Deficiencies (last 8 years)
Deficiencies (over 8 years)
12.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
135% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
88% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 79
Deficiencies: 1
Date: Jan 9, 2025
Visit Reason
The visit was conducted to address a past noncompliance related to abuse and neglect at Ignite Medical Resort Kansas City, LLC, following an incident where a resident was hit by another resident.
Findings
The facility failed to protect a resident from abuse by another resident, resulting in a laceration. The facility conducted an investigation, implemented corrective actions, and provided staff education on abuse prevention.
Deficiencies (1)
F 600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to protect Resident #1 from abuse when hit by another resident, causing a laceration to the lower lip. The facility did not have a plan of correction for past noncompliance but implemented corrective actions immediately upon discovery.
Report Facts
Facility census: 79
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 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.
Findings
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.
Deficiencies (1)
Failure to protect Resident #1 from abuse by another resident resulting in a laceration to the lower lip.
Report Facts
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, specifically failures in providing 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 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.
Findings
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.
Deficiencies (1)
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
Census: 90
Medications prescribed at discharge: 30
Medications sent home: 11
Medications prescribed: 16
Medications prescribed: 27
Medication cards sent incorrectly: 8
Follow-up cardiology appointment: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Casemanager RN | RN Casemanager | Interviewed regarding Resident #1's discharge and follow-up care failures |
| Social Services Designee | Social Services Designee | Interviewed about discharge planning responsibilities and procedures |
| Administrator | Facility Administrator | Interviewed about discharge medication review and education expectations |
| CMT A | Certified Medication Technician | Interviewed about medication review process during discharge |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 7
Date: Oct 3, 2024
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Missouri Department of Health and Senior Services. The visit was triggered by complaints regarding resident rights and transfer/discharge procedures.
Complaint Details
The complaint involved resident rights violations including rude and disrespectful staff behavior, failure to honor resident care preferences, and inadequate notification for transfers and discharges. The complaint was substantiated as evidenced by interviews, record reviews, and policy assessments.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to resident rights, including failure to honor a resident's request regarding care providers, and failure to provide proper notice before transfer or discharge. Additional deficiencies were found in quality of care, colostomy care, dietary staffing, and immunization procedures.
Deficiencies (7)
F550 Resident Rights: The facility failed to honor a resident's request to not have certain staff provide care, potentially decreasing the resident's quality of life.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide written notification of a facility-initiated transfer to the resident and responsible party for two residents.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility failed to provide written notice of the bed hold policy to two residents and responsible parties.
F684 Quality of Care: The facility failed to perform ongoing neurological assessments after unwitnessed falls for three residents, risking undetected head trauma.
F691 Colostomy, Urostomy, or Ileostomy Care: The facility failed to ensure orders for ileostomy care were in place for one resident, negatively affecting skin and quality of life.
F801 Qualified Dietary Staff: The facility failed to employ a qualified dietary manager with required credentials and training, affecting food safety and management.
F883 Influenza and Pneumococcal Immunizations: The facility failed to document education and immunization status for residents, including refusals and consents.
Report Facts
Survey Census: 84
Sample Size: 28
Supplemental Residents: 10
Residents affected by dietary deficiency: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| General Manager | Interviewed regarding resident complaints and staff coaching. | |
| Director of Nursing | DON | Completed in-service training and provided statements on care and deficiencies. |
| Licensed Practical Nurse 4 | LPN4 | Named in resident complaint and medication administration. |
| Certified Nurse Aide 2 | CNA2 | Named in resident complaint and staff behavior issues. |
| Staffing Coordinator | Interviewed about staff scheduling and complaint awareness. | |
| Assistant Director of Nursing | ADON | Completed coaching for staff related to complaint. |
| Assistant Chief Nursing Officer | ACNO2 | Provided statements on neurological assessments and wound care. |
| Registered Nurse 1 | RN1 | Provided statements on fall protocols and neurological assessments. |
| Licensed Practical Nurse 3 | LPN3 | Provided statements on fall incident reports. |
| Dietary Manager | DM | Interviewed regarding qualifications and dietary management deficiencies. |
| Registered Dietitian | RD | Confirmed employment status and dietary management. |
| Infection Preventionist | IP | Interviewed regarding immunization policies and documentation. |
Inspection Report
Routine
Census: 84
Deficiencies: 8
Date: Oct 3, 2024
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, transfer and discharge procedures, fall assessments, ileostomy care, staffing qualifications, and immunization policies at Ignite Medical Resort Kansas City, LLC.
