Inspection Reports for
Ignite Medical Resort KC Northland

The complaint investigation found that Resident #1 was struck in the face by Resident #2 on 1/1/2025, causing a laceration. Resident #1 declined counseling but felt safe in the facility. Interviews with residents and staff confirmed the incident. Staff education on abuse prevention was conducted on 1/1/25 and 1/2/25. The Administrator noted the incident was unexpected as neither resident had displayed physical behaviors previously.

The facility failed to protect Resident #1 from abuse by another resident, resulting in actual harm. The facility conducted an immediate investigation, implemented corrective actions, and provided staff education on resident-to-resident abuse and prevention. Both residents involved had moderately impaired cognition but no prior history of physical behaviors.

The complaint investigation revealed substantiated issues including failure to provide discharge medications, failure to arrange home health care and dialysis, failure to provide discharge instructions and education, and sending residents home with incorrect medication cards. Interviews with residents, family members, and staff confirmed these deficiencies.

The facility failed to ensure safe and orderly discharges for five of six sampled residents by not providing proper discharge orders, medications, home health services, dialysis arrangements, or follow-up care. Residents were discharged without necessary supplies, medication education, or discharge instructions, leading to confusion and lack of care continuity.

The facility was found deficient in honoring resident self-determination regarding staff assignments, providing timely written notification of transfers and bed hold policies, ensuring safe and orderly discharges with proper follow-up care, performing complete neurological assessments after unwitnessed falls, maintaining ileostomy care orders, employing a qualified dietary manager, and documenting resident education and consent/refusal for influenza and pneumonia vaccinations.

The complaint investigation was triggered by an incident where Resident #1 eloped from the facility on 2/29/24 and was found lying near a busy road. The resident's family was not notified promptly, and documentation was lacking. Interviews with staff and family confirmed failures in notification and documentation. The facility stated the resident was not off property and was gone for only 15 minutes, but family was unaware of the incident until days later.

The facility failed to provide adequate protective oversight to a resident with Alzheimer's and dementia who eloped and was found near a busy roadway. Staff did not document the elopement properly nor notify the resident's family or physician as per policy. The facility completed an investigation, but documentation was not included in the resident's medical record.

The facility was found deficient in multiple areas including failure to ensure dignified meal service with appropriate dishware, failure to accommodate resident needs such as bed length, failure to maintain clean and comfortable environment, failure to update care plans and hold care plan meetings, failure to provide professional wound care, inadequate assistance with activities of daily living, medication pass delays, insufficient nursing staff to meet resident needs, and failure to provide palatable, timely, and temperature-appropriate meals and snacks.

The facility was found deficient in multiple areas including failure to honor resident dignity related to meal service with plastic cutlery and Styrofoam, inadequate wound care and failure to obtain timely treatment orders, insufficient assistance with activities of daily living, inadequate staffing leading to delayed call light response and medication administration, and failure to meet resident dietary preferences and timely meal/snack service.

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 plans, failure to follow professional standards in medication and respiratory care, insufficient assistance with activities of daily living, failure to prevent pressure ulcers, inadequate dental care, and food service issues including incorrect meal delivery and unsafe food handling practices.