Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Carondelet Llc during CMS and state inspections, most recent first.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with hemiplegia, aphasia, unsteadiness, ADL deficits, and fall risk had a care plan indicating a desire to remain for LTC, but the facility issued a NOMNC ending Medicare coverage without completing required provider sections and without updating the care plan to reflect an active discharge plan. The DCT documented functional barriers such as stairs and bathing, sent referrals to other facilities, and acknowledged not asking the resident about specific transfer preferences or consistently documenting discharge-planning discussions. The Administrator and DCT told the resident they could not stay, actively sought alternative placement, and discussed possible return to a motel, while no formal discharge notice was issued and the existing care plan still showed an initial plan for LTC.
The facility failed to provide required medically-related social services and discharge planning for a cognitively intact resident with hemiplegia, aphasia, ADL deficits, and fall risk. Although policy required Social Services and the IDT to assess discharge potential, arrange outside services, and assist with community placement options, documentation from the Director of Care Transitions showed no referrals to outside entities or help identifying community placements, despite known barriers such as stairs and bathing. The resident reported being told they could not stay, was unsure whether they were being sent to LTC, housing, or an ALF, and stated they had not received information about outside agency assistance. The DCT and Administrator focused on referrals to other facilities, did not provide other community resource referrals, did not obtain the resident’s transfer preferences, and acknowledged that a discharge notice had not been issued, resulting in a lack of planning for potential community services needed for a successful discharge.
Surveyors found multiple environmental and maintenance deficiencies affecting at least 15 residents, including climate control units in several rooms containing debris such as personal items and medication cups, missing or heavily soiled grates, and significant dust and cobweb buildup. Restroom ceiling vent covers in several rooms were loose or missing, a restroom handrail used by a resident was repeatedly observed to be not firmly attached to the wall, and a wall guard in another room was peeling away with protruding screws. The Maintenance Director reported that units should be checked monthly, acknowledged prior checks of some vents, was unaware of the loose wall guard, and believed nursing and housekeeping staff typically entered such issues into the TELS work order system.
Dust Buildup on Vents and Resident Room Fans: The facility failed to keep ceiling vents in a shower room and tabletop fans in multiple resident rooms free from heavy dust buildup. During observation with the FM Director, heavy dust was seen on two ceiling vents and on fans in several rooms, and the Director said a cleaning schedule for the vents had not yet been developed. Two cognitively intact residents stated their fans were cleaned only every now and then or had not been cleaned in a while.
A facility failed to honor food preferences and provide alternative meal choices for residents who ate in their rooms. A resident with dysphagia and weakness reported that staff did not let him/her choose items, served cold food, and did not offer substitutes; observations showed missing items from the meal ticket and blank preference sections. Two other residents also said they were not asked what they wanted, and observations found no alternative menus available in rooms or the dining room despite staff stating that alternatives were available.
Kitchen and dining area sanitation and maintenance were deficient. Observations showed dust on vents and ceiling lights, an open flour bin door, an open bag of breadcrumbs, holes in the wall, loose metal trim, no drain cover in the dish machine room, and a large unsealed hole with debris and a black substance on piping under the prewash sink. The dining room floor also had dried residue and a fresh spill over multiple observations, and the Executive Chef stated the dining room should be swept and mopped after every meal.
Infection Control and EBP Failures During Resident Care: Staff were observed providing care to residents on EBP without consistent gown use, proper hand hygiene, or correct glove changes during dirty-to-clean tasks. A resident with a feeding tube and another with wounds and urinary devices were cared for without the required PPE, and a resident with a suprapubic catheter had a drainage bag dragging on the floor while direct care was provided without the expected gown, gloves, and mask.
Absent Negative Airflow in Multiple Resident Room Restrooms: Surveyors observed that multiple resident room restrooms did not have negative airflow when tested with tissue paper at the ceiling vents; the paper fell instead of being drawn to the vent. The deficiency affected restrooms in several resident rooms, and the Facility Maintenance Director stated he/she had not checked for negative airflow since starting and had not been told to check it in resident rooms.
A resident with adult failure to thrive and intact cognition repeatedly refused scheduled evening showers, stating a preference for morning bathing, yet staff continued to follow a room-based evening shower schedule without documenting nursing follow-up, education, or care plan interventions to adjust bathing times or address the refusals. Over the same period, another resident with dementia, significant ADL and mobility assistance needs, and a history of falls was repeatedly observed in bed or in a wheelchair with the call light placed behind the nightstand and out of reach, despite a care plan and facility policy requiring staff to keep call lights accessible and to encourage and educate the resident on their use.
