Above average — CMS composite of the measures below.
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 Blue Springs during CMS and state inspections, most recent first.
A resident with dementia, muscle weakness, and impaired mobility was found on the floor outside the bathroom with the bathroom track door also dislodged. The resident sustained a head hematoma and a left femoral neck fracture. Staff and maintenance interviews revealed no prior reports of issues with the door, though it was noted that the door could come off the track if bumped with enough force. The deficiency involved the failure to maintain an environment free from accident hazards, as the door's dislodgement contributed to the resident's fall and injuries.
A nurse administered the wrong medications to a resident with complex medical needs after preparing medications for two residents simultaneously and becoming distracted by interruptions during the medication pass. The resident, who was cognitively intact and had multiple serious diagnoses, became lethargic after receiving the unprescribed medications and was sent to the hospital for evaluation, though no treatment was needed. Staff interviews indicated that distractions and the use of a pre-popping method contributed to the error.
The facility failed to ensure proper infection control during resident care, including inadequate hand hygiene and use of enhanced barrier precautions by staff. An LPN did not follow hand hygiene protocols during colostomy care, and staff failed to wear PPE when caring for a resident with a wound. Additionally, a dietary aide did not receive timely TB screening as per facility policy.
The facility failed to maintain a clean environment in several resident rooms, with observations revealing cobwebs and dust buildup behind beds, armoires, and in corners. Despite expectations for thorough cleaning, these deficiencies were noted during a walkthrough with the EVS Director, potentially affecting 23 residents.
A resident with moderately impaired cognition was found self-administering Miconazole Nitrate 2% powder without a physician order or proper assessment in a facility. The medication was not stored in a locked drawer as required by policy. Staff interviews revealed a lack of clarity and enforcement regarding the assessment and documentation process for self-administration.
A facility failed to assess and document a resident's wounds as per its policy. Despite having a left knee wound and a right hip surgical incision, the resident's records lacked measurements and descriptions. Interviews with staff revealed a lack of awareness and documentation, and observations confirmed the presence of wounds that were not properly recorded.
A facility failed to apply a physician-ordered splint device for a resident with limited mobility due to stroke and hemiplegia. Despite the care plan requiring a left hand splint during waking hours, observations showed the resident without the splint on two occasions. Staff interviews revealed a CNA did not apply the splint due to perceived discomfort, and an RN was unaware of the splint's status. The DON expected staff to apply such devices and not document their application if not done.
A resident with moderately impaired cognition and an ostomy was performing colostomy care independently without a physician's order or a full assessment of their ability to self-administer the care. The facility's policy required such an order and assessment, but these were not completed. Interviews revealed that the nursing staff were responsible for the assessment, but it was not documented, and the resident's care plan and orders were not updated to reflect their ability to self-care.
The facility failed to document physician's orders for CPAP machines on the POS and care plans for two residents with sleep apnea. Observations showed CPAP masks and tubing were left uncovered, and staff interviews revealed a lack of adherence to storage protocols. The DON confirmed the expectation for detailed orders and care plans, which were not met.
A resident with significant cognitive impairment and an indwelling catheter did not have proper orders or documentation for catheter care during their stay. Facility staff acknowledged the need for care but cited the absence of an order as a barrier to documentation. The deficiency was noted when the resident was sent to the hospital for a wound infection, highlighting the lack of verifiable catheter care.
The facility's call light system was found deficient, impacting two residents' care. One resident, needing assistance with toilet hygiene, experienced delays when a family member's call light requests went unanswered, requiring them to seek help at the nurse's station. Another resident, with Spina Bifida, reported past issues with the system, which allowed staff to turn off call lights from the nurse's station without entering rooms. Recent changes now require staff to enter rooms to turn off call lights, addressing previous complaints.
