Inspection Reports for
Ignite Medical Resort Kansas City LLC
2100 NW BARRY ROAD, KANSAS CITY, MO, 64154-1000
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
78% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
79 residents
Based on a January 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
Date: Jan 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where Resident #1 was hit in the face by another resident (Resident #2), resulting in a laceration to Resident #1's lower lip.
Complaint Details
The complaint investigation found that Resident #1 was struck by Resident #2 on 1/1/2025, causing injury. Resident #1 declined counseling but felt safe in the facility. The facility conducted an investigation, notified the physician, and implemented corrective actions. Staff education on resident-to-resident abuse was completed on 1/1/25 and 1/2/25. The Administrator noted the incident was unexpected as neither resident had displayed physical behaviors previously.
Findings
The facility failed to protect Resident #1 from abuse by another resident. The incident was investigated promptly, corrective actions were implemented, and staff were educated on resident-to-resident abuse and prevention. Both residents involved had moderately impaired cognition but no prior physical behaviors. The facility took steps to prevent further incidents and offered counseling to the affected resident.
Deficiencies (1)
Failed to protect Resident #1 from abuse when hit in the face by another resident, resulting in a laceration to the lower lip.
Report Facts
Facility census: 79
BIMS score: 11
BIMS score: 11
Date of incident: Jan 1, 2025
Date of correction: Jan 2, 2025
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 1
Date: Dec 2, 2024
Visit Reason
The inspection was conducted due to complaints regarding unsafe and disorderly discharges from the facility, including failure to provide proper orders, medications, home health services, dialysis services, and follow-up appointments for discharged residents.
Complaint Details
The complaint investigation revealed substantiated issues including failure to provide discharge instructions, failure to arrange home health and dialysis services, sending residents home with incorrect medications, and lack of follow-up care scheduling.
Findings
The facility failed to ensure safe and orderly discharges for five of six sampled residents, including sending residents home without proper medications, failing to arrange home health or dialysis services, not providing discharge instructions, and sending residents home with other residents' medications. Interviews and record reviews confirmed these deficiencies.
Deficiencies (1)
Facility failed to ensure safe and orderly discharge for five residents without proper orders, medications, home health services, dialysis services, and/or follow-up appointments.
Report Facts
Residents affected: 5
Facility census: 90
Medications prescribed: 30
Medications sent home: 11
Medications prescribed: 16
Medications prescribed: 27
Medication cards sent incorrectly: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Casemanager | Registered Nurse Case Manager | Interviewed regarding Resident #1's discharge and in-home visit |
| CMT A | Certified Medication Technician | Interviewed about medication review process during discharge |
| Social Services Designee | Social Services Designee | Interviewed about discharge planning and home health care referrals |
| Facility Administrator | Facility Administrator | Interviewed about discharge procedures and medication education |
Inspection Report
Census: 84
Deficiencies: 8
Date: Oct 3, 2024
Visit Reason
The inspection was conducted to investigate multiple regulatory compliance issues including resident rights, transfer and discharge procedures, neurological assessments after falls, ileostomy care, staffing qualifications, and immunization policies.
Findings
The facility was found deficient in honoring resident self-determination rights, providing timely and written transfer notifications, ensuring safe and orderly discharges, performing required neurological assessments after falls, maintaining ileostomy care orders, employing qualified dietary management staff, and documenting education and consent for influenza and pneumonia vaccinations.
Deficiencies (8)
Failure to honor a resident's request to not have certain staff provide care, impacting resident self-determination rights.
Failure to provide written notification of facility-initiated transfers and appeal rights to residents and their representatives.
Failure to ensure safe and orderly discharge for residents, including lack of proper orders, medications, home health services, dialysis services, and follow-up appointments.
Failure to provide written notification of bed hold policy to residents and responsible parties upon hospital transfers.
Failure to perform ongoing neurological assessments after unwitnessed falls, risking undetected head trauma.
Failure to ensure orders for ileostomy care were in place, resulting in fecal matter leaking into a wound.
Failure to employ a qualified director of food and nutrition services with required credentials and experience.