Insulin was administered to two residents with DM without wiping the insulin pen septum with alcohol before attaching the needle. An LPN was observed giving Humalog to one resident and Novolog and Lantus to another resident without cleaning the pen septum first, and both the LPN and CNO stated the pen should be wiped with alcohol before needle attachment.
A resident with severe vision loss, severe cognitive impairment, total dependence for ADLs/transfers, and pressure injury risk did not have an adaptive call light available and the call light was repeatedly left out of reach or tied to the bed frame. The resident also had an order for Prevalon boots to be worn in bed, but observations showed the boots were not applied during multiple checks. Staff interviews showed uncertainty about the resident’s specific device and boot requirements despite care plan interventions and physician orders.
Lack of Physician Orders for CPAP Use: A resident with OSA, acute respiratory failure, SOB, HF, and hypoxemia was documented by staff as using a CPAP and was observed with the device at the bedside, but the chart had no physician order for CPAP use and no CPAP-related care plan or MDS documentation before the order appeared. Staff interviews confirmed the resident wore the CPAP nightly and that nursing staff were responsible for it, while leadership stated an order should have been in place.
Incomplete dialysis access monitoring and care planning: A resident with ESRD and dependence on dialysis had both a fistula and a CVC, but the care plan and MD orders did not clearly identify the access site or specify daily thrill and bruit checks. Staff described only visual checks for infection, bleeding, or wet/dirty dressings, and monitoring was not consistently performed or documented. During observation, the resident had bruising and puncture wounds at the fistula site and tubing from the CVC covered with a dressing.
A resident with poor dentition and cracked, jagged teeth experienced delayed dental follow-up despite existing dental referral orders and a care plan for oral health monitoring. The record lacked documentation of follow-up dental appointments, dental recommendations, or nursing assessments for ongoing mouth pain, and the resident later developed a dental abscess and reported difficulty chewing, drinking, and pain in the gums, tongue, and jaw. Staff interviews confirmed missing dental documentation and lack of awareness of the resident’s ongoing oral pain.
The facility failed to maintain a comfortable environment, with room temperatures exceeding policy limits, affecting residents' comfort and safety. The cooling system was inadequate, and staff did not consistently report or address the issue, leading to discomfort among residents.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Failure to Develop and Document Appropriate Discharge Plan After Issuing NOMNC
Penalty
Summary
Surveyors identified a failure to develop an appropriate, person-centered discharge plan for a resident when the facility issued a Notice of Medicare Non-Coverage (NOMNC) without completing required elements and without a clear, documented discharge plan. The resident had hemiplegia, aphasia, unsteadiness on feet, ADL deficits, impaired cognitive function, and was at risk for falls. The resident’s care plan documented a wish to remain in the facility for LTC, with goals to evaluate motivation to return to the community and address limitations and needs for maximum independence. Despite this, the facility’s Director of Care Transitions (DCT) documented that there were no environmental barriers impacting discharge, that stairs and bathing were functional/ADL barriers, and that there were no remaining medical education needs, but the care plan was not updated to reflect an active discharge plan. The NOMNC given to the resident stated that Medicare coverage would end on a specified date, but the sections to be completed by the provider (notice delivered by, call date/time, contact person, mailing date to representative, provider signature/title/date) were left blank when given to the resident. The resident reported not receiving a discharge notice but being told by the Administrator and DCT that they could not stay and needed to find another place to go. The resident stated they liked the facility, did not want to move again, wanted to remain in a safe place with shelter, food, showers, and care, and was unsure whether the proposed new placement was LTC or an ALF. The resident also reported that prior medication issues had been resolved and that they did not want to be forced out for expressing anger. Interviews with the DCT and Administrator showed that the facility was actively seeking other placements and intended to move forward with a transfer, without a documented plan for the resident to remain in the facility. The DCT acknowledged sending referrals to other facilities based on the resident’s consent but did not ask about the resident’s specific preferences for transfer locations and did not consistently document conversations about discharge planning. The Administrator stated they were planning to discharge the resident, believed the resident did not need LTC based on level of care, and noted that the care plan still reflected an initial plan for LTC and had not been updated. The Administrator also acknowledged that sending the resident back to a motel would not be a safe discharge and that the resident had not been issued a formal discharge notice, while also indicating that a 30-day discharge could be pursued if the resident declined offered placements.