Failure to Ensure Safe Environment Due to Dislodged Bathroom Track Door
Penalty
Summary
A deficiency occurred when a resident with multiple risk factors, including unspecified dementia, generalized muscle weakness, abnormal gait, cognitive communication deficit, and a need for assistance with personal care, was found on the floor outside their bathroom with the bathroom track door also on the floor. The resident had moderately impaired cognition and required partial to moderate assistance with toileting hygiene. On the day of the incident, staff heard a loud bang from the resident's room and found the resident in a left lateral position, asking for help to get up. The resident sustained a hematoma on the face and additional bruising, and subsequent X-rays revealed a left femoral neck fracture. The bathroom door was found next to the resident, but not on top of them, and the resident was unable to describe what happened. Interviews with staff, the maintenance director, and the resident's roommate indicated that there were no prior reports or documented issues with the bathroom track door before the incident. The maintenance director and several staff members stated they had not received any requests or notifications regarding problems with the door. The maintenance director noted that the door could potentially come off the track if bumped with enough force, but all safety mechanisms were reportedly intact at the time of the incident. The roommate did not witness the fall but heard the noise and believed the resident may have fallen against the door, causing it to come off the track. The facility had a system in place for staff to report maintenance issues, and both housekeeping and nursing staff were expected to report any concerns. However, no work orders or complaints about the bathroom track door were submitted prior to the event. The incident was unwitnessed, and the resident's cognitive impairment limited their ability to provide details. The deficiency centers on the failure to ensure a safe environment free from accident hazards, as the bathroom track door became dislodged during the resident's fall, contributing to the accident and resulting injuries.
Medication Error Due to Distraction and Incorrect Administration
Penalty
Summary
A medication error occurred when a nurse administered the medications intended for one resident to another resident. The nurse was preparing medications for two residents at the same time and typically labeled the medication cups with the residents' names. However, during this medication pass, the nurse accidentally grabbed the wrong cup and gave the incorrect medications to the resident. The nurse realized the error immediately after administration. The resident who received the wrong medications had a medical history that included end-stage renal disease, respiratory syncytial virus pneumonia, generalized anxiety disorder, pulmonary hypertension, and dependence on renal dialysis. The resident was cognitively intact at the time of the incident. After receiving the incorrect medications, the resident appeared lethargic and sleepy, prompting the facility to send the resident to a local hospital for evaluation, where no treatment was required. Interviews with staff revealed that interruptions during medication passes, such as questions from other residents and the presence of a student, contributed to the error. The nurse involved reported being distracted and stated that the pre-popping method of preparing medications, which was not taught by the facility, was used to expedite the medication pass. The Director of Nursing and another RN both identified that the administration of certain medications, such as Losartan Potassium, could have had significant negative outcomes.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures during the care of residents, specifically in the areas of hand hygiene and the use of enhanced barrier precautions. During the care of a resident with a colostomy and a suprapubic catheter, an LPN did not follow the facility's hand hygiene policy. The LPN entered the resident's room without washing or sanitizing hands, failed to perform hand hygiene between glove changes, and did not wear a gown as required by the enhanced barrier precautions policy. This lack of adherence to proper infection control practices was acknowledged by the LPN and confirmed by interviews with other staff members, including the Assistant Director of Nursing and the Director of Nursing. Another deficiency was observed in the care of a resident with a left ankle wound and on enhanced barrier precautions. Staff members, including an LPN and CNAs, entered the resident's room and provided care without performing hand hygiene or wearing the required personal protective equipment, such as gowns and gloves. Despite the presence of signage indicating the need for enhanced barrier precautions, staff failed to comply with these protocols during direct care activities, such as transferring the resident using a mechanical lift. Interviews with staff revealed a lack of awareness and adherence to the enhanced barrier precautions policy. Additionally, the facility did not ensure timely tuberculosis screening for a dietary aide, as required by the facility's policy. The employee's initial TB test was not completed within the required timeframe, and there was no documentation of a previous TB test prior to or upon hire. This oversight was acknowledged by the Director of Nursing and the President of Clinical Operations, who stated that TB tests should be completed before orientation and two weeks after the first step TB test.
Facility Fails to Maintain Clean Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment in several resident rooms, as evidenced by the presence of cobwebs and a buildup of dust. Observations conducted on various rooms revealed dust accumulation behind beds, armoires, and in corners next to cabinets. Cobwebs were also found in multiple locations, including behind chairs and in corners next to beds and armoires. These conditions were observed during a walkthrough with the Environmental Services (EVS) Director, indicating a lapse in the facility's cleaning processes. Interviews with the Lead Housekeeper revealed expectations for housekeepers to use tools such as dust mops to clean behind and under beds and to remove cobwebs. The housekeepers were instructed to move beds when possible and to take their time to ensure thorough cleaning. Despite these expectations, the presence of cobwebs and dust in numerous rooms suggests that the cleaning procedures outlined in the facility's policy were not adequately followed, potentially affecting at least 23 residents out of a census of 87.