Findings
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.
Deficiencies (8)
Failed to honor a resident's request to not have certain staff provide care, impacting resident self-determination.
Failed to provide written notification of facility-initiated transfers and appeal rights to residents and representatives.
Failed to ensure safe and orderly discharge for residents, including lack of proper orders, medications, home health services, and follow-up appointments.
Failed to provide written notification of bed hold policy to residents and representatives upon hospital transfers.
Failed to perform ongoing neurological assessments after unwitnessed falls, potentially missing head trauma symptoms.
Failed to ensure orders for ileostomy care were in place, resulting in fecal matter leaking into a wound.
Failed to employ a qualified director of food and nutrition services with required credentials and experience.
Failed to document resident education and consent/refusal for influenza and pneumonia vaccinations, risking uninformed decisions.
Report Facts
Facility census: 84
Resident sample size: 28
Medication count: 30
Medication count: 27
Fall incidents: 14
Neurological assessments missing: 4
Duration as dietary manager: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA2 | Certified Nurse Aide | Named in resident complaint for rude behavior and providing care against resident's wishes |
| LPN4 | Licensed Practical Nurse | Named in resident complaint for rude behavior and medication administration despite resident's request |
| General Manager | Interviewed regarding resident complaints, staff coaching, and notification procedures | |
| Director of Nursing | DON | Interviewed regarding neurological assessment protocols and staff awareness |
| Staffing Coordinator | Interviewed regarding staff scheduling and awareness of resident complaints | |
| RN1 | Registered Nurse | Provided information on neurological assessment protocols |
| RN3 | Licensed Practical Nurse | Described fall assessment procedures |
| Assistant Chief Nursing Officer | ACNO2 | Interviewed about neurological assessments and ileostomy care orders |
| NP | Nurse Practitioner | Observed wound care and confirmed lack of ileostomy care orders |
| Dietary Manager | Executive Chef | Confirmed lack of required certification and experience |
| Registered Dietitian | RD | Confirmed part-time status and lack of qualified dietary manager |
| Infection Preventionist | IP | Interviewed regarding immunization consent and education documentation |
Inspection Report
Life Safety
Census: 87
Capacity: 89
Deficiencies: 4
Date: Oct 1, 2024
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Department of Health and Senior Services on 10/01/24 to assess compliance with Medicare/Medicaid and NFPA 101 Life Safety Code requirements.
Findings
The facility was found to be in noncompliance with emergency lighting, sprinkler system installation, low voltage wiring protection, and monthly generator load testing requirements. These deficiencies had the potential to affect all 87 residents at the facility.
Deficiencies (4)
K291 Emergency Lighting: The facility failed to ensure emergency lighting was provided on the load side of the transfer switch of the emergency power supply generator. Emergency lighting was not present in the mechanical room where the emergency generator was located.
K351 Sprinkler System Installation: The facility failed to ensure sprinklers were installed within 1 to 12 inches from the ceiling as required. The sprinkler in the Ansul Room for the Fireside Grill was approximately 2 feet down from the ceiling.
K511 Utilities - Gas and Electric: The facility failed to ensure low voltage wiring under seven feet was protected in conduit or walls. Low voltage wiring for the fire alarm system was not protected at the main fire alarm panel in the mechanical room.
K918 Electrical Systems - Essential Electric System: The facility failed to ensure monthly load tests were conducted on the emergency generator as required. Monthly load tests were not completed for multiple months in 2023 and 2024.
Report Facts
Residents affected: 87
Total beds: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and confirmed deficiencies related to emergency lighting, sprinkler installation, low voltage wiring, and generator testing |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 3
Date: Jun 6, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident elopement incident at Ignite Medical Resort Kansas City, LLC.
Complaint Details
The complaint investigation was substantiated based on evidence that the resident eloped on 2/29/24 and staff failed to follow elopement policy and notify the resident's representative in a timely manner.
