Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ignite Medical Resort Rainbow Boulevard, Llc during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments was admitted with existing skin issues, but staff failed to conduct a thorough skin assessment or document a stage 3 sacral pressure ulcer until four days after admission. The care plan lacked specific interventions for the wound, and required risk assessments were not completed, resulting in delayed identification and management of the pressure ulcer.
A resident with severe cognitive impairment and physical limitations fell and sustained a head injury when a CNA attempted to provide incontinence care alone, despite the care plan requiring two-person assistance. The resident, who was at high risk for falls, rolled off the bed during the incident, highlighting a failure to ensure a safe environment.
The facility failed to ensure RN coverage for eight consecutive hours daily, seven days a week, as required. A review of nursing hour sheets and a labor report revealed multiple dates without adequate RN coverage, placing 93 residents at risk of inadequate assessment and care. Administrative staff were involved in verifying schedules, but no policy on RN coverage was provided.
The facility failed to follow infection control standards, particularly in the use of PPE for Enhanced Barrier Precautions, as observed when a nurse changed a resident's wound dressing without wearing a gown. Additionally, the facility lacked a water management program to address Legionella risk, with administrative staff acknowledging the absence of such a program. These deficiencies increased the risk of infectious diseases among residents.
The facility failed to secure hazardous materials and rooms from nine cognitively impaired ambulatory mobile residents, placing them at risk for preventable accidents. Unsecured electrical rooms and cleaning closets with hazardous materials were found, contrary to the facility's policy. Staff confirmed these areas should have been locked to prevent resident access.
The facility failed to securely store medications by not locking three medication carts, which contained insulin pens and medicated creams. Inspections revealed that the carts were left unattended and unlocked, contrary to the facility's policy. LN H admitted that night shift staff sometimes forget to lock the carts, and Administrative Nurse D confirmed that carts should be locked when not in use.
A facility with 93 residents was found to have deficiencies in food storage and labeling practices. Observations revealed unlabeled and undated food items in the main kitchen, including shredded cheese, cake, and deli meats. The 400-floor kitchenette area also had unsanitary conditions, such as sugar granules on counters and water deposit stains. Dietary staff confirmed the need for proper labeling and storage to prevent contamination, but the facility failed to adhere to these standards, risking food-borne illnesses.
The facility failed to ensure agency staff received required training on resident rights, impacting care quality. The facility relied on a sister agency for training records, which were not provided, and lacked a policy for direct care staff education.
The facility did not ensure agency staff received required training on abuse, neglect, and exploitation (ANE), placing residents at risk. The facility could not provide training records for an agency LN and relied on a sister company to maintain these records. The facility also lacked a policy for required education for direct care staff.
The facility failed to ensure agency staff received required infection control training, placing residents at increased risk for infections. The facility could not provide training records for an agency LN and relied on a sister company to maintain these records. Additionally, the facility lacked a policy for required education for direct care staff.
A resident with multiple medical conditions, including blindness, was observed in the dining area with an open gown, exposing his backside. Despite being independent in some activities, he relied on staff for dressing assistance. Staff interviews confirmed the expectation for residents to be appropriately covered, aligning with the facility's dignity policy. The failure to ensure proper dressing compromised the resident's dignity.
A facility failed to provide timely written notification of transfer to a resident or their representative for several facility-initiated transfers. The resident, with a history of neuromuscular dysfunction, CHF, and paraplegia, had multiple unplanned discharges to a hospital without documented notifications. Staff interviews revealed a lack of adherence to the facility's bed hold policy, which required written notification before transfer or within 24 hours in emergencies.
A resident with end-stage renal disease and a newly placed AV fistula did not have her care plan updated to include necessary interventions for dialysis access site monitoring. The facility's oversight in revising the care plan placed the resident at risk for impaired care due to uncommunicated care needs.
A facility failed to properly manage a resident's suprapubic catheter, leading to a deficiency. The resident, with a history of chronic kidney disease and bladder dysfunction, had a catheter anchored on the thigh instead of the abdomen, causing potential complications. Staff interviews revealed uncertainty about proper catheter anchoring, and the care plan lacked specific instructions, placing the resident at risk.
A facility failed to ensure proper communication and monitoring for a resident requiring dialysis. The resident's care plan lacked specific directions for monitoring a dialysis fistula, and the facility did not maintain documentation of monitoring the AV fistula shunt access site. Additionally, communication with the dialysis center was inadequate, as dialysis communication forms were missing for several months. This placed the resident at risk for complications related to dialysis.