Failure to Obtain Physician Order for Self-Administration of Medication
Penalty
Summary
The facility failed to obtain a physician order for self-administration of medication at bedside and did not evaluate or document the ability of a resident to self-administer medication. This deficiency was identified for one resident out of a sample of 19, in a facility with a census of 87 residents. The resident in question had moderately impaired cognition and was observed with a bottle of Miconazole Nitrate 2% powder and a medication cup with an unidentified pill in their room, neither of which were stored in a locked drawer as required by the facility's policy. The facility's policy mandates that self-administration of medications must be determined by a physician order, and medications should be kept in a locked drawer. However, the resident had been using the Miconazole Nitrate Powder without an order or assessment for self-administration. Interviews with staff revealed a lack of clarity and enforcement regarding the assessment and documentation process for self-administration, with no clear timeframe for completing assessments and no designated personnel to ensure compliance. The Assistant Director of Nursing and the Director of Nursing acknowledged that an order and assessment should have been completed prior to the resident's use of the medication. Despite the facility's policy, the resident's care plan did not include self-administration, and the medication was not stored securely. The oversight in following the facility's policy and ensuring proper documentation and assessment led to the deficiency identified by the surveyors.
Failure to Document and Assess Resident Wounds
Penalty
Summary
The facility failed to assess, describe, and measure wounds weekly for a resident who had a left knee wound and a right hip surgical incision. The facility's Wound Policy and Procedure required that wounds be assessed upon admission and weekly thereafter, including details such as location, measurement, appearance, and drainage. However, the resident's records from admission through several weeks showed no measurements or descriptions of the wounds, despite the resident being at risk for skin integrity issues and requiring daily treatment for a surgical site on the right hip. Interviews with facility staff, including LPNs, the ADON, the Wound Nurse, and the DON, revealed a lack of awareness and documentation regarding the resident's wounds. The staff were expected to perform detailed skin assessments and document all wounds, but this was not consistently done. Observations confirmed the presence of a right hip surgical wound and scars on the left knee, yet these were not adequately documented in the resident's records. The facility's failure to adhere to its wound assessment policy resulted in a deficiency in the care provided to the resident.
Failure to Apply Ordered Splint Device for Resident
Penalty
Summary
The facility failed to ensure the proper application of a splint device for a resident with limited mobility, as ordered by the physician. The resident, who was severely cognitively impaired and dependent on staff for upper body dressing, had a diagnosis of stroke and hemiplegia, which resulted in upper extremity range of motion impairment on one side. The resident's care plan included the use of a left functional resting hand splint during waking hours to maintain or improve mobility. However, observations on two consecutive days showed the resident in a wheelchair without the splint device in place. Interviews with facility staff revealed a lack of adherence to the care plan. A CNA reported not applying the splint because the resident grimaced, while an RN was unaware of the resident's splint status and acknowledged there was no reason for the splint not being applied. Despite this, the Treatment Administration Record documented the splint's application on the days in question. The Director of Nursing expressed an expectation for staff to apply ordered devices and not to document their application if they were not applied.
Failure to Obtain Physician's Order for Self-Administered Colostomy Care
Penalty
Summary
The facility failed to obtain a physician's order for a resident to self-perform colostomy care and did not complete a full evaluation to assess the resident's ability to self-administer this care. The resident, who had moderately impaired cognition and an ostomy, was performing colostomy care independently without any documented assessment or physician's order authorizing self-administration. The facility's policy required a physician's order and a documented assessment for self-administration of treatments, which was not followed in this case. Interviews revealed that the resident had not been assessed for the ability to self-care for the ostomy, and no demonstration of the resident's ability to perform the care was requested by the staff. The Occupational Therapist noted that only certain parts of the self-care assessment were completed by therapy staff, and the nursing staff were responsible for the full assessment. However, there was no specific timeline for completing this assessment, and it was unclear if the nursing staff were aware of their responsibilities. The Assistant Director of Nursing and the Director of Nursing acknowledged that there was no specific assessment form for self-administration of treatments and that the resident's care plan and orders needed to be updated to reflect the resident's ability to perform ostomy care independently. Despite the resident's ability to self-administer ostomy care, the necessary documentation and physician's order were not in place, leading to a deficiency in the facility's compliance with its own policies.
