Ignite Medical Resort Kansas City, LLC

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteRefer 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]