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 meet professional standards in medication administration, resulting in a medication error involving Resident #2. Additionally, the facility failed to ensure a safe environment free of accident hazards, as Resident #3 was found on the floor outside their bathroom due to a bathroom track door issue.

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 facility was found deficient in multiple areas including resident self-administration of medications, safe and clean environment, quality of care related to wound assessment and treatment, mobility and range of motion, colostomy and respiratory care, infection prevention and control, and housekeeping. Deficiencies were supported by observations, interviews, and record reviews.

The facility was found not in compliance with emergency preparedness requirements related to communication plans, evacuation procedures, and fire safety systems including sprinkler system impairment and fire watch plans. Deficiencies were cited regarding emergency communication, evacuation arrangements, sprinkler system out of service, smoke barrier construction, and oxygen storage.

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 was found deficient in ensuring proper catheter care for residents with indwelling urinary catheters and in maintaining an adequate resident call system. Deficiencies included lack of physician orders for catheter care and failure to verify catheter care completion, as well as inadequate call light system functioning and response.

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 facility failed to ensure proper catheter care and infection prevention practices for one sampled resident, including inadequate hand hygiene and improper catheter flushing techniques. Deficiencies were noted in maintaining urinary continence and infection control protocols.

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.

The visit was complaint-related, triggered by allegations of failure to conduct proper background checks and other regulatory violations. The complaint was substantiated as evidenced by multiple deficiencies cited.

The facility failed to ensure proper background checks for employees prior to hire, failed to provide proper notice before resident transfers or discharges, and did not meet food safety requirements. Additional deficiencies included failure to obtain a second business license for a dialysis clinic and issues with facility cleanliness and equipment maintenance.