Ignite Medical Resort Kansas City, LLC
2100 N W Barry Road, Kansas City, MO 64154 · For profit - Limited Liability company · 90 certified beds · (816) 521-6610 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $6,368 in federal fines (most recent 2025-01-09)
- its payroll-based staffing rating is low (2/5)
- about 17% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.8% | 18.1% | 15.4% | worse |
| Long-stay residents who lose too much weight | 19.2% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.1% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 12.1% | 2.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 25.9% | 18.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 9.7% | 4.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 20.6% | 17.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 36.0% | 25.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 93.5% | 90.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.4% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 35.4% | 17.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.8% | 23.5% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 69.7% | 63.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 24.4% | 26.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 14.3% | 13.7% | 12.0% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
58.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 444 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 159 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.82 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.6%CMS range 53.8–64.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 14.8%CMS range 12.1–17.2 | 10.7% | Oct 2022–Sep 2024 | worse than U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 71.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 68.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 64.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 95.2% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 87.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.3%CMS range 5.9–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 90 beds and averages 85.7 residents a day — about 95% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.47 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.01 hrs/resident/day on weekends vs 3.65 on weekdays — 18% thinner on weekends. RN hours go from 0.82 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2025-01-09 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect Resident#1's right to be free from abuse when he/she was hit in the face by another resident (Resident #2). Resident #1 sustained a laceration to the lower lip. Facility census was 79. On 1/9/25, the Administrator was notified of the past noncompliance which began on 1/1/2025. Upon discovery, the facility administration immediately conducted an investigation and corrective actions were implemented. The noncompliance was corrected on 1/2/2025. Review of the facility's Abuse Policy, dated November 2018, showed: -Abuse is defined as an infliction of physical, sexual, or emotional injury or harm, including financial exploitation by any person, firm, or corporation; -This facility prohibits abuse, neglect, or mistreatment of residents. The facility will educate all employees upon hire and at least annually on the Abuse Policy and all components. The facility Administrator will be designated as the facility's Abuse Coordinator and is…
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.
- Potential for harm · Ecited before2026-02-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the environment of two sampled residents remained free of accident hazards when the facility failed to ensure oxygen stored in Resident #131's room was stored in accordance with NFPA 99, 1999 Edition, when one type E oxygen cylinder was stored unsecured on the floor in the resident's room and when the resident's room contained more than one emergency use type E oxygen cylinder, and when the facility failed to provide a safe gait belt transfer for Resident #12 when CNA B failed to securely place the gait belt around the resident's waist and also when CMT A grabbed Resident #12 under the arm during a transfer. This affected two of 18 sampled residents (Resident #131 and Resident #12. The facility census was 86. Review of the facility's Oxygen Storage policy dated May 2024, showed:-Fasten cylinders securely in an upright position. Review of NFPA 99, 1999 edition 8-3.1.11 Storage Requirements showed:8-3.1.11.2 Storage for nonflammable…
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.
- Potential for harm · E2026-02-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident's who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections when the facility failed to ensure staff properly clean catheter tubing for Resident #142 and when facility staff failed to wear Enhanced Barrier Precautions (EBP, an infection control strategy where staff wear a gown and gloves when providing direct care to residents with indwelling medical devices) for two Resident's #142 and #4. This affected two of 18 sampled resident's. The facility census was 86.Review of the facilities Catheter Care policy, dated January 2026, showed:- The purpose of catheter care is to prevent possible urinary tract infections from bacteria from spreading from the perineal area and external catheter into the bladder;- Begin cleaning starting at the ureteral meatus wiping away from the body;- The policy did not address using a single cleansing wipe more than once to clean the catheter…
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.
