow enhanced barrier precautions and hand hygiene protocols during resident care. Additionally, one employee did not receive timely tuberculosis screening.

The complaint investigation focused on catheter care for Resident #2 and call light system issues affecting Resident #1 and Resident #4. The catheter care deficiency was substantiated with findings of missing orders and documentation. The call light system was found to have been recently changed, requiring staff to enter resident rooms to turn off call lights, which initially caused delays but later improved response times.

The facility failed to ensure appropriate indwelling urinary catheter orders and catheter care documentation for one sampled resident, and failed to maintain a fully functional call light system, which was not turned off at the nurse's station, affecting two sampled residents. Both issues were associated with minimal harm or potential for actual harm.

The facility failed to ensure correct catheter care procedures and proper hand hygiene for one sampled resident with an indwelling catheter. Licensed nursing staff did not perform handwashing or sanitizing before, during, or after catheter care, and improper catheter flushing technique was observed, posing a risk for urinary tract infection.

The complaint investigation found substantiated deficiencies related to background check failures, transfer/discharge notice failures, and food safety violations affecting some or few residents.

The facility failed to ensure background checks were completed prior to hire for eight out of ten sampled employees, failed to provide proper transfer/discharge notices including location and appeal rights for two residents, and failed to maintain sanitary food storage and preparation practices in the kitchen, including lack of thermometer in the refrigerated unit, unclean floors, sticky beverage nozzles, unlabeled bulk containers, and improper dish storage.