A facility failed to assess the risks of bed rail use for a resident with a low air-loss mattress, despite the presence of a right-sided assist bar. The resident's evaluations did not address the potential risks associated with the mattress, and the care plan lacked documentation on bed rails. Staff interviews revealed inconsistent monitoring and assessment practices, contrary to the facility's policy, placing the resident at risk for impaired safety.
A facility failed to ensure a resident's PRN hydroxyzine had a 14-day stop date or physician documentation for extended use. The resident, with a history of hypertension, CHF, diabetes, and obesity, was taking an antianxiety medication. The facility's policy required a stop date or physician guidance for PRN psychotropic medications, which was not followed.
The facility failed to secure hazardous materials when a Sharps container on a medication cart was found overfilled past the fill line, with lancets accessible. An unidentified staff member used bare hands to push the contents back into the bin. This placed four cognitively impaired, independently mobile residents at risk for preventable injuries and accidents.
The facility failed to follow sanitary dietary standards for food storage and maintaining a sanitary food service environment. Inspections revealed old food particles, stains, expired and undated food items, and calcium-encrusted stains in kitchenettes on the third and fourth floors. Dietary staff acknowledged that the kitchenettes should be managed by contracted dining services, but these practices were not followed.
The facility failed to meet a resident's behavioral health needs, resulting in repeated episodes of verbal and physical aggression towards other residents and staff. Despite having a care plan, non-pharmacological interventions were inconsistently applied and documented, leading to multiple incidents of aggression.
Failure to Timely Identify and Manage Pressure Ulcer on Admission
Penalty
Summary
A resident with significant cognitive and physical impairments, including hemiplegia, Parkinson's disease, seizures, muscle weakness, and dementia, was admitted to the facility. Upon admission, the resident was dependent on staff for all activities of daily living and was incontinent of bowel and bladder. The initial admission assessment documented excoriation to the groin and abdominal fold, a left chest surgical incision, and shearing to the inner buttock, but did not provide detailed descriptions or identify a stage 3 sacral wound. The care plan noted the resident was at risk for skin integrity issues but lacked specific interventions or documentation for the existing stage 3 sacral wound. For four days following admission, there was no documentation in the daily skilled nurses' notes regarding assessment or care for a stage 3 sacral pressure ulcer. The sacral wound was only identified and documented on the fourth day after admission, at which point a wound care consult and specific wound care orders were implemented. Prior to this, the care plan and assessments did not reflect the presence or management of the sacral wound, and no Braden risk scores were recorded to assess the resident's risk for pressure ulcers. Interviews with facility staff revealed that the initial skin assessment should have been completed within 24 hours of admission, but this was not done in detail for this resident. The facility's wound policy required a comprehensive head-to-toe skin assessment and risk scoring upon admission, which was not followed. The lack of timely identification and documentation of the resident's stage 3 sacral pressure ulcer resulted in a delay in appropriate care and placed the resident at risk for harm.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a safe environment for a resident, identified as R1, who was at high risk for falls due to severe cognitive impairment and physical limitations following a stroke. R1 required two-person assistance for all activities of daily living, including incontinence care, as documented in their care plan. Despite this requirement, a Certified Nurse Aide (CNA) attempted to provide incontinence care alone, during which R1 rolled off the bed and sustained a head injury. The incident was witnessed, and the resident was subsequently taken to the emergency room, where imaging showed no significant injury. R1's medical history included cerebral infarction, hemiplegia, hemiparesis, and stage 3 chronic kidney disease, which contributed to their high fall risk. The care plan had previously documented two non-injury falls and directed staff to use bilateral fall mats and maintain the bed in a low position. However, during the incident, these precautions were not sufficient to prevent the fall. The facility did not provide a policy for the prevention of accident hazards, and the failure to adhere to the care plan's requirement for two-person assistance directly led to the resident's fall and injury.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required. This deficiency was identified through a review of daily posted nursing hour sheets from March 1, 2023, to August 15, 2024, which revealed multiple dates lacking RN coverage. Specifically, the facility's Rainbow Labor report, submitted on August 26, 2024, showed no evidence of eight consecutive hours of RN coverage on March 14, 2024, March 18, 2024, May 18, 2024, June 6, 2024, and June 15, 2024. Administrative Staff A and Administrative Nurse D were involved in checking schedules and reviewing timecards to verify RN coverage, but the facility did not provide a policy related to RN coverage. This lack of RN coverage placed all 93 residents of the facility at risk of inadequate assessment and inappropriate care, as there was no assurance that a registered nurse was available to meet their needs consistently.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility, with a census of 93 residents, failed to adhere to infection control standards, particularly in the use of personal protective equipment (PPE) for Enhanced Barrier Precautions (EBP). This was observed when a licensed nurse entered a resident's room, which had signage indicating the need for EBP, and proceeded to change the resident's wound dressing without wearing a gown as required. Despite the facility's policy and training on EBP, this lapse in following the protocol was noted, indicating a failure in implementing the infection prevention and control program effectively. Additionally, the facility did not have a water management program to address and mitigate the risk of Legionella and other waterborne pathogens. When requested, the facility was unable to provide a risk assessment or a water management program for Legionella. Administrative staff acknowledged the absence of such a program, attributing it to the building's ownership. This lack of a water management program further contributed to the facility's failure to maintain sanitary infection control standards, placing residents at increased risk for infectious diseases.
