Ignite Medical Resort Blue Springs

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a safe environment for one sampled resident ( Resident #3) when on 3/8/25 he/she was found on the floor outside of his/her bathroom with his/her bathroom track door. The facility census was 89 residents. 1. Review of Resident #3's admission Record showed he/she admitted to the facility on [DATE] with the following diagnoses: -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). -Generalized Muscle Weakness. -Other Abnormalities of Gait and Mobility. -Cognitive Communication Deficit (an impairment in organization/thought organization, sequencing, attention, memory, planning, problem solving, and safety awareness). -Need for Assistance with Personal Care. Review of the resident's admission Minimum Data Set (MDS- a federally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a medication error did not occur when one sampled resident (Resident #2) received Resident #14's medications instead of his/her own ordered medications out of 14 sampled residents. The facility census was 89 residents. On 4/24/25, the Administrator was notified of the past non-compliance which occurred on 4/16/25. Facility staff were educated on medication administration and the five rights during medication administration. Interventions were put into place to mitigate future occurrences. The deficiency was corrected on 4/17/25. Review of the facility's policy titled Administration of Medications dated October 2024 showed: -A physician or Nurse Practitioner order was required for administration of all medication. -The licensed staff were expected to check the medication administration record prior to administering medication for the right medication, dose, route, resident, and time. -Staff were expected to identify the resident by reading the resident's wristband or checking the picture in the Medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain resident rooms 118, 113, 111, 107, 103, 127, 131, 130, 138, 142, 147, 157, 161, 160, 165, 166, 170, 173, and 176 free from cobwebs (a web spun by certain spiders, often found in the corners of disused rooms) and a buildup of dust behind the beds and in the corners next to the cabinets. This practice potentially affected at least 23 residents. The facility census was 87 residents. Review of the facility's undated policy titled Room Cleaning process showed: -Section 3: Damp wipe. --Wipe everything you can reach. --Start with the door and work around the room in a circular pattern. --Be sure to include wall spotting, light switches, call buttons, telephones, wall moldings, dispensers, windowsills, furniture and Packaged Terminal Air Conditioner (PTAC, is a ductless, self-contained air conditioning unit that heats and cools small areas) climate control units. -Section 5: Dust Mop and Sweep Floor; Dust behind all furniture and doors.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate precautions and correct hand hygiene was completed during colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) care of one sampled resident (Resident #7); failed to ensure enhanced barrier precautions (a set of infection control measures that use personal protective equipment (PPE-protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) to reduce the spread of multidrug-resistant organisms in nursing homes) were used when providing care for one sampled resident (Resident #182); and failed to ensure one sampled employee out of 10 sampled employees received tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, and abnormal lung tissue and function)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a physician order for self-administration of medication at bedside and failed to evaluate and document the ability to self-administer medication for one sampled resident (Resident #49) out of 19 sampled residents. The facility census was 87 residents. Review of the facility's policy titled Self Administration of Medications and Treatments dated May 2023 showed: -Self-administration of medications and treatments were determined by physician order after determining that the resident was able to self-administer. -Medications and treatments for self-administration were kept in a locked drawer in the resident room. -All medications and treatments that were self-administered were signed out in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). -If determined by a member of the interdisciplinary team, or if the resident requested to self-administer, it would be documented in the chart and the physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess, describe and measure wounds weekly for one sampled resident (Resident #69) who had a left knee wound and right hip surgical incision out of 19 sampled residents. The census was 87 residents. Review of the facility's Wound Policy and Procedure dated March 2020 showed: -The facility needed to follow standard of practice for all wounds. -Upon admission, the wound should be assessed. -The wound assessment should include the location, measurement, appearance, drainage, characteristics, and appearance of wound edges. -The staff were to assess the wounds on a weekly basis. 1. Review of Resident #69's Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 9/11/24 showed he/she was admitted for skilled services. Review of the resident's admission nursing evaluation dated 9/11/24 showed: -The resident had a left front knee open area. -There were no measurements or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure the ordered application of splint devices were utilized to improve or maintain mobility for one sampled resident (Resident #58) with limited mobility out of 19 sampled residents. The facility census was 87 residents. Review of a facility policy titled Range of Motion, dated 11/2020, showed: -A resident with limited range of motion would receive services to increase range of motion and/or decrease further range of motion. -Residents of the facility would be provided care and services to prevent formation and progression of contractures (a condition of shortening and hardening of tendons and muscles often leading to rigidity and deformities of joints) and deformities. 