Failure to Provide Medically-Related Social Services and Community Discharge Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide medically-related social services and appropriate discharge planning for one cognitively intact resident with significant physical impairments. The facility’s Discharges policy required Social Services to assess discharge potential upon admission, involve the IDT in person-centered discharge planning, arrange outside services and equipment, and complete a discharge form outlining care needs at home. The resident’s face sheet and initial MDS showed diagnoses of hemiplegia, aphasia, and unsteadiness on feet, with the resident assessed as cognitively intact. The resident’s care plan documented a wish to remain for LTC, with planned evaluation of motivation to return to the community and identification of limitations, risks, benefits, and needs for maximum independence, as well as recognition of impaired cognitive function, ADL deficits, and fall risk. Progress notes by the Director of Care Transitions from an Initial Care Management meeting documented that the resident’s plan for living arrangements had not changed, there were no environmental barriers impacting discharge, there were no remaining medical education needs, and that stairs and bathing were functional and ADL barriers at discharge. However, there was no documentation of referrals to needed outside services or assistance with identifying community placement options, despite the resident’s physical limitations and the facility’s policy requirements. The resident later reported recognizing a need for a safe place with shelter, food, showers, and care, and stated that the Administrator and DCT had told them they could not stay and needed to find somewhere else to go. The resident indicated the DCT was working on a transfer to another facility, but the resident was unsure about the type of placement being pursued and reported not receiving any information about assistance from outside agencies. In interviews, the DCT stated the resident had received a NOMNC, was past the last Medicare-covered day, and also had Medicaid. The DCT reported sending a referral to another facility that declined due to the resident’s behavior, acknowledged that no discharge letter had been given, and confirmed that no other referrals to available community resources were provided, despite acknowledging the resident’s right to return to the community. The DCT said the current goal was to move forward with a transfer and that a discharge notice had not been issued, and also admitted not asking the resident about preferences for transfers and not always documenting conversations. The Administrator stated they were actively seeking placement at other facilities, that the resident had to accept referrals, and that there were no referrals to outside agencies because some required three months in LTC, which was not planned. The Administrator also stated that if the resident did not accept placement, a 30-day discharge would be issued based on offering safe placement and the resident declining. These actions and omissions demonstrate that the facility did not plan for or refer the resident to potential community services necessary for a successful and appropriate discharge back to the community, contrary to its own discharge policy and the resident’s rights.
Environmental Safety and Maintenance Deficiencies in Resident Rooms and Restrooms
Penalty
Summary
Surveyors identified environmental deficiencies involving climate control units, restroom ceiling vents, a restroom handrail, and a wall guard in multiple resident rooms. During observations conducted with the Facility Maintenance Director, surveyors found an ointment bottle, a fork, and a small medication cup inside the climate control unit in one resident room, with the unit’s grate cover missing. Additional resident rooms were noted to have climate control units with heavy dust and cobweb buildup or large amounts of dust and debris. The Facility Maintenance Director stated that climate control units should be checked monthly for debris buildup. Further observations showed restroom ceiling vent covers in several resident rooms that were loose and not firmly attached to the ceiling, and one restroom where the ceiling vent cover was completely absent. A restroom handrail in another resident room was repeatedly observed on different days to be not firmly attached to the wall. In a separate room, the wall guard was seen peeling away from the wall with screws protruding as it detached. The Facility Maintenance Director reported having checked some vents in the past, stated being unaware of the loose wall guard, and indicated a belief that facility staff were generally good about entering such issues into the TELS work order system. These conditions potentially affected at least 15 residents who resided in or used the affected areas, in a facility with a census of 105 residents.
Dust Buildup on Vents and Resident Room Fans
Penalty
Summary
The facility failed to maintain the ceiling vents in the A Hall shower room free from a heavy buildup of dust and failed to keep tabletop fans in multiple resident areas free from a heavy buildup of dust, including resident rooms B10, B5, B4, C5, Resident #33's room, and Resident #101's room. During observation with the Facility Maintenance Director, two ceiling vents in the A Hall shower room were noted to have heavy dust buildup, and the Director stated a cleaning schedule for those vents had not yet been developed after taking over as Director in December 2025. Additional observations showed heavy dust buildup on tabletop fans in several resident rooms. Resident #33, who was cognitively intact per the quarterly MDS dated 4/18/25, stated staff cleaned the fan every now and then but would prefer it be cleaned more often. Resident #101, also cognitively intact per the quarterly MDS, stated it had been a while since the fan on his/her side of the room had been cleaned and that he/she would appreciate it if staff cleaned it a little bit more. In other rooms, the Facility Maintenance Director observed heavy dust buildup on fans in rooms B5, B4, C5, and B10, with no residents present in some rooms to interview at the time of observation.
