Ignite Medical Resort Webster, LLC

Inspectors wroteBased on observation, the facility failed to maintain an infection control protocol to prevent the development and transmission of disease and infection for 1 of 1 resident (Resident #1) observed for infection control. The facility failed to ensure CNA A followed proper infection control protocol and hand hygiene procedures during incontinent care and Foley catheter care for Resident #1. This failure could place residents at risk by exposing them to the spread of infection and or communicable diseases. Record review of Resident #1's face sheet dated 4/24/2026 revealed a [AGE] year-old female admitted to facility on 4/22/2026. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement baseline care plans that included the instructions needed to provide effective and person-centered care within 48 hours of admission for 1 of 1 resident (Resident #66) reviewed for baseline care plans: The facility failed to complete Resident #66's baseline care plan in a person-centered manor that accurately depicted resident's condition upon entrance to the facility. This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objective and time frames to meet a resident's medical, nursing, mental and psychosocial needs for 1 (Resident #3) of 6 residents reviewed for care plans. The facility failed to ensure that Resident #3's care plan was person-centered as it did not include information specifying what Resident #3 was resistive of care to and did not specify specific medications for interventions. This failure could place residents at risk of not receiving appropriate care and interventions to meet their needs or staff having complete knowledge regarding a resident's care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents were free from physical restraints imposed for the purposes of convenience, and not required to treat the resident's medical symptoms for 1 of 8 residents (Resident #40) reviewed for physical restraints. -The facility failed to ensure that physical restraints were not used on Resident #40 during medication administration via G- tube (a tube inserted through the belly that brings nutrition directly to the stomach), which resulted in Resident #40 suffering from emotional distress and increased behaviors. This failure could place the residents at risk for psychological harm, emotional distress and at risk for injury.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident who displays or was diagnosed with a mental illness or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 8 Residents (Resident #40) reviewed for behavioral services. - The facility failed to appropriately treat Resident #40's behaviors by staff restraining the resident during G-tube medication administration. This use of restraints resulted in the resident experiencing acute emotional distress. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents had a right to organize and participate in resident groups in the facility for 5 of 5 residents (#16, #31, #17, #37, and #7) reviewed for resident rights, in that: -The facility failed to organize and allow Residents #16, #31, #17, #37, and #7 to participate in monthly resident council meeting. This failure could place residents who reside at the facility at risk of not being able to voice their concerns without staff being present, overhearing their concerns, and to conduct resident council meetings without interference.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 8 residents (Resident #109, CR #1) reviewed for pharmacy services. - The facility failed to ensure that Resident #109 received her full dose of medications by not leaving the medication at the resident's bedside. - The facility failed to ensure that the Kindle Medication Room did not contain expired IV medications. These failures could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, which were complete and accurately documented for 8 of 15 residents (Resident # 40, Resident #7, Resident #10, Resident #24, Resident #29, Resident #31, Resident #54 and Resident #308 ) whose records were reviewed. - Nursing staff failed to properly document Resident #40's behaviors. - LVN A documented administration of Glucerna (a nutritional supplement) to Resident #40 on 03/15/23 even though it was not performed - The facility failed to ensure their system of documenting weights for residents was accurate. These failures could affect any resident, placing them at risk of inaccurate information and resulting inappropriate care.

Inspectors wroteBased on observation interview and record review the facility failed to ensure all alleged violations involving abuse was reported immediately, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term facilities) in accordance with State law through established procedures for 1 of 8 residents (Resident #40) reviewed for abuse in that: - LVN A failed to report use of restraint, a form of abuse, by a family member on Resident #40 prior to 03/15/23 This failure could place residents at risk of psychological harm, emotional distress and further abuse.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and prevent complications of enteral feeding including but not limited to aspiration, pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 1 of 1 resident (Resident #40) reviewed for enteral nutrition. - The facility failed to ensure Resident #40's Glucerna, a nutritional supplement, was administered via G-tube as ordered by administering it when the patient ate greater than 50% of her meal. - The facility failed to track all of Resident #40's meal intake in order to determine if the resident's Glucerna should be given. These failures could place residents at risk of insufficient nutritional supplementation and weight loss. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 8 percent based on 2 errors out of 34 opportunities, which involved 1 of 7 residents (Resident #109) reviewed for medication errors. - MA A failed to administer Resident #109's Vitamin D (cholecalciferol) as ordered by administering 25 mcg (1000 UT) instead of 125 mcg (5000 UT). - MA A failed to administer Resident #109's full dose of Polyethylene Glycol. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, comfortable, and homelike environment for 1 of 2 staff (Housekeeper A) reviewed for safe and sanitary environment for residents. - Housekeeper A had an unlabeled, undated, unnamed bottle of liquid on her housekeeping cart used for cleaning. This could place the facility at risk of inadequate disinfection and transmission of communicable diseases and infections.