Ignite Medical Resort Overland Park LLC

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation in the facility's one kitchen to prevent the spread of food borne illness.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident (R)121's call light was within his reach to enable him to call for staff assistance.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Office of the Long Term Care Ombudsman was notified when Resident (R) 3 was transferred to the hospital. The facility failed to ensure R3, R4. and R8 and their representatives were provided with a bed hold policy that included their daily rate to hold the bed. The facility failed to ensure R3 and their representatives were provided with a written notification of transfer that included a statement of the right to appeal and the state ombudsman information, upon their transfer to the hospital as soon as practicable upon their transfer to the hospital.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure appropriate care and services were provided to promote wound healing (R)72 when staff failed to follow the physician's treatment order for leg wraps.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an environment free from accident hazards for Resident (R) 121 when staff transferred R121 using the full body lift (Hoyer) and did not maintain direct contact to provide safety and stabilization during the transfer.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide adequate infection control practices related to utilization of Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high-contact care), Personal Protective Equipment (PPE), or proper hand hygiene, while providing direct care to Resident (R) 120 and R29. Additionally, the facility failed to implement adequate infection control practices related to sanitary storage of respiratory equipment for R41.

Inspectors wroteBased on the record review and interview, the facility failed to conduct a thorough facility-wide assessment to determine the nursing staff resources necessary to care for residents competently during both day-to-day operations and emergencies. Findings Included:- An inspection of the Facility Assessment dated 03/22/2026 provided by the facility revealed the following: The assessment failed to identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, patient acuity, and census. The assessment lacked the staffing levels required for each daily shift and on weekends. On 07/29/2026 at 12:45 PM, Administrative Nurse D stated that the facility assessment should reflect the number of total hours for each nursing staff. [...]

Inspectors wroteThe facility identified a census of 110 residents. The sample included 20 residents with three residents reviewed for notification of roommate/room changes. Based on observation, record review, and interviews, the facility failed to provide written notice, including the reason for the change, to Resident (R) 1 and/or his representative before R1 received a roommate, R2.

Inspectors wroteThe facility identified a census of 98 residents which included ten residents reviewed for transfers to another room in the facility for the convenience of staff. Based on observations, interviews, and record review, the facility failed to inform Residents (R) 1, R2, R3, R4, R5, R6, R7, R8, and R9 in writing of the impending room change in order to create a hall to group skilled residents. This placed the residents at risk for impaired resident rights and decreased psychosocial well-being.

Inspectors wroteThe facility identified a census of 98 residents. The sample included three residents reviewed for weight loss. Based on record review, observation, and interview, the facility failed to monitor the effectiveness of weight loss interventions after a significant weight loss for Resident (R)1. This deficient practice placed R1 at risk for further loss and malnutrition.

Inspectors wroteThe facility identified a census of 93 residents. The sample included five residents reviewed for abuse. Based on record review, interviews, and observations, the facility failed to ensure an environment free from avoidable accidents for Resident (R) 72 when staff failed to apply wheelchair pedals to her chair when propelled by staff and failed to use the required amount of staff assistance for transfers to ensure safety. Subsequently, R72 sustained a comminuted (a type of broken bone that is broken in at least two places and are usually caused by severe trauma) distal (away from the farthest point of origin or attachment) left femur (the thigh bone) fracture. This also placed R72 at risk for increased pain and impaired well-being.

Inspectors wroteThe facility identified a census of 83 residents. The sample included 18 residents with four residents sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure that Resident (R)11, R43, and R80 had call lights to call for assistance. The facility further failed to provide footrests for R72's wheelchair. This deficient practice left these residents at risk for impaired care due to unmet care needs.

Inspectors wrote- R44's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dysphagia (swallowing difficulty), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and severe protein-calorie malnutrition. The Significant Change Minimum Data Set (MDS) dated [DATE] documented R44 had severely impaired cognition. The MDS documented R44 was dependent on staff assistance for positioning. The Quarterly MDS dated 06/05/24 documented R44 had severely impaired cognition. The MDS documented that R44 was dependent on staff assistance for positioning. [...]

Inspectors wroteThe facility identified a census of 83 residents. The sample included 18 residents with eight medication carts, four treatment carts, and three medication rooms. Based on observation, record review, and interviews, the facility failed to properly store medications in seven of the eight medication carts and four of the four treatment carts. This placed the residents at risk for adverse outcomes or ineffective medication regimens.