Food Preferences and Alternative Meal Choices Not Honored
Penalty
Summary
The facility failed to ensure that resident food preferences were honored and that alternative menu choices were provided for three sampled residents who ate in their rooms. The cited policy stated that if a resident did not like the food served, a substitute was to be offered, and that individual preferences regarding where residents ate were to be accommodated as much as possible. The census was 105 residents, and the deficiency was identified during observation, interview, and record review. Resident #95 had diagnoses including difficulty walking, dysphagia, and muscle weakness, and his/her care plan identified a potential for altered nutrition and hydration related to risk for malnutrition and acute illness. The record contained no documentation that the resident refused meals or had meal preferences documented. During interviews, the resident stated that staff did not let him/her choose meal items, that food was cold, and that no alternative was offered. Observations showed the resident eating in bed with meal trays in the room, including one breakfast tray that did not include oatmeal listed on the meal ticket and another tray where oatmeal was listed but not provided. The dislikes and other sections on the meal ticket were blank, and the resident refused one meal because it was cold and did not contain the items wanted. Resident #110 and Resident #112, both of whom ate in their rooms, stated during interview that no one asked what they wanted to eat and that they received whatever was brought to them. Observation of their meal tickets showed no alternative choices offered, and no menu was available in the room. In the dining room, observations on multiple days showed no alternative menus on the menu board or available to residents. Staff and leadership interviews stated that alternatives were available, that preferences should be communicated through meal tickets, progress notes, or dietary orders, and that residents could request other items; however, the observed meal service for these residents did not reflect those stated practices.
Kitchen and Dining Area Sanitation and Maintenance Deficiencies
Penalty
Summary
The facility failed to keep the kitchen and dining areas clean and maintained in accordance with professional standards. During observations, dust was noted on vents and ceiling lights throughout the kitchen and over-serving area, a large bag of breadcrumbs was left open, and the flour bin door was open. In the dining room, dried spilled residue was observed throughout the sitting area on multiple occasions, along with a fresh liquid spill near a support column and later dried residue in the same area. The dining room floors were not mopped as observed over several days. The facility also had maintenance and sanitation issues in the kitchen and dish machine room. Observations showed holes in the wall adjacent to the serving area, metal trim coming off a corner near the bread rack, and no drain cover over the drain in the dish machine room. The area around the piping under the prewash sink was not sealed, with a large hole and wall debris spilling onto the floor, and a black substance potentially mold was seen on the piping and around the hole. Dust was also observed on the black fan in the dish machine room. The Executive Chef stated the holes in the walls and the drain cover should have been reported to maintenance in the tracking system, and that the dining room should be swept and mopped after every meal.
Infection Control and EBP Failures During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program for residents on Enhanced Barrier Precautions (EBP), and survey observations showed repeated lapses in PPE use and hand hygiene during resident care. For one resident with a gastrostomy tube, cognitive impairment, and total dependence for care, staff entered the room without gowns, gloves were applied without hand hygiene, and handwashing was not performed after glove removal or between dirty and clean tasks during incontinence care. The resident’s care involved repeated repositioning, cleaning, and linen changes, yet staff were observed moving from soiled to clean tasks without sanitizing or washing hands and without consistently wearing the required gown. A second resident with diabetes, anemia, atrial fibrillation, kidney failure, seizures, and a urinary catheter was also on EBP for wounds, a urinary catheter, and a nephrostomy tube. During observation, a CNA entered the room without a gown, did not sanitize hands before gloving, repositioned the resident, and then exited without hand hygiene after glove removal. The resident’s catheter collection bag was observed at the side of the bed below the bladder, and the nephrostomy bag was lying on the bed. Staff interviews confirmed they were expected to wear gowns for residents on EBP and to perform hand hygiene when entering and leaving rooms, but the observed practice did not match those expectations. For a third resident with bladder cancer and urinary retention, the suprapubic catheter drainage bag and tubing were observed dragging on the floor underneath a wheelchair, with thick yellow substance in the tubing at one point and the bag again observed dragging on the ground on another occasion. During catheter care, the resident did not have EBP signage posted, and a CNA entered the room with only gloves, emptied the drainage bag, and provided incontinent care without a gown or mask. Interviews with staff and leadership confirmed the resident was expected to be on EBP, that the drainage bag should not touch the ground, and that direct care for the resident should include gown, gloves, and mask, yet these practices were not followed during the observed care.