Failure to document resident education and consent/refusal for influenza and pneumonia vaccinations.
Report Facts
Facility census: 84
Resident sample size: 28
Medication count: 30
Medication count: 27
Medication count: 16
Fall incidents: 14
Neuro assessment frequency: 15
Bed hold duration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 4 | LPN | Named in resident complaint about rude behavior and medication administration |
| Certified Nurse Aide 2 | CNA | Named in resident complaint about rude behavior and providing care against resident's wishes |
| General Manager | Interviewed regarding resident complaints, staff coaching, and transfer notifications | |
| Director of Nursing | DON | Interviewed regarding neurological assessments and resident care protocols |
| Assistant Director of Nursing | ADON | Completed coaching for LPN4 related to resident complaints |
| Staffing Coordinator | Interviewed regarding staff scheduling and resident care assignments | |
| Registered Nurse 1 | RN | Provided information on neurological assessment protocols |
| Nurse Practitioner | NP | Observed resident wound and confirmed lack of ileostomy care orders |
| Assistant Chief Nursing Officer | ACNO | Interviewed regarding ileostomy care and neurological assessments |
| Dietary Manager | DM | Confirmed lack of required certification and experience for dietary manager role |
| Registered Dietitian | RD | Confirmed part-time status and lack of full dietary management staffing |
| Infection Preventionist | IP | Interviewed regarding immunization consent and education documentation |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 1
Date: Jun 6, 2024
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to provide adequate protective oversight to a resident with Alzheimer's and dementia who eloped from the facility and was found near a busy roadway without staff awareness or timely family notification.
Complaint Details
The visit was complaint-related due to the resident eloping from the facility unnoticed on 2/29/24 and the failure of staff to notify the resident's legal power of attorney or family in a timely manner. The complaint was substantiated based on interviews and record reviews.
Findings
The facility failed to prevent elopement of a cognitively impaired resident, did not document the incident properly, and failed to notify the resident's family or physician in a timely manner. The resident was found outside the facility but unharmed. The facility conducted an internal investigation and followed some policy steps but lacked proper communication and documentation.
Deficiencies (1)
Failure to provide protective oversight to a resident at risk of elopement, resulting in the resident leaving the facility unnoticed and staff failing to notify the resident's personal representative.
Report Facts
Facility census: 89
BIMS score: 12
BIMS score: 14
Incident date: Feb 29, 2024
Initial care plan date: Feb 26, 2024
MDS completion date: Mar 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee A | Interviewed about recognizing the resident after elopement and family notification | |
| Family Member B | Legal Power of Attorney | Interviewed about lack of notification regarding the resident's elopement |
| LPN A. | Licensed Practical Nurse | Interviewed about assessment and documentation of the elopement incident |
| Director of Nursing | Interviewed about the incident, resident's condition, and facility response | |
| Interim Administrator | Interviewed about facility investigation and policy adherence |
Inspection Report
Routine
Census: 89
Deficiencies: 7
Date: Jul 25, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, facility operations, and safety.
Findings
The facility was found deficient in multiple areas including failure to ensure dignified care related to meal service using Styrofoam and plastic cutlery, failure to obtain timely treatment orders and provide appropriate wound care, inadequate assistance with activities of daily living, insufficient nursing staff to meet resident needs, delayed medication administration, failure to honor resident meal preferences and menu substitutions, and failure to provide timely meals and snacks.
Deficiencies (7)
Failure to ensure dignified care when serving meals with plastic cutlery and Styrofoam for six of 18 sampled residents and failure to set up meals within reach for three residents.
Failure to obtain treatment orders for surgical site and failure to provide appropriate wound care for one resident.
Failure to provide adequate assistance with activities of daily living including repositioning, incontinent care, oral care, and showers for four residents.
Failure to provide sufficient nursing staff to meet resident needs including timely response to call lights and timely medication administration for multiple residents.
Failure to provide appropriate treatment and care according to orders and resident preferences including repositioning and wound dressing care for two residents.
Failure to ensure each resident receives food that accommodates allergies, intolerances, preferences, and appealing options including failure to offer condiments, larger portions, and follow posted menu substitutions.
