Deficiencies (last 4 years)
Deficiencies (over 4 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
138% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
98% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 1
Date: Mar 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely identify and prevent a pressure ulcer in a dependent resident.
Complaint Details
The complaint investigation found that Resident 2 developed a stage 3 sacral pressure ulcer that was not identified until four days after admission. The facility's initial skin assessment was delayed, and care plans lacked specific treatment for the wound. The resident was at risk for pain, infection, and complications due to this delay.
Findings
The facility failed to identify and prevent a stage 3 sacral pressure ulcer for Resident 2, which was not documented until four days after admission. This deficient practice placed the resident at risk for pain, infection, and worsening condition.
Deficiencies (1)
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, as Resident 2's stage 3 sacral pressure ulcer was not identified until four days after admission.
Report Facts
Resident census: 94
Wound measurement: 4.43
Wound measurement: 0.5
Wound measurement: 0.1
Braden score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Provided statement about Resident 2's skin assessment on admission |
| Administrative Nurse E | Administrative Nurse | Acknowledged delayed skin assessment and described nursing practices |
| Administrative Nurse D | Administrative Nurse | Stated unawareness of delayed assessment and need for nurse re-education |
| Administrative Staff A | Administrative Staff | Acknowledged facility policy was not followed and noted staffing issues |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 1
Date: Dec 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation related to a resident fall and the facility's failure to ensure a safe environment free from preventable accidents.
Complaint Details
The investigation was triggered by a complaint regarding a fall of Resident 1 on 11/11/24. The fall was witnessed, resulted in a minor injury, and was not reported to the State Agency as it was considered without significant injury. The fall investigation was in risk management.
Findings
The facility failed to ensure a safe environment for Resident 1, who fell from bed and hit his head due to staff not following the two-person assistance care plan. The fall resulted in a minor injury and revealed deficiencies in accident hazard prevention policies and staff supervision.
Deficiencies (1)
F0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents. Staff did not follow the two-person assistance requirement for Resident 1, resulting in a fall and head injury.
Report Facts
Resident census: 89
Fall Risk Assessment score: 9
Previous falls: 3
Inspection Report
Routine
Census: 93
Deficiencies: 15
Date: Aug 22, 2024
Visit Reason
Routine inspection of Ignite Medical Resort Rainbow Boulevard, LLC to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including resident dignity, transfer notification, care plan updates, safety hazards, catheter care, dialysis care, bed rail assessments, RN coverage, medication management, food safety, infection control, and staff training.
Deficiencies (15)
F 0550: The facility failed to promote a dignified care environment for Resident 51 during mealtime, exposing his backside to peers and visitors, risking impaired dignity and psychosocial well-being.
F 0623: The facility failed to provide timely written notification of transfer to Resident 238 or their representative for multiple unplanned hospital transfers, risking miscommunication and missed healthcare opportunities.
F 0657: The facility failed to revise Resident 62's care plan to include interventions for dialysis AV fistula access site monitoring and care, risking impaired care due to uncommunicated needs.
F 0689: The facility failed to secure hazardous materials and rooms from nine cognitively impaired ambulatory residents, placing them at risk for preventable accidents and injuries.
F 0690: The facility failed to ensure Resident 12's suprapubic catheter was anchored on the abdomen to prevent pulling and injury, risking catheter-related complications.
F 0698: The facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding Resident 62's dialysis care and failed to identify and assess dialysis access type and location, risking complications.
F 0700: The facility failed to assess risks of bed rail use related to Resident 73's low air-loss mattress, placing him at risk for impaired safety due to unidentified risks.
F 0727: The facility failed to provide Registered Nurse coverage for eight consecutive hours daily, seven days a week, placing residents at risk of lack of assessment and inappropriate care.
F 0758: The facility failed to ensure Resident 79's PRN hydroxyzine order had a 14-day stop date or documented physician rationale, risking unnecessary psychotropic medication and side effects.