Findings
The facility failed to provide adequate protective oversight to a resident with cognitive impairments, resulting in the resident eloping from the facility and being found off premises. Staff failed to follow policy and notify the resident's representative promptly.
Deficiencies (3)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide protective oversight to a resident with Alzheimer's disease and other cognitive impairments, resulting in elopement and delayed notification to the resident's representative.
A4074 19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: The facility did not have a procedure to inquire about the resident's whereabouts during voluntary leave as required.
A4088 19 CSR 30-85.042(79) Notify Responsible Party-Change in Condition: The facility failed to immediately notify the designated person in the resident's record after the elopement incident.
Report Facts
Facility census: 89
BIMS score: 12
BIMS score: 14
Elopement drill date: Jun 18, 2024
Plan of correction completion date: Jun 28, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephen Smith | Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Named in corrective action plan to complete staff education on elopement policy | |
| LPN A. | Interviewed regarding resident's return and documentation of elopement | |
| Employee A | Interviewed about resident elopement and recognition of resident in photo | |
| Family Member B | Interviewed as legal power of attorney and regarding notification of elopement |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 3
Date: Jun 6, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident who eloped from the facility on the night of 2/29/24 and was found off the property without staff awareness or notification to the resident's personal representative.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to provide protective oversight to a resident at risk for elopement, resulting in the resident leaving the facility unnoticed.
Failed to notify the resident's personal representative of the elopement incident as required by facility policy.
Failed to document the elopement incident in the resident's clinical record as per protocol.
Report Facts
Facility census: 89
BIMS score: 12
BIMS score: 14
Elopement duration: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee A | Witnessed the elopement incident and recognized the resident in a photo sent by family member | |
| Family Member B | Legal Power of Attorney | Resident's legal power of attorney who was not notified of the elopement incident |
| LPN A. | Licensed Practical Nurse | Conducted head to toe assessment of resident after elopement and reported uncertainty about documentation and notification |
| Director of Nursing | Director of Nursing | Observed resident outside with police, notified staff, and reported facility investigation and resident's BIMS score |
| Interim Administrator | Interim Administrator | Reported facility investigation completion and adherence to elopement policy |
Inspection Report
Routine
Census: 89
Deficiencies: 9
Date: Jul 25, 2023
Visit Reason
The inspection was a routine regulatory survey of Ignite Medical Resort Kansas City, LLC to assess compliance with healthcare facility regulations including resident care, safety, and food service.
Findings
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.
Deficiencies (9)
Failure to honor residents' right to dignified existence by serving meals on Styrofoam and plastic cutlery for multiple residents.
Failure to accommodate resident needs by providing a bed sufficient in length for one resident.
Failure to maintain a clean, comfortable, and homelike environment including clean floors, toilets, and timely linen changes for residents.
Failure to update resident care plans and hold care plan meetings involving residents or their guardians.
Failure to provide professional wound care including obtaining treatment orders and timely dressing changes for a resident with a surgical site.
Failure to provide adequate assistance with activities of daily living including repositioning, incontinent care, oral care, and showers for multiple residents.
Failure to provide sufficient nursing staff to meet resident needs including timely response to call lights and timely medication administration.
Failure to ensure food and drink is palatable, attractive, and served at safe and appetizing temperatures; meals served cold and late; food substitutions without proper notification; and failure to honor resident food preferences and portions.
Failure to ensure meals and snacks are served at times in accordance with resident needs and preferences, including failure to provide nourishing bedtime snacks and allowing excessive time between evening meal and breakfast.
Report Facts
Facility census: 89
Residents sampled: 18
Meal service start times: 7
Meal service start times: 11
Meal service start times: 16
Meal temperature: 127
Meal temperature: 120
Meal temperature: 149
Pressure ulcer size: 6.3
Pressure ulcer size: 4.3
Pressure ulcer size: 0.1
Braden score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided expectations on meal service, wound care, call light response, and resident care |
| Administrator | Administrator | Provided expectations on meal service, staffing, resident care, and facility operations |
| Dietary Manager | Dietary Manager | Provided information on food service, ordering, and meal preparation |
| Licensed Practical Nurse B | Licensed Practical Nurse | Provided information on resident bed length and care |
| Physical Therapist A | Physical Therapist | Provided information on resident bed length and mobility |
| Charge Nursing Officer | Charge Nursing Officer | Provided information on care plan meetings and resident care |
| Registered Nurse B | Registered Nurse | Provided information on medication passes and staffing |
| Certified Nurse Aide A | Certified Nurse Aide | Provided information on shower schedule and resident care |
| Certified Nurse Aide E | Certified Nurse Aide | Observed assisting resident with repositioning and care |
Inspection Report
Routine
Census: 89
Deficiencies: 6
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 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.