Deficiency in CPAP Machine Documentation and Storage
Penalty
Summary
The facility failed to ensure that physician's orders for CPAP machines were documented on the Physician's Order Sheet (POS) and care plans for two residents. Resident #183, who was admitted with diagnoses including sleep apnea, did not have orders for the CPAP machine settings or duration of use documented on the POS. The resident's care plan also lacked information about the CPAP machine, its usage, and care instructions. Observations showed that the resident's CPAP face mask and tubing were left uncovered on the bed, contrary to the facility's expectations for storage when not in use. Similarly, Resident #280, diagnosed with obstructive sleep apnea, did not have a detailed physician's order for the use and care of the CPAP machine documented in the Treatment Administration Record (TAR) or Nursing Medication Administration Record (MAR). The resident's care plan did not include information about the CPAP machine or its care. Observations revealed that the CPAP face mask was left uncovered on the dresser, and there was no documentation of monitoring the resident's use of the CPAP machine. Interviews with staff, including CNAs and LPNs, indicated a lack of awareness and adherence to the facility's expectations for covering respiratory equipment when not in use. The staff also failed to ensure that physician's orders for CPAP machines were obtained and transcribed upon admission. The Director of Nursing and President of Clinical Operations confirmed the expectation for detailed physician orders and updated care plans for CPAP machine use and care, which were not met in these cases.
Lack of Catheter Care Documentation for Resident
Penalty
Summary
The facility failed to ensure proper orders and documentation for indwelling urinary catheter care for a resident, leading to a deficiency in care. The resident, who was significantly cognitively impaired and completely dependent on staff for toileting hygiene, had an indwelling catheter but lacked a physician's order for catheter care upon admission. This oversight meant there was no documentation of catheter care in the resident's Treatment Admission Record (TAR) until the day of discharge. Interviews with facility staff, including Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs), revealed a lack of clarity and responsibility regarding catheter care documentation. While staff acknowledged the necessity of catheter care, they indicated that without an order, there was no designated place to document the care provided. The Director of Nursing (DON) confirmed the expectation for catheter care to be performed every shift and during perineal care, but also noted the absence of an order prevented proper documentation. The deficiency was further highlighted when the resident was sent to the hospital for evaluation due to a wound infection. Despite staff assertions that catheter care was performed, the lack of an order and documentation made it impossible to verify. The facility's policy required a physician's order for catheterization, including care instructions, which was not in place for this resident until the day of discharge.
Deficiency in Call Light System Affects Resident Care
Penalty
Summary
The facility failed to ensure that the call light system was adequately equipped and functioning, affecting the care of two residents. The call light system was intended to allow residents to communicate with staff, but it was found that the system could be turned off at the nurse's station without staff entering the resident's room. This deficiency was highlighted by incidents involving two residents who required assistance with personal care and experienced delays in receiving help due to the call light system's inadequacies. One resident, who was moderately cognitively impaired and needed assistance with toilet hygiene, experienced a delay in receiving help when a family member pressed the call light multiple times without a response. The family member had to go to the nurse's station to request assistance, and although a CNA eventually came to help, the resident's request to speak with a nurse was not fulfilled before the family member left. This incident demonstrated the failure of the call light system to ensure timely and adequate communication between residents and staff. Another resident, who was cognitively intact but required assistance with toileting hygiene and lower body dressing due to Spina Bifida, reported past issues with the call light system. Although the resident noted improvements, the previous system allowed staff to turn off call lights from the nurse's station without entering the resident's room, which could lead to delays in care. Interviews with staff confirmed that the system had been recently changed to require staff to enter residents' rooms to turn off call lights, addressing previous complaints about response times.
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 818 citations issued within 25 miles in the last 12 months — including the 17 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 Blue Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monterey Park Rehabilitation & Health Care Center | 0.4 mi | ★★★★★ | 13 | 0 |
| Jackson Creek Post Acute | 1 mi | ★★★★★ | 21 | 0 |
| Sunterra Springs Independence | 1.5 mi | ★★★★★ | 0 | 0 |
| Abode Health And Wellness Center | 3.4 mi | ★★★★★ | 6 | 0 |
| Rehabilitation Center Of Independence, The | 3.8 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ignite Medical Resort Blue Springs.
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.