1. Review of Resident #58's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment completed by the facility) dated 8/14/24, showed the resident: -Was severely cognitively impaired. -Did not reject cares in the assessment period. -Was dependent on staff for upper body dressing. -Had upper extremity range of motion…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to obtain a physician's order for one sampled resident (Resident #49) to self-perform colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) care and failed to complete a full evaluation to self-perform the colostomy care out of 19 sampled residents. The facility census was 87 residents. Review of the facility's policy titled Self Administration of Medication and Treatments dated May 2023 showed: -Self-Administration of medications and treatments was determined by a physician order after determining that the resident was able to self-administer. -Treatments for self-administration were kept in a locked drawer in the resident's room. -All treatments that were self-administered were signed off in the Treatment Administration Record (TAR). -If it was determined by a member of the interdisciplinary team, or if the resident requested to self-administer, it would be documented in the chart and the physician would be called…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure physician's orders for a Continuous Positive Airway Pressure (CPAP a form of positive airway pressure ventilation in which a constant level of pressure greater than atmospheric pressure is continuously pumped into the lungs during spontaneous breathing) machine was on their Physician's Order Sheet (POS) and care plan; and failed to ensure respiratory face masks and tubing were kept covered when not in use for two sampled residents (Resident #183 and #280) out of 19 sampled residents. The facility census was 87 residents. Review of the facility policy for Respiratory Supplies revised 5/2023 showed: -There was no policy documentation related to obtaining physician orders for a CPAP machine or storage of CPAP and oxygen supplies. 1. Review of Resident #183's Face Sheet showed the resident was admitted on [DATE], with diagnoses including sleep apnea (a sleep disorder that causes breathing to repeatedly stop or become shallow during…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure indwelling urinary catheter (a catheter which is inserted into the bladder in the urethra and remains in place to drain urine) orders were in place including catheter care for one sampled resident (Resident #2) out of six sampled residents. The facility census was 90 residents. Review of the facility's policy titled Foley Catheter (a brand name for one of many brands of urinary catheters) Care dated April 2023 showed: -The purpose of catheter care was to prevent possible urinary tract infections (UTI- an illness in any part of the urinary tract) from bacteria spreading from the perineal area and external catheter into the bladder. -A physician's order for catheterization should include the reason/indications for catheterization, frequency, and type of irrigation if necessary. 1. Review of Resident #2's Face Sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Periprosthetic (a structure in close…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the call light system was adequately equipped and functioning including that the system was not turned off at the nurse's station only which affected the care of two sampled residents (Resident #1 and Resident #4) out of six sampled residents. The facility census was 90 residents. Review of the facility's policy titled Call Light-Ability to Use dated January 2024 showed: -The call light system was provided as a tool for residents to communicate with staff. -Staff members will acknowledge and respond to the call light by entering the resident's room and determining and assisting with the resident's needs. 1. Review of Resident #1's Face Sheet showed he/she was admitted to the facility with the following diagnoses: -Heart Failure. -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure checks through the Employee Disqualification List (EDL - a listing, maintained by the Department of Health and Senior Services (DHSS), of individuals deemed to have abused or neglected residents, patients, or clients or falsified documentation of services to in-home clients), Criminal Background Checks (CBCs), and/or Federal Indicators (FI) through the Nurse Aide (NA) Registry were completed prior to hire in accordance with State requirements and facility policy to ensure potential employees did not have a history of abuse or neglect or a disqualifying crime against persons for eight out of ten sampled employees. This deficient practice had the potential to affect all residents in the facility. The facility census was 89 residents. Record review of the facility's Applicant Reference and Background Checks policy, dated 10/2020 showed all selected applicants must have references checked, licensure and certification verified, and have a background check before an employment offer can be made. 1. Record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to properly store food in the refrigerated walk-in unit and to practice sanitary procedures before food preparation tasks. These practices potentially affect an unknown number of residents who received their meals from the facility's kitchen. The facility census was 89 residents. 1. Observations on 12/8/22 between 5:05 A.M. and 8:20 A.M., in the kitchen, showed: -In the refrigerated, walk-in cooling unit, there was no portable thermometer inside to display the temperature of how cool/warm the unit and the stored foods were being maintained or becoming. -The floors near and behind the convection oven and the deep fryer had visible piles of grease on them. -The stove top burner grates were blackened with cooked on debris attached to them. -On the juice dispensing equipment (gun), its nozzles connected to six different dispensing beverages of orange juice, a lemon beverage, cranberry juice, fruit punch, apple juice and thickened water. These nozzles were sticky with multi-colored debris on the inside and outside of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the written notice of transfer or discharge was provided to the resident/family and to ensure the notice contained the location of transfer/discharge and the information to appeal the transfer/discharge of the regional Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) for one sampled resident (Resident #56) out of 18 sampled residents and for one closed record resident (Resident #267) out of three closed record sampled residents. The facility census was 89 residents. A policy was requested and no policy was received related to transfer/discharge notices. 1. Record review of Resident #56's admission Record showed he/she was admitted for Medicare Part A skilled services at the facility. Record review of the resident's Transfer Form dated 9/25/22 showed: -The resident was sent to the hospital. -There was no documentation that showed which hospital the resident was sent to.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.