Deficiencies (6)
Failure to honor residents' dignity by serving meals with plastic cutlery and Styrofoam containers for six sampled residents.
Failure to obtain timely wound care treatment orders and provide appropriate dressing changes for one resident with a surgical site.
Failure to provide adequate assistance with activities of daily living including repositioning, incontinent care, oral care, and showers for four sampled residents.
Failure to provide sufficient nursing staff to meet residents' needs, resulting in delayed call light response and medication administration for multiple residents.
Failure to accommodate resident dietary preferences, provide meal choices, and follow posted menus, resulting in residents receiving substituted or unavailable food items and inadequate portions.
Failure to provide bedtime snacks and maintain no more than 14 hours between evening meal and breakfast for five sampled residents.
Report Facts
Facility census: 89
Deficiency count: 6
Deficiency count: 1
Deficiency count: 4
Deficiency count: 6
Deficiency count: 5
Pressure ulcer size: 6.3
Pressure ulcer size: 4.3
Pressure ulcer size: 0.1
Braden score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Named in relation to food shortages, meal substitutions, and kitchen ordering practices | |
| Director of Nursing | DON | Provided expectations on meal service, wound care, call light response, and staffing |
| Administrator | Provided expectations on meal service, staffing, and resident care | |
| Nurse Practitioner A | NP | Provided wound care encounter note for Resident #181 |
| LPN C | Licensed Practical Nurse | Observed wound condition and provided care instructions for Resident #181 |
| RN A | Registered Nurse | Obtained wound care orders late for Resident #181 |
| CNA E | Certified Nurse Aide | Observed assisting Resident #2 with pressure relieving cushion and care |
| RN B | Registered Nurse | Described medication pass timing and staffing |
| LPN D | Licensed Practical Nurse | Described medication pass and new admit medication process |
| CNA A | Certified Nurse Aide | Described shower and snack provision practices |
| CNA B | Certified Nurse Aide | Described call light response and snack provision |
Inspection Report
Life Safety
Census: 89
Capacity: 90
Deficiencies: 7
Date: Jul 25, 2023
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to meet several Life Safety Code requirements including exit door widths and automatic flush bolts, sprinkler system maintenance and testing, smoke barrier integrity, fire door inspections, portable space heater restrictions, electrical system maintenance, and safe use of power cords and extension cords. These deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (7)
K233: The facility failed to ensure exit doors with an inactive leaf had automatic flush bolts, affecting one of ten smoke compartments. The double doors to the dialysis storage room had a manual flush bolt on one door leaf.
K353: The facility failed to maintain the sprinkler system according to NFPA 25, including missing inspections, incorrect sprinkler heads, and paint on sprinkler heads. This affected all residents, staff, and visitors.
K372: The facility failed to maintain smoke barrier walls to ensure they were complete and intact, affecting five of ten smoke compartments.
K761: Facility staff failed to properly inspect, test, maintain, and document fire-rated doors in accordance with NFPA 101 requirements.
K781: The facility failed to maintain proper space heating appliances limited to 212 degrees Fahrenheit in one smoke compartment. A portable heater in the dialysis room lacked a temperature rating.
K918: The facility failed to establish a program to exercise main and feeder breakers for the emergency generator, risking generator reliability.
K920: The facility failed to assure the safe use of power strips in resident rooms, affecting seven of ten smoke compartments. Power strips were used improperly with medical equipment and extension cords.