Failure to Secure Hazardous Areas and Materials
Penalty
Summary
The facility failed to secure hazardous materials and rooms from nine cognitively impaired ambulatory mobile residents, placing them at risk for preventable accidents and injuries. During a walk-through of the facility's fourth floor, it was observed that two electrical rooms were unsecured. One room, located across from a resident's room, contained two large unlocked high-voltage switch panels with warnings indicating the danger of hazardous voltage. Another room across from a different resident's room had six smaller unlocked electrical switch panels with similar warnings. Additionally, a cleaning closet across from a resident's room was found unsecured, containing various hazardous cleaning products with warnings about potential harm. Further observations on the third floor revealed that the facility's beauty salon was left unlocked, with an unlocked cabinet containing several bottles of sanitizing spray and barbicide, both labeled as hazardous. Interviews with staff, including a Licensed Nurse and an Administrative Nurse, confirmed that these areas should have been locked at all times to prevent resident access to potentially hazardous materials. The facility's policy on the control of hazardous chemicals, revised in June 2024, indicated that such materials should be securely stored and inaccessible to residents, which was not adhered to in this instance.
Medication Storage Deficiency
Penalty
Summary
The facility failed to securely store medications, specifically insulin pens and medicated creams and ointments, by not locking three medication carts. During an inspection, it was observed that a treatment cart stationed across from the fourth-floor elevators was left unsupervised and unlocked, containing 12 labeled but unsecured insulin pens. Another cart, located next to the fourth-floor rehab gym entry, was also found unattended and unlocked, containing 10 labeled insulin pens and assorted medicated creams and ointments. A third cart, across the hall from a resident's room, was similarly unsecured with six insulin pens and various medicated creams and ointments. Licensed Nurse H acknowledged that sometimes the night shift staff forgets to lock the carts after moving items between them. Administrative Nurse D confirmed that medication carts should be locked when not in use or directly monitored. The facility's Medication Access and Storage policy, reviewed in January 2023, mandates that all medications and biologicals be stored safely and securely, following the manufacturer's storage recommendations. The failure to adhere to this policy placed residents at risk for unsafe medication practices and potential misappropriation.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility, with a census of 93 residents, was found to have deficiencies in food storage and labeling practices during a survey. Observations in the main kitchen revealed several food items, including containers of shredded cheese, slices of cake, and various deli meats, that were not labeled or dated after their original packaging was opened. Additionally, a half onion was found in a plastic bag without a label or date. These practices were contrary to the facility's policy, which requires all opened food items to be placed in sealed containers and labeled with the name of the food, the date it was opened, and the expiration date. Further inspection of the 400-floor kitchenette area showed unsanitary conditions, such as sugar granules on the counters and water deposit stains around the water and ice machine dispenser spout. Interviews with dietary staff confirmed that all food items should be labeled and stored properly to prevent contamination and the growth of pathogenic organisms. The facility's failure to adhere to these standards placed residents at risk of food-borne illnesses and food safety concerns.