Inspectors wroteThe facility identified a census of 83 residents and 13 residents who were on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to follow sanitary infection control standards related to the handling of soiled laundry, storage of oxygen tubing while not in use, and hand hygiene during catheter (a tube inserted into the bladder to drain urine) care. The facility further failed to follow EBP. These deficient practices placed the residents at risk for infectious diseases.

Inspectors wroteThe facility identified a census of 83 residents. The sample included 18 residents with one reviewed for self-administration of medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)53 was safe to self-administer her medications. This deficient practice placed R53 at risk for unidentified medication complications and administration errors. Findings Included: -The Medical Diagnosis section within R53's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), and obstructive uropathy (structural blockage within the urinary tract blocking urine flow). [...]

Inspectors wroteThe facility identified a census of 83 residents with 18 residents included in the sample. Based on interview and record review the facility failed to issue Center for Medicare/Medicaid Services (CMS) Notification of Medicare Non-Coverage Form 10123 (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R)139. This failure placed the resident at risk for decreased autonomy and impaired decision-making.

Inspectors wroteThe facility identified a census of 83 residents. The sample included 18 residents with four residents sampled for transfer and discharge. Based on observations, record review, and interview the facility failed to provide a written notice of transfer as soon as practicable to Resident (R) 13 and R56 or their representative for their facility-initiated transfers. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R13 and R56.

Inspectors wroteThe facility identified a census of 83 residents. The sample included 18 residents with four residents sampled for transfer and discharge. Based on observations, record review, and interview the facility failed to provide a bed hold notice with the required information to Resident (R) 13 and R56 and/or to their family representative when transferred to the hospital. This deficient practice placed R13 and R56 at risk for impaired ability to return to the facility or his same room.

Inspectors wroteThe facility identified a census of 83 residents. The sample included 18 residents with five reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide assistance for Resident (R)10 and R11 during mealtimes to promote and maintain their highest practicable abilities. This deficient practice placed both residents at risk for impaired nutrition and a decline in their ADLs. Findings Included: - The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), left-sided hemiparesis (weakness and paralysis on one side of the body), and insomnia (difficulty sleeping). [...]

Inspectors wroteThe facility identified a census of 83 residents. The sample included 18 residents with three residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing measures were placed on Resident (R) 11 and R80's bilateral lower extremities to prevent pressure ulcers. This placed R11 and R80 at increased risk for pressure ulcer development. Findings Included: [...]

Inspectors wroteThe facility identified a census of 83 residents. The sample included 18 residents with two residents reviewed for catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and urinary tract infection (UTI-an infection in any part of the urinary system). Based on observation, record review, and interviews, the facility failed to provide appropriate treatment for Resident (R) 11 with an indwelling catheter (a tube inserted into the bladder to drain urine into a collection bag) when the facility failed to prevent the drainage bag tubing from resting on the floor and failed to practice good hand hygiene during catheter care. These deficient practices placed R11 at risk for catheter-related complications.

Inspectors wroteThe facility identified a census of 83 residents. The sample included 18 residents with one resident reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care services. Based on observation, record review, and interviews, the facility failed to provide Resident (R)73 with dementia-related care and practices during her mealtimes. This deficient practice placed the R73 at risk for impaired quality of life. Findings Included: - The Medical Diagnosis section within R73's Electronic Medical Records (EMR) included diagnoses of major depressive disorder (major mood disorder), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), hypertension (high blood pressure), and dementia. [...]

Inspectors wroteThe facility identified a census of 83 residents. The facility identified one main kitchen. Based on observation, record review, and interview, the facility failed to ensure the kitchen's walk-in refrigerator and freezer unit was in safe operating condition.

Inspectors wroteThe facility identified a census of 86 residents. The sample included one resident reviewed for accidents. Based on record review, interview, and observations, the facility failed to provide adequate assistance during transfer to prevent injury from avoidable accidents for Resident (R)1, who required assistance of one staff member with the use of a gait belt (belt used to help transfer or stabilize during activity) during transfers. As a result, R1 sustained a medial (towards the middle) and lateral (pertaining to the side, away from the middle) tibial (bone of the lower leg) plateau (an elevated and usually flat area) fracture as well as an associated fibular (one of the two bones of the lower leg) fracture and increased pain.