F 0761: The facility failed to store medications securely by leaving three medication carts unlocked, risking unsafe medication practices and misappropriation.
F 0812: The facility failed to ensure food items were appropriately labeled and stored after opening, risking food-borne illnesses and food safety concerns.
F 0880: The facility failed to follow infection control standards for Enhanced Barrier Precautions and lacked a water management program for Legionella, increasing residents' risk for infectious diseases.
F 0942: The facility failed to ensure agency staff received required resident rights training, placing residents at risk for impaired care and decreased quality of life.
F 0943: The facility failed to ensure agency staff received required abuse, neglect, and exploitation training, placing residents at risk for abuse, neglect, and exploitation.
F 0945: The facility failed to ensure agency staff received required infection control training, placing residents at increased risk for infections.
Report Facts
Residents affected: 93
Residents in sample: 19
Residents on Enhanced Barrier Precautions: 27
Dates lacking 8 consecutive RN hours: 5
Unsecured insulin pens found: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided statements on dignity, transfer notification, dialysis care, bed rail assessments, RN coverage, medication management, infection control, and medication cart security |
| Licensed Nurse H | Licensed Nurse | Secured medication carts and provided statements on hazardous materials and medication cart security |
| Licensed Nurse I | Licensed Nurse | Provided statements on dialysis care and bed rail safety |
| Certified Nurse Aide M | Certified Nurse Aide | Assisted Resident 12 with catheter care and provided observations |
| Administrative Staff A | Administrative Staff | Provided statements on RN coverage and agency staff training |
| Administrative Staff C | Administrative Staff | Provided statements on infection control and staff training |
| Licensed Nurse L | Licensed Nurse | Observed failure to wear gown during wound care on Enhanced Barrier Precautions |
Inspection Report
Routine
Census: 93
Deficiencies: 15
Date: Aug 22, 2024
Visit Reason
Routine inspection of Ignite Medical Resort Rainbow Boulevard, LLC to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity, inadequate notification of transfers, incomplete care plans for dialysis, unsecured hazardous materials, improper catheter care, insufficient dialysis communication, unassessed bed rail risks, lack of consistent RN coverage, improper medication management, food safety violations, infection control lapses, and incomplete staff training for agency personnel.
Deficiencies (15)
F 0550: The facility failed to promote a dignified care environment for Resident 51 during mealtime, exposing the resident's backside to others, risking impaired dignity and psychosocial well-being.
F 0623: The facility failed to provide timely written notification of transfer to Resident 238 or their representative for multiple unplanned hospital transfers, risking miscommunication and missed healthcare opportunities.
F 0657: The facility failed to revise Resident 62's care plan to include interventions for dialysis fistula access site monitoring and care, risking impaired care due to uncommunicated needs.
F 0689: The facility failed to secure hazardous materials and rooms from nine cognitively impaired ambulatory residents, placing them at risk for preventable accidents and injuries.
F 0690: The facility failed to ensure Resident 12's suprapubic catheter was anchored on the abdomen to prevent pulling and injury, risking catheter-related complications.
F 0698: The facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding Resident 62's dialysis care and failed to identify and assess her dialysis access type and location, risking complications.
F 0700: The facility failed to assess risks of bed rail use related to Resident 73's low air-loss mattress, placing the resident at risk for impaired safety.
F 0727: The facility failed to provide Registered Nurse coverage for eight consecutive hours daily, seven days a week, placing residents at risk of lack of assessment and inappropriate care.
F 0758: The facility failed to ensure Resident 79's PRN hydroxyzine order had a 14-day stop date or documented physician rationale, risking unnecessary psychotropic medication use and side effects.
F 0761: The facility failed to store medications securely when staff left three medication carts unlocked, risking unsafe medication practices and misappropriation.
F 0812: The facility failed to ensure food items were appropriately labeled and stored after opening, risking food-borne illnesses and food safety concerns.