Report Facts
Facility capacity: 90
Resident census: 89
Smoke compartments affected: 1
Smoke compartments affected: 5
Smoke compartments affected: 7
Inspection Report
Routine
Deficiencies: 0
Date: Dec 14, 2022
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC guidelines and 42 CFR 483.73.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 2, 2022
Visit Reason
A COVID-19 focused infection control survey and a COVID-19 focused emergency preparedness survey were conducted from 10/28/22 through 11/2/22 to assess compliance with CMS and CDC recommended practices and federal emergency preparedness regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR-483.73 related to emergency preparedness.
Inspection Report
Plan of Correction
Census: 86
Deficiencies: 2
Date: Aug 17, 2022
Visit Reason
The inspection was conducted to investigate deficiencies related to pressure ulcer treatment and medication administration at Ignite Medical Resort Kansas City, LLC.
Findings
The facility failed to ensure proper pressure ulcer care and prevention for a resident, including timely treatment orders and repositioning. The facility also failed to prevent significant medication errors related to administration of hydrocodone to a resident with a documented allergy.
Deficiencies (2)
F686: The facility failed to follow pressure ulcer wound care treatment and change a resident's condition policies, including turning and repositioning every two hours and obtaining timely treatment orders for a pressure ulcer.
F760: The facility failed to prevent significant medication errors by administering hydrocodone to a resident with a documented allergy to the medication.
Report Facts
Facility census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Named in relation to nursing notes and progress notes documenting pressure ulcer condition |
| LPN E | Licensed Practical Nurse | Interviewed regarding treatment of resident's heel pressure ulcer |
| Administrator | Interviewed about facility awareness and actions regarding pressure ulcer | |
| Director of Nursing | Director of Nursing (DON) | Interviewed about pressure ulcer concerns and medication error investigation |
| Registered Nurse A | Registered Nurse | Interviewed about resident medication allergies and admission |
| LPN A | Licensed Practical Nurse | Interviewed about medication administration and allergies |
| LPN B | Licensed Practical Nurse | Interviewed about medication administration and allergies |
| LPN C | Licensed Practical Nurse | Interviewed about medication administration and allergies |
| CMT B | Interviewed about medication administration and allergies | |
| Pharmacist | Interviewed about medication order clarification and allergy documentation |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 11
Date: Jul 15, 2021
Visit Reason
Annual survey conducted to assess compliance with federal regulations at Ignite Medical Resort Kansas City, LLC.
Findings
The facility was found to have multiple deficiencies related to resident rights, abuse/neglect policies, comprehensive care plans, professional standards of care, medication labeling, and food safety. Several residents' care plans and medical records lacked required elements, and staff failed to follow proper procedures in various areas.
Deficiencies (11)
F550 Resident Rights: The facility failed to ensure one resident was treated in a dignified manner and did not provide care plans in the resident's primary language.
F607 Abuse/Neglect Policies: The facility failed to develop and implement policies regarding employee background checks and Family Care Safety Registry checks for sampled employees.
F656 Comprehensive Care Plan: The facility failed to develop and implement comprehensive person-centered care plans for two residents, missing measurable objectives and addressing medical conditions.
F658 Professional Standards: Staff failed to follow professional standards of care, including obtaining orders for oxygen therapy and nebulizer treatments for sampled residents.
F679 Activities: The facility failed to provide an ongoing program to support residents' choice of activities based on comprehensive assessments.
F686 Skin Integrity: The facility failed to prevent the development of new pressure ulcers and did not follow care plans for one resident with pressure ulcers.
F695 Respiratory Care: The facility failed to provide proper respiratory care, including humidified water bottle replacement and cleaning of oxygen concentrator filters.
F761 Labeling of Drugs and Biologicals: The facility failed to properly label medications and discard expired or loose medications.
F790 Dental Services: The facility failed to provide routine and emergency dental services to sampled residents in a timely manner.
F804 Food and Drink: The facility failed to ensure residents received nutritious, properly prepared meals and did not follow food safety policies.
F812 Food Procurement and Sanitation: The facility failed to ensure proper food handling, sanitation, and storage practices in the kitchen.
Report Facts
Facility census: 85
Sampled residents: 18
Sampled employees: 10
Inspection Report
Routine
Census: 85
Deficiencies: 11
Date: Jul 15, 2021
Visit Reason
Routine inspection of Ignite Medical Resort Kansas City, LLC to assess compliance with regulatory standards including resident rights, care planning, abuse prevention, medication administration, respiratory care, nutrition, and food service safety.