Failure to Provide Resident Rights Training to Agency Staff
Penalty
Summary
The facility, with a census of 93 residents, failed to ensure that agency staff received the required training on resident rights, which is essential for providing proper care and maintaining the quality of life for residents. On a specific date, the facility was unable to provide training records for an agency Licensed Nurse (LN) identified as K. During an interview, Administrative Staff A revealed that the facility relied on the agency company, which is a sister company, to ensure that the required education was provided and records were maintained. However, the facility was still waiting for the agency to send the requested staff information. Additionally, the facility did not have a policy related to the required education for direct care staff, leading to a deficiency in ensuring agency staff received necessary training.
Failure to Provide ANE Training to Agency Staff
Penalty
Summary
The facility failed to ensure that agency staff received the required training on abuse, neglect, and exploitation (ANE), which placed residents at risk. The facility had a census of 93 residents and was unable to provide training records for an agency Licensed Nurse (LN) identified as K. During an interview, Administrative Staff A stated that the facility relied on the agency company, which was a sister company, to ensure that the required education was provided and records were maintained. However, the facility was still waiting for the agency to send the requested staff information. Additionally, the facility did not have a policy related to the required education for direct care staff.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to ensure that agency staff received the required infection control training, which placed residents at increased risk for infections. The facility had a census of 93 residents and was unable to provide training records for an agency Licensed Nurse (LN) identified as K. During an interview, Administrative Staff A stated that the facility relied on the agency company, which was a sister company, to ensure that the required education was provided and records were maintained. However, the facility was still waiting for the agency to send the requested staff information. Additionally, the facility was unable to provide a policy related to the required education for direct care staff, further contributing to the deficiency.
Resident Dignity Compromised Due to Inadequate Dressing
Penalty
Summary
The facility failed to maintain a dignified care environment for a resident, identified as R51, during mealtime. R51, who has a medical history including respiratory failure, hypertension, diabetes, and blindness, was observed in the dining area with his gown open at the back, exposing his backside to peers and visitors. Despite having intact cognition and being independent in eating and wheeling his wheelchair, R51 required assistance with dressing due to his medical conditions. The resident expressed that he was unaware of his exposure and relied on staff to tie his gown or provide a second gown for coverage. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that residents should have their backsides covered, especially in communal areas like the dining room. The facility's dignity policy emphasized the importance of maintaining residents' dignity by ensuring they are dressed appropriately and that hospital gowns should only be used if specifically requested and documented in the care plan. The failure to adhere to this policy resulted in a deficiency that compromised R51's dignity and psychosocial well-being.
Failure to Provide Timely Written Notification of Transfer
Penalty
Summary
The facility failed to provide timely written notification of transfer to a resident, identified as R238, or their representative for several facility-initiated transfers. The resident's electronic medical record documented multiple unplanned discharges to a short-term acute hospital with a return anticipated, yet there was no evidence of written notification for these transfers on specific dates. The resident had a history of neuromuscular dysfunction of the bladder, congestive heart failure, and paraplegia, and was dependent on staff for functional abilities such as bathing, toileting, and dressing. Despite having intact cognition, as indicated by a BIMS score of 14, the resident's clinical record lacked documentation of the required written notifications for transfers. Interviews with facility staff revealed that the responsibility for ensuring written notification of transfer and bed hold completion before a resident's transfer lay with the nurses. However, the administrative nurse was unable to find any record of the written notifications for the resident's transfers prior to a specific discharge date. The facility's bed hold policy, revised in April 2023, required written notification to be provided to the resident or their representative before a transfer, or within 24 hours in case of an emergency, but this was not adhered to in the case of R238.
Failure to Update Dialysis Care Plan for Resident
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R62, to include necessary interventions for her dialysis access site. R62, who has end-stage renal disease and relies on dialysis, had a left arteriovenous (AV) fistula placed in December 2023. Despite this significant change, the care plan did not include directions for monitoring the AV fistula, such as assessing for a thrill or bruit, or restrictions on using the affected extremity for blood pressure measurements. The lack of updated care plan interventions was confirmed through observations, record reviews, and staff interviews. The deficiency was identified during a survey where it was noted that the facility's care plan policy required updates at least every 90 days or with significant changes in the resident's condition. However, the policy lacked specific directions for revising care plans. Interviews with staff revealed that the oversight was unintentional, and the care plan had not been updated to reflect the resident's current dialysis access needs. This oversight placed the resident at risk for impaired care due to uncommunicated care needs.