- Potential for harm · E2026-02-11 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to ensure the kitchen was in good repair and maintained the kitchen in a clean and sanitary manner when cooking and food prep areas where dirty with dust and food debris, and when repairs in the kitchen had not been completed. This had the potential to affect all residents who received a meal from the kitchen. The facility census was 86. The facility did not provide a policy on cleaning and repairs in the kitchen. Observation of the kitchen on 02/08/26 at 09:12 A.M. showed:-The grill with a thick layer of encrusted grease and food debris;-The shelf above the stove with a thick layer of grease and food debris;-The ceiling in the dish room with a round brown stain the size of a basketball with pieces of ceiling tile hanging down.Observation of the kitchen on 02/11/26 at 10:42 A.M. showed:-The grill with a thick layer of encrusted grease and food debris;-The shelf above the stove with thick layer of grease and food debris;-The ceiling in the dish room with a round brown stain the size of a basketball with pieces of ceiling tile…
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.
- Potential for harm · E2026-02-11 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections when the facility failed to ensure staff wore enhanced barrier precautions (EBP, an infection control strategy where staff wear a gown and gloves when providing direct care to residents with wounds or indwelling medical devices) for Resident #142, and Resident #4 and failed to ensure dirty gloves were changed before providing catheter care for resident #142. Facility staff failed to provide a barrier between a resident's wound and the floor when performing a dressing change for resident #16. This affected three of 18 sampled residents. The facility census was 86. Review of the facilities Infection Control Policy dated May 2024, showed: - Perform hand hygiene when moving from contaminated body sites to clean body sites 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.
- Potential for harm · Dcited before2026-02-11 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to treat Resident #131 with dignity and respect when staff failed to assist the resident with trimming facial hair. This affected one of 18 sampled residents. The facility census was 86. Review of the facilities Resident Rights policy, dated May 2023, showed: - Resident's had rights to a dignified existence, self-determination, and communication; - The facility must protect and promote the rights of the resident's; - The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Review of the facility's Bathing policy dated April 2023, showed:-All residents are given a bath or shower in accordance with their preferences;-If no preference is voiced a bath or shower will be offered twice a week. Review of Resident #131's admission MDS a dated 10/20/25 showed:-No cognitive impairment;-Substantial assistance with showers and…
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.
- Potential for harm · Dcited before2026-02-11 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure Resident #143 received insulin as with meals ordered when staff served the resident the noon meal tray at 12:05P.M. and administered insulin at 12:37 P.M. This affected on of 18 sampled residents. The facility census was 86. Review of the facility's Administration of Medication Policy dated 04/2023, showed:-Staff to read each order entirely;-Read label of medication three times;-If there is a discrepancy between Medication Administration Record (MAR) and label, check orders before administering medications;-Follow instructions written on label.Review of the facility's Pharmacy Services Policy dated 05/2024, showed:-Staff to follow specific monitoring related to medications, such as blood sugar;-Staff to follow specific timing and parameters of medications (e.g. before or after meals)Review of the facility's Insulin Administration Procedure Policy dated 05/2023, showed:-Insulin is only given with a practitioner order;-Objective is to safely and accurately inject insulin.Review of resident #143's POS dated…
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.
- Potential for harm · Dcited before2026-02-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (AQDLs) received the necessary services to maintain good personal hygiene when staff used a soiled incontinence wipe to perform per-care and did not fully clean the peri-area, which affected one of the 18 sampled residents, (Resident #12). The facility census was 86. Review of the facility's policy for Perineal Care, reviewed 5/23 showed:- Perineal care is done daily and as needed for all residents requiring assistance and/or those residents with a Foley catheter (sterile tube inserted into the bladder to drain urine).Wash perineal area with peri wash and water using a washcloth. If appropriate, rinse with warm water. For males, retract foreskin if present, wash, dry and replace foreskin. When complete, remove gloves and cleanse hands. 1. Review of Resident #12's care plan dated 12/21/25, showed: - The resident had bowel incontinence. Check resident every two hours and assist with toileting as needed. Provide peri care after…
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.