Inspectors wroteThe facility identified a census of 90 residents. The facility identified one resident positive for Clostridium difficile (C-diff- contagious bacteria characterized by foul smelling frequent bowel movements). Based on observations, record review, and interviews, the facility failed to follow transmission-based precautions related to isolation practices for Resident (R)60 (mildly cognitively impaired resident) and failed to perform adequate infection control practices including hand hygiene practices during wound care for R4. The deficient practice placed both residents at risk for the spread of infectious diseases and delayed healing. Findings Included: - A review of the facility's Infection Control Log revealed one resident on isolation precautions for March 2023; R60 for C-Diff. [...]

Inspectors wroteThe facility identified a census of 90 residents. The sample included 18 residents with one resident reviewed for self-administration of medications. Based on observations, record reviews, and interviews, the facility failed to ensure safe and appropriate self-administration of medication for Resident (R) 47. This placed the resident at risk for unnecessary medication side effects and self-administration errors.

Inspectors wroteThe facility identified a census of 90. The sample included 18 residents with one resident reviewed for notification of changes. Based on observation, record review and interview, the facility failed to notify Resident (R)30 and/or his family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) of a significant change in skin condition when R30 developed a pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) during his stay at an acute hospital which was identified when R30 readmitted to the facility. This deficient practice placed the resident at risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service.

Inspectors wroteThe facility identified a census of 90 residents. The sample included 18 residents with one resident reviewed for abuse and mistreatment. Based on observation, record review, and interviews, the facility failed to identify an allegation of abuse, and report to the State Agency, when Resident (R) 40 told the Hospice nurse he received rough treatment from staff, and the Hospice nurse then informed the facility Director of Nursing (DON). This placed the resident at risk for unidentified and ongoing abuse and /or neglect. Findings Included: [...]

Inspectors wroteThe facility identified a census of 90 residents. The sample included 18 residents with one resident reviewed for abuse and neglect. Based on observation, record review, and interviews, the facility failed to investigate an allegation of staff to resident abuse when Resident (R)40 reported rough treatment from direct care staff. This placed R40 at risk for ongoing and/or unidentified abuse and mistreatment. Findings Included: [...]

Inspectors wroteThe facility identified a census of 90. The sample included 18 residents. Two sampled residents were reviewed for hospitalization. Based on observation, record review and interview, the facility failed to provide written notice of transfer with the required information to Resident (R)30 and R4 and/or to their family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R30 and R4.

Inspectors wroteThe facility identified a census of 90 residents. The sample included 18 residents with two residents reviewed for activities of daily living (ADL) cares. Based on observation, record review, and interview, the facility failed to ensure bathing was provided for two residents who required assistance from staff to complete the care. This deficient practice placed Resident (R) 47 and R60 at risk for impaired psychosocial wellbeing, potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices.

Inspectors wroteThe facility identified a census of 90 residents. The sample included 18 residents. Based on observations, record review, and interviews, the facility failed to provide bowel monitoring as ordered by a physician for Resident (R) 6 who received opioid (medications used to treat pain). This deficient practice placed the resident at risk for constipation (difficulty passing stools) and physical complications.

Inspectors wroteThe facility identified a census of 90 residents. The sample included 18 residents with two residents reviewed for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure staff implemented infection control practices during wound care for Resident (R) 4 who received antibiotics to treat a wound infection. This deficient practice placed R4 at risk of delayed healing, ongoing infection, and worsening of her wound.

Inspectors wroteThe facility identified a census of 90 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to ensure foot pedals were used for Resident (R) 67 and R11, when staff pushed residents in their wheelchairs. This deficient practice placed these residents at risk of avoidable accidents.

Inspectors wroteThe facility identified a census of 90 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported a lack of an appropriate diagnosis for antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing] and other mental emotional conditions) medication usage. [...]

Inspectors wroteThe facility identified a census of 90 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to provide bowel monitoring for Resident (R) 47, who received opioid (medication used to relieve pain) medications; failed to ensure antihypertensive (medications used to treat high blood pressure) medications were not given outside of parameters for R6; failed to provide laboratory monitoring for R6 who received Depakote (medication used to treat seizures) for two years, and failed to ensure Voltaren (topical pain reliever medication) gel had dosing instructions for R6. This deficient practice had the risk for unnecessary medication use and unwarranted physical complications for the affected residents.

Inspectors wroteThe facility identified a census of 90 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure Resident (R)47 and R65 had an appropriate diagnosis for antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing] and other mental emotional conditions) medication use and failed to ensure an as needed (PRN) antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication had a 14-day stop date for R6 and R142. This deficient practice had the risk for unnecessary medication use and physical complications for the affected residents.