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 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.
Deficiencies (11)
Failure to ensure one resident was treated in a dignified manner with activities and communication in their primary language (Farsi).
Failure to develop and implement a policy regarding employee background checks and incomplete Family Care Safety Registry checks for sampled employees.
Failure to develop and implement comprehensive person-centered care plans for two residents addressing mood, dementia, anxiety, diabetes, and anticoagulant therapy.
Failure to ensure professional standards of care in medication administration including lack of physician orders for oxygen therapy, nebulizer treatments, and improper application of Silvadene cream.
Failure to provide activities of daily living including showers and shaving per resident preferences for multiple residents.
Failure to prevent development of new pressure ulcers for one resident due to inadequate skin assessments, repositioning, and wound care.
Failure to provide safe and appropriate respiratory care including undated oxygen and nebulizer tubing, unclean filters, and empty humidifier bottles.
Failure to discard expired medications and presence of loose pills in medication carts and storage rooms.
Failure to provide routine and emergency dental care for a resident with severe dental issues causing pain, poor appetite, and weight loss.
Failure to ensure food and drink were palatable, attractive, and served at safe temperatures; incorrect meals delivered; and pureed food not prepared to correct consistency.
Failure to ensure kitchen staff followed food service safety standards including improper glove use, failure to wash or sanitize hands between tasks, and manual handling of food without utensils.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 5
Loose pills: 5
Expired medications: 1
Pressure ulcer size: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide E | Certified Nurse Aide | Mentioned in relation to Resident #28's television programming in primary language |
| Director of Nursing | Director of Nursing | Provided statements regarding care plans and medication orders |
| Director of Culture and Engagement | Director of Culture and Engagement | Interviewed regarding employee background checks |
| Registered Nurse A | Registered Nurse | Interviewed regarding care plans and medication orders |
| Certified Nurse Aide A | Certified Nurse Aide | Interviewed regarding pressure ulcer care |
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed regarding wound care and medication cart |
| Chief Clinical Officer | Chief Clinical Officer | Interviewed regarding skin assessments and medication cart |
| Registered Nurse B | Registered Nurse | Resident's nurse, interviewed regarding dental care |
| Assistant Dietary Director | Assistant Dietary Director | Interviewed regarding food service and pureed food preparation |
| Kitchen Manager | Kitchen Manager | Interviewed regarding food service safety and meal preparation |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 21, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 28, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted from December 28, 2020 to December 30, 2020 to assess compliance with relevant CMS and CDC requirements.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 11-19-20 through 11-30-20 to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS/CDC recommended practices for COVID-19 infection control during the survey period.
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 4
Date: Jul 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted from July 16, 2020 to July 22, 2020 to investigate compliance with professional standards and infection control related to a complaint.
Complaint Details
The investigation was complaint-related focusing on COVID-19 emergency preparedness and professional standards of care following a resident fall and subsequent treatment failures.
Findings
The facility failed to provide appropriate treatment and services for one sampled resident, including failure to follow up with a neurosurgeon after a fall and inadequate monitoring and treatment of head lacerations. The facility also failed to maintain proper infection control practices during the COVID-19 pandemic.
Deficiencies (4)
F658 Comprehensive Care Plans: The facility failed to provide appropriate treatment and services for a resident, including failure to follow up with a neurosurgeon after a fall and inadequate monitoring and treatment of head lacerations.
F880 Infection Prevention & Control: The facility failed to maintain proper infection control practices based on facility policy and accepted standards during the 2019 Novel Coronavirus Disease (COVID-19) pandemic.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by Class II deficiency.
A4085 Infection Control/Communicable Disease: Residents shall be cared for by using acceptable infection control procedures to prevent the spread of infection. This regulation was not met as evidenced by Class II deficiency.
Report Facts
Facility census: 80
Number of sampled residents: 6
Deficiencies cited: 4
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 1
Date: Jun 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to investigate compliance with infection prevention and control regulations related to COVID-19.
Complaint Details
This was a complaint-related investigation focusing on infection control practices during the COVID-19 pandemic. The facility was found noncompliant with infection prevention and control requirements.