- Potential for harm · D2026-02-11 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure staff prepared foods in a form designed to meet the needs of individual residents when they did not ensure the puree (a texture-modified diet in which all foods have a soft, pudding-like consistency) food had a smooth and appropriate consistency. This affected one resident identified by the facility as having an order for a pureed diet (Resident #115). The facility census was 86. The facility did not provide the requested policy on pureed diets.1. Review of Resident #115's Discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/6/26 showed:-Moderate cognitive impairment;-Supervision with eating;-Mechanically altered diet;-Diagnoses included diabetes, dysphagia (difficulty swallowing, causing pain or choking) and asthma. Review of the resident's care plan dated 2/9/26 showed:-Moderate assistance with Activities of Daily Living;-The resident is on a pureed diet related to dysphagia.Review of the resident's Dietitian Evaluation dated 11/08/25…
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.
- Potential for harm · Ecited before2024-12-02 · tag F0624 — patternPrepare residents for a safe transfer or discharge from the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Refer to Event ID 1YDJ12 Based on observation, interview, and record review, the facility failed to ensure a safe and orderly discharge from the facility for five (5) out of the six (6) sampled residents (Resident #1, #2, #3, #4, and #5) when five (5) residents were discharged without proper orders, medications, home health services, dialysis services, and/or follow up appointments. The facility census was ninety 90. Review of the facility's policy for discharge to home, revised 04/2023, showed: - (3.) Social services will meet with the resident and/or family to set up outside services and equipment. - (4.) A discharge form is completed by all involved members of the IDT (interdisciplinary team) that explain the resident care needs at home. - (6.) Teaching will be done with the resident/family on any dressings or special tasks. - (8.) If necessary, therapy will provide any necessary instructions. - (9.) On the day of discharge, the nurse will review the discharge form as well as the medications with the family.…
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.
- Potential for harm · F2024-10-03 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to employ a qualified director of food and nutrition services. This deficient practice had the potential to affect 87 of 87 residents who received meals prepared in the facility's only kitchen. The facility census was 84. Findings include: Review of the Dietary Manager's (DM) job description, titled Executive Chef, dated 01/08/23, revealed, . Must have Food Service Sanitation certification . Review of the DM's employee file revealed an original date of hire was September 2018. No training course document was included in the file. Review of the Dietary Schedule for 09/29/24 through 10/05/24 revealed the DM was listed as Manager. During an interview on 09/30/24 at 9:35 AM, the DM was asked how long she had worked as the dietary manager and if she was a certified dietary manager (CDM) or had other qualifying credentials as a dietary manager. The DM stated she had been employed at the facility for five years as a cook but had only been the dietary manager for nine months. The DM confirmed she did not have two or more years 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.
Show the remaining 19 citations
- Potential for harm · E2024-10-03 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to provide written notification of a facility-initiated transfer to the resident and responsible party (RP) for two of five residents (Resident (R)19, R38, and R66) reviewed for hospitalization out of a total sample of 28. The failure had the potential to affect the residents and/or their representative concerning the reason for the transfer and the resident's appeal rights. The facility census was 84. Findings include: Review of the facility's Admission, Transfer, & Discharge policy, revised 05/2023, revealed, . Facility staff will document in the clinical record discharge information provided to the resident and the receiving organization, if applicable: the basis for the transfer . instruction provided to the resident and/or surrogate decision-maker prior to discharge . 1. Review of R38's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/24 and located in the MDS tab of the Electronic Medical…
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.
- Potential for harm · Ecited before2024-10-03 · tag F0624 — patternPrepare residents for a safe transfer or discharge from the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe and orderly discharge from the facility for five (5) out of the six (6) sampled residents (Resident #1, #2, #3, #4, and #5) when five (5) residents were discharged without proper orders, medications, home health services, dialysis services, and/or follow up appointments. The facility census was ninety 90. Review of the facility's policy for discharge to home, revised 04/2023, showed: - (3.) Social services will meet with the resident and/or family to set up outside services and equipment. - (4.) A discharge form is completed by all involved members of the IDT (interdisciplinary team) that explain the resident care needs at home. - (6.) Teaching will be done with the resident/family on any dressings or special tasks. - (8.) If necessary, therapy will provide any necessary instructions. - (9.) On the day of discharge, the nurse will review the discharge form as well as the medications with the family. - The nursing discharge…
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.