Deficiency in Suprapubic Catheter Management
Penalty
Summary
The facility failed to ensure proper care for a resident with a suprapubic catheter, leading to a deficiency in catheter management. The resident, identified as R12, had a history of chronic kidney disease, malignant neoplasm of the prostate, and bladder dysfunction. Despite having an indwelling catheter and being treated for a urinary tract infection, the care plan lacked specific instructions for anchoring the catheter to prevent pulling or injury. Observations revealed that the catheter was anchored on the resident's left thigh, contrary to the resident's previous experience of having it anchored on the abdomen. This improper anchoring resulted in the catheter tubing being tinged with white mucous and bright red blood, indicating potential complications. Interviews with facility staff, including a CNA and a licensed nurse, highlighted a lack of clarity and knowledge regarding the appropriate placement of the catheter anchor for a suprapubic catheter. The CNA was unsure of the correct placement, and the licensed nurse suggested that the anchor should be placed according to the resident's preference, which was not documented in the care plan. The administrative nurse stated that the facility followed the manufacturer's instructions, which allowed for placement on the abdomen or upper thigh, but did not believe this needed to be included in the care plan. This lack of specific guidance and adherence to standard practices placed the resident at risk for catheter-related complications.
Failure in Dialysis Care Communication and Monitoring
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding a resident's health status with each dialysis procedure. The resident, who had end-stage renal disease and required dialysis, had a care plan that directed staff to monitor and report any signs of infection or complications at the dialysis access site. However, the care plan lacked specific directions related to the resident's dialysis fistula, such as assessing for a thrill or bruit and restrictions for the extremity. Additionally, the facility did not maintain documentation of monitoring the resident's AV fistula shunt access site for a thrill or bruit from December 2023 to August 2024. The facility was unable to provide dialysis communication forms for the resident from December 2023 to June 2024, indicating a lack of proper communication with the dialysis center. The resident reported that while communication sheets were sent with her to dialysis, they were not always returned. An administrative nurse acknowledged the oversight in updating the resident's orders to reflect the presence of the AV fistula, which resulted in the fistula not being monitored as required. This deficiency placed the resident at risk for complications related to dialysis.
Failure to Assess Bed Rail Risks with Low Air-Loss Mattress
Penalty
Summary
The facility failed to properly assess the risks associated with the use of bed rails for a resident, identified as R73, who was using a low air-loss mattress. Despite the presence of a right-sided assist bar on the resident's bed, the evaluations conducted did not address or acknowledge the potential risks associated with the combination of the assist bar and the low air-loss mattress. The resident's medical records indicated severe cognitive impairment and significant physical limitations, requiring extensive assistance with activities of daily living. However, the care plan lacked documentation regarding the use of bed rails or assistive positioning devices, and the evaluations failed to consider the specific risks posed by the low air-loss mattress. Observations and interviews revealed that the facility's staff did not consistently monitor or assess the safety of the bed rails in conjunction with the low air-loss mattress. A licensed nurse admitted uncertainty about the frequency of checks and whether the mattress was included in the assessments. The administrative nurse confirmed that device assessments should include the use of low air-loss mattresses, but documentation for R73 was lacking. The facility's policy required appropriate assessment for the risk of entrapment and adherence to manufacturer's recommendations, yet these procedures were not followed, placing the resident at risk for impaired safety.
Failure to Document PRN Psychotropic Medication Stop Date
Penalty
Summary
The facility failed to ensure that a resident's as-needed (PRN) hydroxyzine, a psychotropic medication, had a 14-day stop date or documentation of a physician's rationale and specific duration of use. This oversight was identified during a review of the resident's electronic medical records, which revealed an active order for hydroxyzine without a stop date. The facility was unable to provide the necessary documentation for the continuation of the medication past the required 14-day stop date when requested by surveyors. The resident involved had a medical history that included hypertension, congestive heart failure, type two diabetes mellitus, and morbid obesity. The resident's admission data indicated intact cognition and no behavioral symptoms, although he was taking an antianxiety medication. Observations and interviews with the resident and facility staff confirmed the lack of appropriate documentation for the PRN medication. The facility's policy required that PRN psychotropic medications include a stop date or documented physician guidance for extended use, which was not adhered to in this case.