F 0880: The facility failed to follow infection control standards related to PPE use for Enhanced Barrier Precautions and lacked a water management program for Legionella, increasing infection risk.
F 0942: The facility failed to ensure agency staff received required resident rights training, placing residents at risk for impaired care and decreased quality of life.
F 0943: The facility failed to ensure agency staff received required abuse, neglect, and exploitation training, placing residents at risk for abuse, neglect, and exploitation.
F 0945: The facility failed to ensure agency staff received required infection control training, placing residents at increased risk for infections.
Report Facts
Residents Affected: 93
Residents Affected: 19
Residents Affected: 27
Medication carts unlocked: 3
Dates without 8-hour RN coverage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided statements on dignity, transfer notification, dialysis care plan, hazardous materials, catheter care, dialysis communication, bed rail assessments, RN coverage, medication cart security, infection control, and staff training |
| Licensed Nurse H | Licensed Nurse | Secured medication carts and provided statements on hazardous materials |
| Certified Nurse Aide M | Certified Nurse Aide | Assisted Resident 12 with catheter care and provided information on catheter anchoring |
| Licensed Nurse I | Licensed Nurse | Provided statements on dialysis care and catheter anchoring |
| Administrative Staff A | Administrative Staff | Provided statements on RN coverage and agency staff training |
| Administrative Staff C | Administrative Staff | Provided statements on Enhanced Barrier Precautions and agency staff training |
| Licensed Nurse K | Licensed Nurse | Agency staff with missing training records |
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 3
Date: Mar 21, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards in multiple areas including safety, behavioral health care, and dietary services.
Findings
The facility was found deficient in maintaining safe hazardous material disposal, adequately meeting behavioral health needs of a resident, and following sanitary dietary standards. These deficiencies posed risks of injury, behavioral outbursts, and food-borne illnesses to residents.
Deficiencies (3)
F 0689: The facility failed to ensure a Sharps container was maintained within acceptable standards, resulting in an overfilled sharps bin accessible to residents. This placed four cognitively impaired, independently mobile residents at risk for preventable injuries.
F 0740: The facility failed to adequately meet Resident R1's behavioral health needs related to non-pharmacological care approaches, resulting in repeated behavioral episodes and placing R1 and others at risk for behavioral outbursts and injuries.
F 0812: The facility failed to follow sanitary dietary standards for food storage and maintaining a sanitary food service environment, including expired foods, unclean equipment, and improper labeling. These practices placed residents at risk for food-borne illnesses.
Report Facts
Residents census: 91
Residents affected: 4
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Provided statements regarding sharps bin replacement and behavioral interventions |
| Administrator A | Administrator | Provided statements regarding sharps bin management and behavioral interventions |
| Certified Nurses Aid M | Certified Nurses Aid | Reported on Resident R1's behaviors and interactions |
| Administrative Nurse D | Administrative Nurse | Commented on behavioral improvements and interventions for Resident R1 |
| Dietary Staff BB | Dietary Staff | Provided statements regarding kitchenettes management and food safety |
| Administrative Staff A | Administrative Staff | Commented on kitchenettes cleaning responsibilities |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 1
Date: Jan 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow-up with a resident's physician after a change in condition.
Complaint Details
The complaint investigation found that the facility did not properly notify or follow-up with the physician after Resident 1 showed signs of decline on 12/30/23. The facility's policy required notification and escalation if the physician did not respond, but staff failed to ensure follow-up. The complaint was substantiated with findings of deficient practice.
Findings
The facility failed to follow-up with Resident 1's physician after a significant change in condition, risking delayed treatment and physical complications. Documentation and interviews revealed inadequate communication with the physician and on-call services despite the resident's deteriorating status.
Deficiencies (1)
F 0684: The facility failed to follow-up with Resident 1's physician when he experienced a change in condition. This deficient practice had the risk for delayed treatment and unwarranted physical complications.