- Potential for harm · E2024-10-03 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide written notification of the bed hold policy to the resident and responsible party (RP) for two of five residents (Resident (R)38 and R19) reviewed for hospitalization out of a total sample of 28. The failure had the potential to affect the residents planning on returning to the facility. The facility census was 84. Findings include: Review of the facility's policy titled, Bed Hold and Therapeutic Leave, revised 11/2018 and provided by the facility, revealed, . 2. For hospital leaves, the facility will hold a bed (not necessarily that specific bed) for up to 10 days during the hospitalization. On the 11th day, there is no requirement to hold a bed but the resident is still a resident and should receive the next available bed when they are ready to return, even if there is a waiting list . The policy did not include the cost per day or that the notice must be written. Review of the facility's Admission, Transfer, & Discharge policy, dated 07/2020…
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.
- Potential for harm · Ecited before2024-10-03 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to perform ongoing neurological assessments when residents had unwitnessed falls, which could have resulted in head trauma, for three of three residents (Resident (R) 19, R222, and R226) reviewed for falls out of a sample of 28 residents. The lack of proper assessment could result in the facility potentially not noticing symptoms of head trauma and initiating interventions. The facility census was 84. Findings include: Review of the facility's Post-Fall Policy, revised/reviewed 05/2023, revealed, lf the resident reports hitting head, if there is any indication of head injury, or if ANY incident is un-witnessed, the neuro check protocol will be implemented, and reported to the physician. Review of the facility's Neurological Assessment procedure, dated 09/2019, revealed, . Neurological assessments are done upon physician order when indicated for a change of resident condition, unwitnessed fall and with all head injuries . Observe…
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.
- Potential for harm · E2024-10-03 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to 1.) document that residents were offered and provided education about the influenza vaccine during the influenza season for two of five residents (Resident (R) 8 and R35) reviewed for immunizations, and 2.) document that residents were offered and provided education about the pneumonia vaccine for four of five residents (R3, R8, R26, and R35) reviewed for immunizations. This had the potential for residents or their representatives not to make an educated decision regarding obtaining the immunizations at the facility which could lead to illness. The facility census was 84. Findings include: Review of the facility's Immunization Policy, revised/reviewed in 05/2023, revealed, . all admissions throughout the year will be offered the pneumovax injection as recommended by Centers for Disease control [CDC] and desired by the resident and approved by the primary care physician . CDC recommends adults aged [AGE] years old or older who…
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.
- Potential for harm · Dcited before2024-10-03 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to honor a resident request to not have certain staff provide care for one of one resident (Resident (R)26) reviewed for self-determination out of a total sample of 28. This failure had the potential to decrease R26's quality of life. The facility census was 84. Findings include: Review of the facility policy titled, Self-Determination, revised July 2024 and provided by the facility, revealed, Each resident who chooses to reside in this facility has the right to and the facility pledges to promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified as Resident Rights . The resident has a right to choose activities, schedules including but not limited to sleeping and waking times, health care and providers of health care services consistent with his/her interests, assessments, and plan of care and other daily life enhancement enrichment activities on a daily basis. Review of R26's annual Minimum Data Set (MDS), with an Assessment…
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.
- Potential for harm · D2024-10-03 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure orders for ileostomy care were in place for one of one resident (Resident (R)38) reviewed for colostomy care out of a total sample of 28. This had the potential to have a negative effect on R38's skin and quality of life. The facility census was 84. Findings include: Review of the facility policy titled, Physician's Orders, dated 11/2020 and provided by the facility revealed, All medications will be administered as ordered by a health care professional authorized by the state to order medications . Orders for treatments will include: Description of treatment including use of topical medications, Frequency of treatment, Specific precautions or directions if needed, Clinical rationale for order (indication/diagnosis). Review of the facility policy titled, Colostomy- Ileostomy Care, dated 11/2018 and provided by the facility, revealed, . 13. Document changing of colostomy bag on TAR [treatment administration record] . Review of R38's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD)…
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.
