Inspection Reports for
Ignite Medical Resort St Mary‘s

MO, 64014

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 7.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

40% worse than Missouri average
Missouri average: 5.5 deficiencies/year

Deficiencies per year

12 9 6 3 0
2020
2022
2024

Occupancy

Latest occupancy rate 65% occupied

Based on a August 2024 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy rate over time

40% 60% 80% 100% Jan 2020 Oct 2022 Aug 2024

Inspection Report

Census: 84 Deficiencies: 7 Date: Aug 21, 2024

Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment for residents, focusing on environmental cleanliness and equipment maintenance.

Findings
The facility failed to maintain commode risers in multiple resident rooms free from areas that were not easily cleanable, failed to maintain fans and ceiling vents free from dust buildup, failed to keep floors clean in certain rooms, failed to repair damaged countertops and grab bars, and failed to ensure shower chairs were in good repair. These deficiencies potentially affected at least 30 residents.

Deficiencies (7)
Failed to maintain commode risers in multiple resident rooms free from areas that were not easily cleanable
Failed to maintain the fan in resident room B105 free from a buildup of dust
Failed to maintain the ceiling vent in resident room A101 free from heavy dust buildup
Failed to ensure the floor was maintained clean in resident rooms A105 and C109
Failed to ensure the countertop in the A Hall shower room was in good repair (missing tile pieces)
Failed to ensure the grab bar was firmly attached to the wall in the restroom of B105
Failed to ensure the shower chair in D105 was in good repair (broken and needed to be discarded)
Report Facts
Residents affected: 30 Facility census: 84 Missing tile pieces length: 12 Missing tile pieces length: 8

Employees mentioned
NameTitleContext
Housekeeper BHousekeeperReported on fan cleaning and loose grab bar
Environmental Services DirectorInterviewed multiple times regarding deficiencies and maintenance issues

Inspection Report

Complaint Investigation
Census: 76 Deficiencies: 7 Date: Oct 25, 2022

Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to properly manage resident funds, ensure background checks for employees, follow feeding tube orders, limit psychotropic medication use, maintain proper sanitation, and ensure working call light systems for residents.

Complaint Details
The complaint investigation was triggered by allegations of improper management of resident funds, failure to conduct proper employee background checks, failure to follow medical orders for feeding tubes, inappropriate use of psychotropic medications, sanitation issues with dumpsters, and lack of accessible call light systems for residents.
Findings
The facility was found deficient in multiple areas including failure to obtain resident signatures for goods and services, improper handling and commingling of resident funds, incomplete employee background checks, failure to follow physician orders for tube feeding, lack of timely re-evaluation of psychotropic PRN medications, failure to keep dumpster lids closed, and failure to maintain a working call light system accessible to a resident.

Deficiencies (7)
Failed to ensure resident signatures were obtained for goods and services and proper handling of resident funds.
Failed to properly hold, secure, and manage each resident's personal money and prevent commingling of funds.
Failed to check Employee Disqualification List as part of background checks for newly hired employees and failed to check current employees against quarterly updates.
Failed to follow physician's orders for continuous tube feeding for one resident.
Failed to limit PRN anti-anxiety medication use to 14 days and ensure physician re-evaluation.
Failed to ensure dumpster lids were closed for three days during the survey.
Failed to ensure a working call light system or alternate system was consistently accessible within reach for one resident dependent on staff for ADLs.
Report Facts
Facility census: 76 Resident funds amount: 3789.77 Resident funds amount: 646.82 Resident funds amount: 2221.06 Resident funds amount: 3040.3 Resident funds amount: 15550.64 Number of employees: 151 PRN Ativan doses: 3

Employees mentioned
NameTitleContext
Employee ANewly hired employeeFailed to have complete background check including EDL quarterly updates
Employee FNewly hired employeeFailed to have complete background check including EDL quarterly updates
Business Office ManagerResponsible for resident trust funds accounts and signed receipts as representative payee
Director of Culture and EngagementResponsible for prospective new employee background screenings
Assistant Chief Nursing Officer AProvided clarifications on tube feeding and call light system issues
Chief Nursing OfficerProvided clarifications on tube feeding and call light system issues
Licensed Practical Nurse AProvided information on PRN medication re-certification
Nursing Assistant AReported call button pendant not working and checked on resident
Certified Nursing Assistant AReported call button pendant not working and checked on resident

Inspection Report

Routine
Census: 75 Deficiencies: 9 Date: Jan 14, 2020

Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, and facility operations including dignity in care, financial management, cleanliness, discharge procedures, medication administration, personal care, respiratory care, and infection control.

Findings
The facility was found deficient in multiple areas including failure to assist residents with dignity during meals, improper distribution of resident trust fund interest, inadequate cleanliness of bathrooms and handrails, failure to provide timely written discharge notifications, incomplete discharge summaries, improper medication administration techniques, incomplete perineal care, failure to date and clean oxygen equipment, and lapses in infection control practices including hand hygiene and catheter care.

Deficiencies (9)
Failed to treat residents with dignity and respect during meal times by not assisting a resident with feeding needs.
Failed to distribute interest evenly to residents in the Resident Trust Fund.
Failed to maintain a clean environment including bathrooms and handrails; laundry service was not timely.
Failed to provide written notice of transfer or discharge to residents and responsible persons.
Failed to complete comprehensive discharge summaries for discharged residents.
Failed to follow manufacturer guidelines for administering nasal spray and eye drops and wound treatment orders.
Failed to provide complete perineal care for residents dependent on staff assistance.
Failed to date oxygen tubing and maintain oxygen concentrator filters clean and free of dust.
Failed to follow infection control protocols during medication administration and catheter drainage bag emptying.
Report Facts
Residents affected: 19 Resident Trust Fund accounts: 17 Resident census: 75 Interest earned: 1.24 Interest earned: 0.94 Interest earned: 1

Employees mentioned
NameTitleContext
LPN ALicensed Practical NurseNamed in medication administration and wound care deficiencies
LPN CLicensed Practical NurseNamed in medication administration deficiencies
CNA ACertified Nurse AideNamed in dignity and perineal care deficiencies
CNA GCertified Nurse AideNamed in catheter care and perineal care deficiencies
Director of NursesDirector of NursingProvided interview statements regarding care expectations and deficiencies
Business Office ManagerProvided interview statements regarding Resident Trust Fund interest distribution
Lead HousekeeperProvided interview statements regarding housekeeping and laundry services
Executive DirectorProvided interview statements regarding facility issues and corrective actions
RN ARegistered NurseNamed in discharge notification deficiencies
CNA ECertified Nurse AideNamed in perineal care deficiencies
Social Worker AProvided interview statements regarding discharge summary follow-up

Report

August 27, 2024

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