Failure to Secure Hazardous Materials
Penalty
Summary
The facility failed to secure hazardous materials when a Sharps container on a medication cart was found overfilled past the fill line, with lancets resting on top and accessible. This was observed during a walkthrough of the fourth-floor hallway. Later, the contents of the Sharps bin overflowed onto the floor and were picked up by an unidentified staff member using their bare hands, who then shoved the contents back into the bin and left the area. The medication cart was eventually removed from the area. Licensed Nurse G confirmed that nursing staff should replace Sharps bins before they reach the full mark and should never attempt to push or reach inside the bins due to the risk of being stuck by hazardous materials. Administrator A stated that staff were expected to replace the Sharps bins or notify maintenance instead of allowing the bins to overflow. A review of the facility's Injection Safety and Sharps Injury Protection Plan indicated that bins were to be changed out frequently and never allowed to be filled past the full mark, and staff should never attempt to push down materials into the bins. This deficient practice placed four cognitively impaired, independently mobile residents at risk for preventable injuries and accidents.
Sanitary Dietary Standards Not Followed
Penalty
Summary
The facility failed to follow sanitary dietary standards for food storage and maintaining a sanitary food service environment. During an inspection of the fourth-floor kitchenette, surveyors found old food particles and debris in the microwave, food debris and stains in the condiment food chiller, and old coffee and stains in the coffee pot and machine. Additionally, an ice chest contained warm stale-smelling water, and the refrigerator had dried food stains with no evidence of temperature assessments. The storage cabinets contained brown-stained towels and an uncovered food thermometer touching dirty surfaces. The ice machine had calcium-encrusted stains on the ice outlets. On the third floor, the refrigerator temperature log had not been checked recently, and the refrigerator contained expired thickened juices, an undated sandwich and pie, and undated packages of cookie dough in the freezer. The condiment food chiller had an undated small carton of milk, and the cabinets contained a stained hospital blanket and a portable griddle placed face down on dirty surfaces. Cups labeled with residents' names were stored face down in soiled cabinets. The ice machine also had calcium-encrusted stains. Dietary staff stated that the kitchenettes should be managed by contracted dining services, and facility staff were expected to clean up minor spills, inspect food daily, and ensure open food was labeled and dated. However, these practices were not followed, leading to the identified deficiencies.
Failure to Adequately Address Behavioral Health Needs
Penalty
Summary
The facility failed to adequately meet the behavioral health needs of a resident (R1) with diagnoses of major depressive disorder, Alzheimer's disease, and bipolar disorder. Despite having a care plan in place that included non-pharmacological interventions, the facility did not effectively implement these strategies, resulting in repeated behavioral episodes. R1 exhibited verbal and physical aggression towards other residents and staff on multiple occasions, including incidents where R1 verbally threatened and physically scratched another resident (R2) and aggressively kicked a different resident (R3). The care plan lacked specific details on the non-pharmacological interventions used during these episodes, and there were instances where no de-escalation techniques were documented or attempted during behavioral outbursts. The facility's records indicated that R1 had a history of behavioral issues, including verbal aggression and physical aggression, which were documented in various incident reports. Despite these documented behaviors, the facility's interventions were inconsistent and insufficient. For example, after an incident of verbal aggression towards R2, R1 was temporarily placed on 15-minute checks, but the care plan did not detail specific non-pharmacological interventions. Additionally, during an episode where R1 chased and attempted to hit a nurse, the progress note failed to document any de-escalation attempts or notification to the medical provider. Interviews with facility staff revealed that they were aware of R1's behavioral triggers and the need for non-pharmacological interventions, such as distraction techniques and environmental changes. However, these strategies were not consistently applied or documented in R1's care plan. The facility's Behavioral Management policy emphasized a person-centered approach and the need for individualized interventions, but the facility did not adhere to this policy, resulting in repeated behavioral episodes and placing R1 and other residents at risk for harm.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 866 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bishop Spencer Place, Inc, The | 1.8 mi | ★★★★★ | 18 | 0 |
| Summit, The | 1.8 mi | ★★★★★ | 1 | 0 |
| Clara Manor Nursing Home | 2.5 mi | ★★★★★ | 21 | 1 |
| Parkway Health Care Center | 3.9 mi | ★★★★★ | 2 | 1 |
| The Village At Mission | 3.9 mi | ★★★★★ | 7 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ignite Medical Resort Rainbow Boulevard, Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.