Absent Negative Airflow in Multiple Resident Room Restrooms
Penalty
Summary
The facility failed to ensure negative airflow in the restrooms of multiple resident rooms, including H7, H6, H5, H4, H2, H1, G8, G5, G7, G9, G12, G14, D8, D7, D4, D5, D3, D2, and D1. Based on observation with the Facility Maintenance Director and the Senior [NAME] President of Facility Services, surveyors tested airflow by holding tissue paper to the ceiling vent; in each of the listed restrooms, the paper fell rather than being drawn to the vent, indicating the absence of negative airflow. The observations were made in the resident rooms identified in the report, and the deficiency potentially affected 23 residents who lived in those rooms. During interview, the Facility Maintenance Director stated that he/she had not checked for negative airflow since starting in the role and had not been told to check for negative airflow in resident rooms. The report documents repeated observations of absent negative airflow across multiple resident room restrooms on two survey dates, along with the maintenance director’s statement regarding the lack of checks for negative airflow.
Failure to Address Shower Refusals and Maintain Call Light Accessibility
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s repeated refusals of scheduled showers were assessed, documented, and addressed in relation to the resident’s bathing preferences, and the failure to ensure another resident’s call light was kept within reach despite care plan requirements and facility policy. One resident was admitted with adult failure to thrive and a need for assistance with personal care, was cognitively intact, and able to understand and make needs known. The facility assigned shower days and times by room number, placing this resident on an evening/night schedule twice weekly, with instructions that CNAs report refusals to the charge nurse and obtain resident or guest signatures on shower sheets. The resident’s care plan identified ADL self-care deficits, need for assistance with showering, delirium, delusions, and known noncompliance with medical treatment. From early December through early January, the resident refused all offered evening/night showers on multiple assigned days. Documented reasons included that it was too late for a shower and a preference for morning showers. Some refusal entries lacked the resident’s signature, and there was no documentation on the shower sheets that refusals were addressed by licensed nursing staff or that the resident was educated about noncompliance with bathing. Review of the medical record for the same period showed no nursing documentation related to the repeated evening shower refusals and no new interventions regarding bathing preferences or changes to shower days/times. Although the care plan was updated to note a history of refusal of care, treatments, and medications, there were no added interventions specifically addressing shower timing or offering alternative shower schedules aligned with the resident’s stated preference for morning showers. The second deficiency concerns a resident with dementia, muscle weakness, difficulty walking, a need for assistance with personal care, and a history of falls, who required moderate to maximal assistance with self-care and mobility. Observations over several days showed this resident in bed or in a wheelchair with the call light consistently located behind the nightstand and not within reach. The resident reported that staff kept him/her in bed most of the time due to frequent falls and that night shift staff purposefully placed the call light out of reach, leaving the resident unable to get up independently to use the bathroom and having to wait until staff entered the room. The resident’s care plan required staff to ensure a safe environment by keeping the call light within reach, to encourage and educate the resident on using the call light for assistance, and to ensure it was within reach at all times. Despite staff interviews confirming knowledge of policies that call lights must be within reach and checked before leaving the room, repeated observations documented that this resident’s call light remained behind the nightstand and inaccessible.
Insulin Pen Septum Not Cleansed Before Administration
Penalty
Summary
The facility failed to meet professional standards of practice when administering insulin to two residents with diabetes by not cleansing the insulin pen rubber septum with alcohol before attaching the pen needle and giving the injection. Resident #75 was admitted with a diagnosis of Diabetes Mellitus and had an order for Humalog 20 units every day before meals. During observation, an LPN applied the needle, drew up insulin, discarded it because the wrong amount was drawn, removed the needle, did not wipe the pen septum with alcohol, replaced the needle, primed the pen, and then drew up 20 units of insulin. Resident #115 was admitted with a diagnosis of Diabetes Mellitus and had orders for Novolog FlexPen on a sliding scale before meals and at bedtime, as well as Lantus SoloStar 10 units subcutaneously two times a day. During observation, an LPN did not clean either the Novolog or Lantus insulin pen septum with alcohol before applying the pen needle, priming, and drawing up the medication. In interview, the LPN stated the facility policy was to wipe the insulin pen with alcohol before attaching the needle, and the CNO stated nurses were expected to clean the insulin pens with alcohol prior to attaching the pen needle.