- Potential for harm · Dcited before2024-06-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide protective oversight to one resident (Resident #1) with a known diagnoses including Alzheimer's disease, Dementia (unspecified), Cognitive Communion Deficit, Difficulty Walking and Falls. The resident eloped from the facility the night of 2/29/24 and was found by a motorist lying in the grass just off a nearby busy roadway. The facility staff were unaware the resident had left the facility. In addition, the staff failed to follow their policy and notify Resident #1's personal representative of the elopement. The facility census was 89. Review of the facility's policy on elopement, revised on 5/2024., included: -Elopement is defined as an incident in which a resident who has impaired decision-making ability and is oblivious to his/her own safety needs leaves the facility without knowledge of the facility staff. -Staff will immediately begin a search for the missing resident, once the resident is found notify the resident's responsible party 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.
- Potential for harm · Ecited before2023-07-25 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure they cared for residents in a dignified way when they served meals with plastic cutlery and Styrofoam for six of the 18 sampled residents(Residents #273, #280, #29, #3, #23, and #18, as well as failed to set up meals within reach for three of eighteen residents (Resident #33, #285, and #4). The facility census was 89. Review of facility policy, Resident Dignity, dated 5/2023, showed: - The facility will promote care for elders of the facility in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of the resident's individuality. -The facility will not routinely use any plastic cutlery and paper/plastic dishware unless indicated for infection control. 1. Review of Resident #273's admission Minimum Data Set (MDS),(a federally mandated assessment completed by staff) dated 7/20/23, showed: -Resident's Brief Interview of Mental Status (BIMS) score of 15, indicated no…
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.
- Potential for harm · E2023-07-25 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to maintain a clean, comfortable, and homelike environment when the facility failed to maintain clean floors and toilets in resident rooms. The facility also failed provide linen changes to resident bed's. This affected five, (Resident #280, #25, #282, #33, #285) of 18 sampled residents. The facility census was 89. Review of facility room cleaning process, undated, showed: -Clean Bathroom: Start at the door spray down all surfaces and wipe down sink, spray window cleaner on mirror and wipe down with paper towel. Spray the toilet with cleaner. Use a bowl mop inside the bowl and wipe the outside with a disinfectant. Do not use the same rag on any other surface after cleaning the toilet. Sweep and damp mop floor. Discard the dirty mop head after uses. -Dust mop/sweep floor including behind furniture and doors -Damp mop: Place wet floor sign at the entrance before you begin. Start with the corner farthest from the door and work your way out. Mop…
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.
- Potential for harm · E2023-07-25 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to update resident care plans and failed to hold care plan meetings involving the residents and or their guardian. This affected three (Resident #12, #269 and #285) of the 18 sampled residents. The facility census was 89. 1. Review of resident #12's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 4/16/23 showed: - Resident re-admitted to facility on 10/6/21; - Cognition severely impaired; - Preferences for customary routine and activities: very important to have family or close friend involved in discussions about his/her care; - He/she is extensive assist in bed mobility, transfer, dressing, toilet use and hygiene with supervision in eating; - Diagnosis include cancer, anemia, hypertension, gastroesophageal reflux disease, hyperlipidemia, arthritis, dementia, malnutrition, anxiety, and depression; - Hospice care. Review of resident's face sheet showed the resident has a durable power 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.
- Potential for harm · Ecited before2023-07-25 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure four of 18 sampled residents who required staff assistance (Resident (#2, #4, #269, and #280), were provided with adequate assistance for activities of daily living (ADL's: tasks completed to care for oneself daily such as bathing, dressing, moving from a chair to bed, and personal hygiene), as well as failed to provide repositioning and incontinence care for resident #2, failed to provide appropriate oral care for resident #4 and failed to provide showers to maintain personal hygiene for resident #269 and #280. The facility census was 89. Review of the facility ADL policy dated 04/23 showed in part: -This facility will provide each resident with care, treatment, and services according to the resident's individualized care plan. 1. Review of Resident #2's admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 7/6/23 showed: - Brief Interview of Mental Status (BIMS) of 4, indicating significant…
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.