Report Facts
Resident census: 82
Vital signs: 97.61
Vital signs: 111
Vital signs: 20
Oxygen saturation: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Reported resident's condition and attempted to contact on-call physician |
| Administrative Nurse D | Administrative Nurse | Provided expectations for nurse follow-up and escalation after resident's change in condition |
| LN I | Licensed Nurse | Stated protocol for calling physician and 911 after resident's change in condition |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 3
Date: Sep 12, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to provide appropriate nursing care, including failure to monitor blood thinner medication and failure to change PICC line dressings as ordered.
Complaint Details
The investigation was complaint-driven, focusing on allegations of failure to monitor blood thinner medication and failure to change PICC line dressings as ordered. The complaint was substantiated with findings of deficient nursing care and medication errors.
Findings
The facility failed to ensure nursing staff followed physician orders for monitoring blood thinner medication and changing PICC line dressings, resulting in increased risk of bleeding, infection, and medication errors. The facility also failed to prevent a significant medication error related to Coumadin administration due to a transcription error.
Deficiencies (3)
F 0684: The facility failed to provide appropriate treatment and care by not following physician orders to monitor Resident 1's PT/INR related to Coumadin and Lovenox use, placing the resident at risk for bleeding or complications.
F 0726: The facility failed to ensure nursing staff changed Resident 2's PICC line dressing as ordered and signed the treatment record without performing the dressing change, placing the resident at risk for infection.
F 0760: The facility failed to prevent a significant medication error when Coumadin was not administered to Resident 1 due to a transcription error, placing the resident at risk for health complications and ineffective medication regimen.
Report Facts
Residents census: 93
Medication doses: 6
Dates of orders: Sep 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Provided statements regarding blood draw refusals and documentation |
| Licensed Nurse G | Licensed Nurse | Verified PICC dressing status and discussed Coumadin monitoring |
| Administrative Staff A | Administrative Staff | Acknowledged medication error and admission double check failure |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Ignite Medical Resort Rainbow Boulevard, LLC.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 28, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Ignite Medical Resort Rainbow Boulevard, LLC.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 89
Deficiencies: 8
Date: Jan 5, 2023
Visit Reason
Routine inspection of Ignite Medical Resort Rainbow Boulevard, LLC to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and facility environment.
Findings
The facility failed to maintain a sanitary and homelike environment, ensure proper application of physician-ordered treatments including support stockings and weights, provide adequate dementia care, prevent medication errors, coordinate hospice care, and implement infection control precautions effectively. These deficiencies placed residents at risk for adverse health outcomes and exposure to infections.
Deficiencies (8)
F 0584: The facility failed to maintain a sanitary, clean, and homelike environment, including urine odors, soiled linens, and unclean equipment, placing residents at risk for negative psychosocial outcomes.
F 0684: The facility failed to ensure physician-ordered support stockings were applied and weekly weights were taken as ordered for residents R51 and R46, risking complications from swelling and edema.
F 0744: The facility failed to provide adequate dementia care and supervision for Resident R11, placing her at risk for impaired physical and emotional well-being.
F 0756: The facility failed to ensure the consultant pharmacist identified and reported irregularities in administration of as needed antihypertensive medication for Resident R51, risking high blood pressure and adverse effects.
F 0757: The facility failed to ensure Resident R51 received physician-ordered as needed antihypertensive medication, risking uncontrolled blood pressure and related complications.
F 0760: The facility failed to prevent significant medication errors by administering incorrect doses of antidepressant medication to Resident R289, risking adverse medication effects and decreased therapeutic benefit.
F 0849: The facility failed to coordinate care and services with the hospice provider for Resident R12, including lack of hospice plan of care in the resident's hospice book, risking missed care opportunities.
F 0880: The facility failed to follow transmission-based precautions while weighing Resident R25 on isolation and allowed Resident R11 to enter an isolation room without PPE. Clean linens and briefs were stored uncovered, risking exposure to dangerous pathogens.