Findings
The facility was found to be in compliance with some infection control requirements but failed to properly plan for COVID-19 spread prevention and did not document resident temperatures consistently. Dietary staff failed to sanitize or wash hands between rooms and did not follow posted contact precautions for residents.
Deficiencies (1)
F880 Infection Prevention & Control: The facility failed to properly plan for COVID-19 spread and did not document temperatures for one sampled resident on multiple days. Dietary staff failed to sanitize or wash hands between rooms and did not follow posted contact precautions.
Report Facts
Facility census: 76
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding resident temperature documentation and infection control practices |
| Dietary Aide A | Dietary Aide | Observed failing to wash or sanitize hands and not wearing gloves during food service |
| Dietary Aide B | Dietary Aide | Observed handling dirty dishes without gloves or hand sanitizer use |
| Dietary Manager | Dietary Manager | Interviewed about hand hygiene expectations for dietary staff |
| Hospitality Director | Hospitality Director | Interviewed about infection control practices and resident contact precautions |
| Administrator | Administrator | Interviewed regarding resident temperature documentation and dietary staff hand hygiene |
Inspection Report
Plan of Correction
Census: 90
Deficiencies: 2
Date: Feb 11, 2020
Visit Reason
The inspection was conducted to investigate compliance with professional standards of care, specifically regarding comprehensive care plans and appointment scheduling for residents.
Findings
The facility failed to ensure staff followed professional standards of care by not keeping a physician-ordered appointment for a sampled resident. The facility lacked a system to ensure appointment orders were followed and documented properly.
Deficiencies (2)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i). The facility failed to ensure staff followed professional standards of care by not keeping a physician-ordered appointment for a sampled resident and lacked a system to ensure appointment orders were followed and documented.
A4074 Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as referenced by F658.
Report Facts
Facility census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Sellers | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 4
Date: Jan 8, 2020
Visit Reason
The inspection was conducted due to a complaint alleging misappropriation and exploitation of resident property by a contracted beautician using residents' credit card information without authorization.
Complaint Details
The complaint investigation substantiated that the Facility Stylist used a resident's credit card without authorization to order pizza delivered to an unrecognized address. The facility administrator filed a police report and terminated the contract with the beautician. The facility failed to conduct required background checks on the contracted stylist.
Findings
The facility failed to prevent misappropriation of one resident's credit card information resulting in unauthorized charges. The facility also failed to conduct required background checks on the contracted beautician prior to employment.
Deficiencies (4)
F602: The resident was not free from misappropriation and exploitation as the facility staff failed to prevent unauthorized use of a resident's credit card for charges to an unrecognized address.
F606: The facility did not employ or engage staff with adverse actions, failing to perform criminal background checks, federal marker checks, Employee Disqualification List checks, and CNA registry checks on the contracted beautician prior to allowing work.
A4017: The facility failed to request and maintain criminal background checks for employees within two working days of hire, violating state regulations.
A8023: The facility failed to develop and implement policies prohibiting mistreatment, neglect, and abuse, including misappropriation of resident property and funds, and failed to report such incidents to appropriate authorities.
Report Facts
Facility census: 87
Unauthorized charge amount: 63.32
Inspection Report
Plan of Correction
Census: 86
Deficiencies: 9
Date: Oct 17, 2019
Visit Reason
The document is a Plan of Correction submitted by Ignite Medical Resort Kansas City following a survey conducted on 10/17/2019. It addresses deficiencies cited in the facility's inspection report.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, required postings, abuse/neglect policies, criminal background checks, notice requirements before transfer/discharge, professional standards of care, medication administration, infection control, bowel/bladder incontinence care, tube feeding management, and other regulatory requirements. The facility census was 86 at the time of the survey.
Deficiencies (9)
F550 Resident Rights. The facility failed to assure staff treated residents with dignity, including rude behavior by a Certified Nurse Aide (CNA E) toward residents. The facility census was 86.
F575 Required Postings. The facility failed to post a list of names, addresses, and telephone numbers of pertinent state agencies and advocacy groups in a conspicuous location. The facility census was 86.