- Potential for harm · Ecited before2023-07-25 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to assure staff provided the necessary care and services to attain or maintain the highest practical physical, mental and psychosocial well-being for two of 18 sampled residents (Resident #285 and #179). The facility failed to reposition (Resident #285). and failed to provide appropriate wound dressing care to one sampled resident (Resident #179). The facility census was 89. Facility provided no policy on positioning. Review of the facility Wound Policy and Procedure dated 5/2023 showed in part: -Any resident with a wound receives treatment and services consistent with the resident's goals. Typically the goal is promoting healing and preventing infection. A commitment to wound management program is demonstrated by implementation of processes founded on accepted standards of practice. -admission wound assessment and management should include at a minimum: -Discharge records from the prior facility are reviewed for information relating 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.
- Potential for harm · E2023-07-25 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide sufficient nursing staff to meet residents needs for four of eighteen (Resident #273, #4, #269, #280, #282, and #25) when staff failed to answer residents call lights in a timely manner (Resident #273, #4, #269, #280) and when facility failed to pass medications in a timely manner (#282, #280, and #25). The facility census was 89. Review of facility call light response policy, dated January 23 showed: -It is expectation that all staff members have responsibility to respond to call lights; -If the request is outside the scope of practice for the person answering the light, the appropriate personnel will be contacted immediately to respond to the resident's needs; -Call lights will be answered in a timely manner; -If the facility has call light reporting capability, the Director of Nursing (DON) and/or designee will regularly review call light responsiveness and provide education to direct care staff on an as needed basis. Review…
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.
- Potential for harm · E2023-07-25 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature to six of 18 sampled residents (Resident #282, #27, #29, #18, #221, and #13). The facility had a census of 89. Review of the undated In-Room Dining facility policy showed: - In-room dining will be served in a way to compliment the primary dining program. Because the presentation of the meal directly affects how much the individual eats, presentation will include dining environment, attitude of server and the appearance of the meal. - Insulated plate covers and bowls will help maintain food temperatures during delivery. All foods should be covered and delivered as soon as possible after plating to maintain food quality and temperature; - Hot food must be hot and cold food must be cold. Review of the undated Meat and Vegetable Preparation facility policy,…
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.
- Potential for harm · E2023-07-25 · tag F0806 — failed to honor food preferences — patternEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to honor resident preferences when the facilty failed to offer condiments to one resident (Reisdent #29), failed to offer bigger portions to one resident (Resident #221), and failed to follow the posted menu when they ran out of posted menu items for three residents (Resident #18, #221 and #13) out of 18 sampled residents. The facility census was 89. Review of the undated facility policy, Menu Planning showed: - Policy: Nutritional needs of individuals will be provided in accordance with the established national standards adjusted for age, gender, activity level and disability, through nourishing, well-balanced diets, unless contraindicated by medical needs. Based on a facility ' s reasonable efforts, menus should reflect the religious, cultural and ethnic needs of the population served as well as input received from individuals and groups. - Procedure: Menu planning will be completed by the facility at least two weeks in advance of service…
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.
- Potential for harm · E2023-07-25 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure staff offered each resident a bedtime snack (HS).The facility failed to maintain the standard of no more than 14 hours between a substantial evening meal and breakfast the next morning unless a nourishing snack is served at bedtime by allowing 15 hours between supper and breakfast and not providing a nourishing snack. This affected five (Resident #273, #178, #176, #30, #282) of 18 sampled residents The facility census was 89 Review of facility policy titled menu planning, dated 2019 showed: -Menus will include at least three meals daily at regular times comparable to the normal mealtimes in the community or in accordance with the individual's needs and preferences. -A substantial evening meal consisting of three or more menu items will be offered, one of which includes high quality protein -If there are more than 14 hours between the evening meal and breakfast the following day, a nourishing snack will be offered at bedtime. A…
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.
- Potential for harm · D2023-07-25 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review, the facility failed to accommodate the needs of a resident to prevent the resident from hanging partially off the bed, when they failed to provide a bed sufficient in length to accommodate the height for one resident (Resident #23) out of 18 sampled residents. The facility census was 89. Review of the facility's Accommodation of Needs policy, dated July 2020 showed: - Purpose: Each resident has a right to receive services at this facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the resident or other residents would be endangered. - Procedure: The facility maintains a safe, functional environment for all residents residing in the facility. - Interior spaces accommodate the use of equipment and assistive devices necessary to maximize each resident's functionality of activities of daily living. Review of resident #23's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 7/9/23 showed: - He/she was re-admitted to facility…
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.