Failure to ensure meals and snacks are served at times in accordance with resident needs, preferences, and requests, including failure to provide nourishing bedtime snacks and allowing excessive time between evening meal and breakfast.
Report Facts
Facility census: 89
Deficiencies cited: 7
Medication pass times: 7
Medication pass times: 10
Meal service times: 7
Meal service times: 11
Meal service times: 16
Meal service times: 17
Meal substitution log entries: 22
Call light response time: 15
Call light response time: 16
Medication administration delay: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided expectations on meal tray setup, call light response, wound care, and staff responsibilities |
| Administrator | Administrator | Provided expectations on meal service, call light response, wound care, and staffing |
| Dietary Manager | Dietary Manager | Discussed food ordering, substitutions, meal service delays, and staffing |
| Licensed Practical Nurse C | Licensed Practical Nurse (LPN) | Observed wound condition and provided care instructions |
| Registered Nurse A | Registered Nurse (RN) | Obtained wound care orders late and explained admission process |
| Certified Nurse Aide E | Certified Nurse Aide (CNA) | Provided resident care and reported resident complaints |
| Registered Nurse D | Registered Nurse (RN) | Discussed medication pass and resident complaints |
| Licensed Practical Nurse D | Licensed Practical Nurse (LPN) | Discussed medication pass and pharmacy issues |
Inspection Report
Routine
Census: 89
Deficiencies: 10
Date: Jul 25, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, environment, staffing, and food service at Ignite Medical Resort Kansas City, LLC.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care related to meal service using Styrofoam and plastic cutlery, failure to accommodate resident needs such as appropriate bed length, failure to maintain a clean and homelike environment, failure to update care plans and hold care plan meetings, failure to provide adequate assistance with activities of daily living, failure to ensure timely medication administration and call light response, failure to serve palatable and appropriately heated food, and failure to provide meals and snacks according to resident needs and preferences.
Deficiencies (10)
Failure to ensure dignified care when serving meals with plastic cutlery and Styrofoam for six of 18 sampled residents and failure to set up meals within reach for three residents.
Failure to accommodate the needs of a resident to prevent hanging partially off the bed due to insufficient bed length.
Failure to maintain a clean, comfortable, and homelike environment including clean floors, toilets, and timely linen changes for five residents.
Failure to update resident care plans and hold care plan meetings involving residents or guardians for three residents.
Failure to assure staff followed acceptable standards of practice for wound care and treatment orders for one resident.
Failure to provide sufficient nursing staff to meet residents' needs including timely response to call lights and medication administration for six residents.
Failure to provide adequate assistance with activities of daily living including repositioning, incontinent care, oral care, and showers for four residents.
Failure to ensure food served was palatable, attractive, and served at a safe and appetizing temperature for six residents.
Failure to ensure meals and snacks were served at times in accordance with resident needs and preferences, including failure to provide bedtime snacks and maintain no more than 14 hours between evening meal and breakfast.
Failure to ensure food accommodated resident allergies, intolerances, and preferences, including failure to offer condiments, larger portions, and follow posted menu substitutions.