F607 Abuse/Neglect Policies. The facility failed to perform required criminal background checks on nine of ten newly hired staff prior to direct resident contact. The facility census was 86.
F623 Notice Before Transfer/Discharge. The facility failed to provide written notice of transfer or discharge to residents or responsible parties in a language they understood, affecting two of 18 sampled residents. The facility census was 86.
F658 Professional Standards. The facility failed to provide services meeting professional standards of care, including improper administration of nasal sprays and eye drops to multiple residents. The facility census was 86.
F690 Bowel/Bladder Incontinence. The facility failed to provide appropriate catheter care and maintain continence for one resident with a urinary tract infection. The facility census was 86.
F693 Tube Feeding Management. The facility failed to provide appropriate care and services for residents with percutaneous endoscopic gastrostomy (PEG) tubes, including medication administration and placement checks. The facility census was 86.
F759 Medication Error Rate. The facility failed to maintain a medication error rate below 5%, with a rate of 24% affecting three of 18 sampled residents. The facility census was 86.
F880 Infection Control. The facility failed to establish and maintain an infection prevention and control program, including failure to follow isolation precautions and dietary staff awareness. The facility census was 86.
Report Facts
Facility census: 86
Medication error rate: 24
Medication error rate threshold: 5
Number of sampled residents: 18
Number of newly hired staff checked: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Hampton | Resident Funds Director | Mentioned in relation to staff hire dates and orientation |
| CNA E | Named in allegations of rude and discourteous behavior toward residents | |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding staff treatment of residents and corrective actions |
Inspection Report
Life Safety
Census: 86
Capacity: 96
Deficiencies: 7
Date: Oct 17, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related fire safety regulations.
Findings
The facility failed to meet several fire safety requirements including proper signage on delayed egress doors, installation of a deep fat fryer with required clearances, semi-annual fire alarm inspections, maintenance of sprinkler systems, smoke barrier construction and doors, and fire drills. These deficiencies had the potential to affect all residents in the event of a fire emergency.
Deficiencies (7)
K222 Egress Doors: The facility failed to provide a durable sign with contrasting background on delayed egress doors and failed to place 'This is not an EXIT' signs on courtyard doors.
K324 Cooking Facilities: The facility failed to install a deep fat fryer with required 18 inches clearance or a baffle to prevent grease and flame contact.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to perform the semi-annual inspection of the automatic fire alarm system.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the sprinkler system properly, including late quarterly inspections and missing tools for sprinkler head replacement.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barrier walls, with holes and gaps found in the smoke barrier construction affecting eight of ten smoke compartments.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: The facility failed to properly install smoke barrier doors to prevent gaps and maintain a 20-minute fire protection rating.
K712 Fire Drills: The facility failed to conduct fire drills on each shift per quarter at varied times, including missing night shift drills and insufficient monthly drills.
Report Facts
Facility Capacity: 96
Census: 86
Fire Drill Dates: 7
Inspection Report
Plan of Correction
Census: 71
Deficiencies: 2
Date: May 16, 2019
Visit Reason
The inspection was conducted to assess compliance with care requirements for dependent residents, specifically focusing on assistance with activities of daily living such as nutrition and supervision during meals.
Findings
The facility failed to provide adequate assistance with nutrition and supervision during meals for three sampled residents. Observations and interviews showed residents were not offered sufficient food or assistance, and staff did not adequately monitor or encourage residents during dining.
Deficiencies (2)
F 677 Care Provided for Dependent Residents CFR(s): 483.24(a)(2) The facility failed to provide necessary assistance with nutrition and supervision during meals for three sampled residents. Staff did not offer additional food or assist residents adequately during dining times.
A4074 Nursing Care per Resident Condition 19 CSR 30-85.042(67) Each resident shall receive personal attention and nursing care consistent with their condition. This regulation was not met as referenced by F677.
Report Facts
Facility census: 71
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 9, 2018
Visit Reason
Annual licensure inspection of Ignite Medical Resort Kansas City, LLC to assess compliance with state health facility regulations.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Life Safety
Deficiencies: 0
Date: Nov 9, 2018
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility met the applicable provisions of the 2012 edition of the Life Safety Code. No deficiencies or state licensure deficiencies were cited during this inspection.
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