Report Facts
Residents on isolation precautions for COVID-19: 3
Residents on isolation precautions for CRAB: 4
Residents reviewed for medication: 20
Residents reviewed for dementia care: 2
Residents reviewed for unnecessary medications: 5
Residents reviewed for edema: 20
Dates with SBP > 170 mmHg for R51: 5
Residents in sample: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided statements on housekeeping, medication administration, infection control, and hospice care coordination |
| Licensed Nurse H | Licensed Nurse | Provided statements on support stockings, medication administration, and resident monitoring |
| Certified Nurse Aide Q | Certified Nurse Aide | Reported observations on room cleanliness and linen changes |
| Certified Nurse Aide M | Certified Nurse Aide | Reported on resident wandering and infection control practices |
| Consultant Pharmacist GG | Consultant Pharmacist | Reviewed medication irregularities and monthly medication reviews |
| Consultant HH | Consultant | Reviewed hospice book and infection control observations |
| Licensed Nurse I | Licensed Nurse | Provided statements on hospice care and housekeeping policies |
| Certified Nurse Aide O | Certified Nurse Aide | Reported on assistance with support stockings |
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 10
Date: Jul 9, 2021
Visit Reason
Annual inspection of Ignite Medical Resort Rainbow Boulevard, LLC to assess compliance with healthcare regulations including resident care, wound care, bathing services, medication administration, food safety, and infection control.
Findings
The facility failed to provide appropriate bariatric beds, adequate bathing services, sanitary wound care, proper foot care, timely medication administration, safe food handling, and infection control in laundry processing. Several residents experienced inadequate care in these areas, placing them at risk for harm.
Deficiencies (10)
F 0558: The facility failed to provide a bariatric bed for Resident 45 after the resident requested one, resulting in use of an inappropriate bed size.
F 0657: The facility failed to ensure application of compression stockings and sanitary wound care for Resident 24, resulting in a worsening full thickness wound.
F 0676: The facility failed to provide bathing services and clean clothing for dependent residents, including Residents 24, 42, 45, and 5, due to lack of towels and linens.
F 0677: The facility failed to provide bathing opportunities as preferred by residents, including Residents 14, 57, 60, 219, 22, 30, and 24, resulting in poor hygiene and resident discomfort.
F 0684: The facility failed to provide wound care in a sanitary manner for Residents 24 and 46, including failure to sanitize surfaces and perform hand hygiene, risking infection spread.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for Residents 52 and 60, including failure to use sanitary techniques and to reposition a resident.
F 0687: The facility failed to provide proper foot care for Residents 3 and 60, resulting in long, untrimmed toenails and foot abrasions.
F 0755: The facility failed to administer Resident 24's morning medications within the prescribed time frame, risking suboptimal medication response.
F 0812: The facility failed to maintain safe food handling practices when staff touched food and plates with contaminated gloves and entered the kitchen without hairnets, risking foodborne illness.
F 0880: The facility failed to maintain sanitary laundry processing areas, with soiled laundry bags on the floor and spillage, risking infection spread.
Report Facts
Residents sampled: 21
Residents reviewed for ADLs: 11
Residents reviewed for pressure ulcers: 4
Residents reviewed for unnecessary medications: 6
Stage II pressure ulcer size: 3
Stage II pressure ulcer size: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN J | Licensed Nurse | Named in wound care sanitary technique deficiency for Resident 46 |
| LN L | Licensed Nurse | Named in wound care sanitary technique deficiency for Resident 52 |
| CMA S | Certified Medication Aide | Named in medication administration deficiency for Resident 24 |
| CDM BB | Certified Dietary Manager | Named in food safety deficiency |
| Administrative Nurse D | Administrative Nurse | Named in multiple deficiencies including medication administration, bathing, foot care, and wound care |
| Administrative Nurse E | Administrative Nurse | Named in wound care sanitary technique deficiency |
| Administrative Nurse F | Administrative Nurse | Named in wound care and bathing deficiencies |
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