- Potential for harm · Dcited before2023-07-25 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to assure staff followed acceptable standards of practice for one of 18 sampled residents, (Resident #181), when staff failed to obtain treatment orders for his/her surgical site. The facility census was 89. Review of the facility Wound Policy and Procedure dated 5/2023 showed in part: -Any resident with a wound receives treatment and services consistent with the resident's goals. Typically the goal is promoting healing and preventing infection. A commitment to wound management program is demonstrated by implementation of processes founded on accepted standards of practice. -admission wound assessment and management should include at a minimum: -Discharge records from the prior facility are reviewed for information relating to wounds or alterations in skin integrity. -Discussion with the attending physician. -Orders are verified or obtained as needed. 1. Review of Resident #181's admission Minimum Data Set (MDS: a federally mandated…
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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$6,368 in federal fines across 1 penalty.
- $6,368 — penalty dated 2025-01-09
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to IGNITE MEDICAL RESORTS — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.7 | +0.3 vs chain |
| Health inspection | 3 of 5 | 2.4 | +0.6 vs chain |
| Staffing | 2 of 5 | 1.9 | +0.1 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 21 homes this chain runs (chain average 2.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| HAGEMAN INVESTMENTS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 06/05/2018 |
| IGNITE KC LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 06/05/2018 |
| HAGEMAN FAMILY TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 30% | since 06/05/2018 |
| IGNITE KC JV LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 25% | since 12/19/2018 |
| IGNITE V-JV LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 25% | since 12/19/2018 |
| PRESTIGE WORLDWIDE KC LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 5% | since 06/05/2018 |
| HAGEMAN, SHANE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 5% | since 06/11/2018 |
| GOLD PEARL, LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 10/15/2018 |
| ISRAEL FAMILY INVESTMENT TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 10/15/2018 |
| ISRAEL INVESTMENT TR | Organization | INDIRECT OWNERSHIP INTEREST | — | since 10/15/2018 |
| THE HAGEMAN FAMILY DELAWARE TRUST I | Organization | INDIRECT OWNERSHIP INTEREST | — | since 09/29/2020 |
| THE HAGEMAN FAMILY DELAWARE TRUST II | Organization | INDIRECT OWNERSHIP INTEREST | — | since 09/29/2020 |
| CARR, JARED | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/15/2018 |
| FALK, MOLLY | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/15/2018 |
| GOBST, RYAN | Individual | INDIRECT OWNERSHIP INTEREST | — | since 10/15/2018 |
| HAGEMAN, SANDRA | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/11/2018 |
| HAGEMAN, STEVE | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/11/2018 |
| JABLONSKI, NICOLE | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/15/2018 |
| MCFARLANE, JOHN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/15/2018 |
| ROGERS, DYLAN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2024 |
| ROSE, MARC | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/20/2020 |
| THENGIL, MATHEW | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/05/2018 |
| WHITE, JIM | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/15/2018 |
| BERGER, MENACHEM | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 10/15/2018 |
| CARR, BARRY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/15/2018 |
| FIELDS, TIMOTHY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/15/2018 |
| ISRAEL, BENJAMIN | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 10/15/2018 |
| STERN, TODD | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 10/15/2018 |
| IGNITE TEAM PARTNERS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2025 |
| SPARK THERAPY LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/19/2020 |
| DREWS, DENNIS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/15/2018 |
| BERGER, AVIVA | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 02/27/2025 |
| ISRAEL, YEHUDIS | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 02/27/2025 |
| LUXE STAFFING LLC | Organization | ADP OF THE SNF | — | since 01/04/2021 |
CMS files one row per role, so the 64 rows in the source record cover these 34 parties — each is shown once here with every role it holds. Nothing is omitted.
14 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MO
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265872. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.