Report Facts
Facility census: 89
Residents sampled: 18
Meal service start times: 7
Meal service start times: 11
Meal service start times: 16
Meal service duration: 120
Meal temperature: 127
Meal temperature: 120
Meal temperature: 149
Bedside table cleaning interval: 13
Pressure ulcer size: 6.3
Pressure ulcer size: 4.3
Pressure ulcer size: 0.1
Braden score: 13
Medication pass time: 22
Medication pass time: 0
Call light response time: 15
Call light response time observed: 16
Call light response time observed: 45
Meal substitution count: 22
Bedside table cleaning interval: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Discussed food service issues, meal preparation, and ordering |
| Director of Nursing | Director of Nursing | Provided expectations on meal service, wound care, call light response, and staff responsibilities |
| Administrator | Administrator | Provided expectations on meal service, staffing, care plan meetings, and resident accommodations |
| Licensed Practical Nurse B | Licensed Practical Nurse | Observed resident bed length issue and discussed bed accommodations |
| Physical Therapist A | Physical Therapist | Discussed resident bed length and mobility |
| Charge Nursing Officer | Charge Nursing Officer | Discussed care plan meeting notes and resident involvement |
| Registered Nurse B | Registered Nurse | Discussed staffing and call light response |
| Certified Nurse Aide A | Certified Nurse Aide | Discussed shower schedule and snack passing |
| Licensed Practical Nurse E | Licensed Practical Nurse | Discussed staffing and call light response |
| Dietary Aide A | Dietary Aide | Observed meal preparation and service |
| Dietary Aide B | Dietary Aide | Observed meal preparation and service |
Inspection Report
Routine
Census: 85
Deficiencies: 11
Date: Jul 15, 2021
Visit Reason
The inspection was a routine survey of Ignite Medical Resort Kansas City, LLC to assess compliance with regulatory requirements related to resident rights, care planning, abuse prevention, professional standards of care, activities, pressure ulcer care, respiratory care, medication management, dental care, food service, and other aspects of facility operation.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights related to language and activities, incomplete employee background checks, inadequate care planning for residents, failure to follow professional standards of care including medication administration and respiratory care, failure to provide activities in accordance with resident preferences, inadequate pressure ulcer prevention and care, failure to provide appropriate dental care, issues with food service including incorrect meal delivery and improper food handling, and failure to maintain medication carts and storage properly.
Deficiencies (11)
Failed to ensure one resident was treated in a dignified manner by not providing television programs in the resident's primary language (Farsi).
Failed to develop and implement a policy regarding employee background checks and failed to ensure Family Care Safety Registry checks were completed for some employees.
Failed to develop and implement comprehensive person-centered care plans for two residents, missing key health issues and therapies.
Failed to ensure staff followed professional standards of care by not obtaining orders for oxygen therapy and nebulizer treatments and improper administration of Silvadene cream.
Failed to provide activities in accordance with resident choice and preferences for one resident who spoke Farsi and had no activity participation.
Failed to prevent development of new pressure ulcers by not following care plans, completing assessments, or applying interventions for one resident with a worsening pressure ulcer.
Failed to provide safe and appropriate respiratory care by not replacing humidified water bottles, not dating oxygen and nebulizer tubing, and not cleaning oxygen concentrator filters for three residents.
Failed to discard expired medications and remove loose pills from medication carts and storage rooms.
Failed to provide routine and 24-hour emergency dental care for one resident with multiple decayed, broken, and missing teeth causing pain and weight loss.
Failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures; residents reported incorrect meals, missing items, and poor food quality; pureed food was improperly prepared.
Failed to ensure kitchen staff followed professional food service safety standards including proper glove use, hand hygiene, and utensil use during meal preparation and serving.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 5
Residents affected: 2
Loose pills: 5
Expired medications: 15
Expired medication: 1
Pressure ulcer size: 7
Pressure ulcer size: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide E | CNA | Mentioned in relation to Resident #28's television program language issue |
| Activity Director | Interviewed regarding lack of activity calendar in other languages and awareness of resident language needs | |
| Director of Nursing | DON | Interviewed regarding care plan deficiencies and oxygen/nebulizer orders |
| Director of Culture and Engagement | Interviewed regarding employee background check policies | |
| Certified Nurse Aide A | CNA | Interviewed regarding pressure ulcer care and notification |
| Licensed Practical Nurse C | LPN | Interviewed regarding wound care measurements |
| Chief Clinical Officer | Interviewed regarding skin assessments and medication management | |
| Registered Nurse A | RN | Interviewed regarding oxygen and nebulizer tubing maintenance |
| Certified Medication Technician A | CMT | Interviewed regarding expired medications and medication cart conditions |
| Licensed Practical Nurse D | LPN | Interviewed regarding expired lidocaine medication |
| Resident #330 | Interviewed regarding dental pain and care needs | |
| Family Member A | Interviewed regarding Resident #330's dental pain and care | |
| Kitchen Manager | KM | Interviewed regarding food preparation and pureed food consistency |
| Assistant Dietary Director | Interviewed regarding food service and pureed food preparation |
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