Call Light and Ordered Boots Not Provided as Directed
Penalty
Summary
The facility failed to ensure that Resident #93 had access to an adaptive call light device and that the call light remained within reach. The resident was admitted with diagnoses including protein-calorie malnutrition, palliative care, cognitive communication deficit, difficulty walking, legal blindness, senile degeneration of the brain, and type 2 diabetes mellitus. The quarterly MDS showed the resident had severely impaired vision, was severely cognitively impaired, was completely dependent for all ADLs and transfers, and was at risk for pressure ulcer/injury development. The resident’s care plan directed staff to keep the call light and other key items within reach, tell the resident where items were placed, encourage use of a bell to call for assistance, ensure the call light was within reach, and provide a soft touch call light for use. The resident also had a physician order for Prevalon boots to be worn when in bed, and the care plan included pressure injury prevention interventions with bunny boots to both feet for pressure relief. During multiple observations, the resident was in bed without Prevalon boots applied. The standard call light was observed on the floor between the bed and nightstand, tied to the lower bed frame, and not within the resident’s reach. On each observation, there was no adaptive call light present. Staff interviews reflected uncertainty about the resident’s specific call light device and pressure injury prevention equipment, while the CNO stated staff were expected to keep call lights within reach, follow the care plan, and have Prevalon boots on the resident while in bed as ordered.
Lack of Physician Orders for CPAP Use
Penalty
Summary
The facility failed to ensure there were physician orders for the use of a CPAP machine for one resident with diagnoses including acute respiratory failure, shortness of breath, obstructive sleep apnea, heart failure, hypoxemia, and need for assistance with personal care. The resident’s annual MDS showed the resident was cognitively intact, dependent on staff for self-care, independent for functional cognition, and dependent on a motorized wheelchair, but CPAP was not marked as being used and respiratory failure was not marked yes. The resident’s current physician orders for January 2026 contained no order for CPAP use prior to 1/15/26, and the care plan also did not mention CPAP use or related interventions prior to that date. Despite the lack of orders and care plan documentation, staff documented in the oxygen saturation daily records that the resident used a CPAP starting on 1/2/26. Observations on 1/12/26, 1/13/26, 1/15/26, and 1/16/26 showed the CPAP machine on the nightstand next to the resident’s bed, and on 1/16/26 the mask was lying on the bed. During interviews, a CNA stated the resident wore a CPAP every night, staff helped put it on at night, and there should be orders for it. Another CNA and an LPN were unable to confirm details about the CPAP, but both stated that if a resident needed a CPAP, nursing staff would be responsible for it and that an order should exist. The MDS/Care Plan Coordinator stated the resident did not have the CPAP when admitted and first heard about the resident having one on 1/15/26, and both the ACNO and CNO stated there should have been orders when a resident wore a CPAP. The resident stated the CPAP had been used since 2016, had to be worn every night, and staff needed to put it on each night. The ACNO and CNO also stated the CPAP should have been documented in the care plan and MDS, and the CNO said the charge nurse recorded oxygen saturation data while the resident wore the CPAP.
Incomplete dialysis access monitoring and care planning
Penalty
Summary
The facility failed to ensure dialysis orders for monitoring the dialysis site were complete for a resident who received dialysis services. The resident had diagnoses including end stage renal disease, dependence on dialysis, diabetes, high blood pressure, and high cholesterol. The resident’s care plan showed in-house dialysis on Monday, Wednesday, and Friday and included interventions to check and change the dressing at the access site, monitor for bleeding after dialysis, and monitor for signs and symptoms of infection, but it did not identify the dialysis access site or the type of access site, and it did not describe how the facility was to monitor the access site. The resident’s physician orders showed in-house dialysis on Monday, Wednesday, and Friday, removal of the dressing from the dialysis access site the next day after treatment, and a CVC location of the right chest. The orders did not show how the facility was to monitor the CVC, and there were no orders showing the resident had a permanent access site such as a fistula, where it was located, or how to care for or monitor that site. Facility staff and dialysis staff gave differing descriptions of what monitoring was expected, including visual checks for infection, removal of dressings after dialysis, and documentation on the MAR, but the orders and care plan did not reflect daily thrill and bruit checks. During observation, the resident was in a wheelchair and had a right below-knee amputation with a prosthetic. The resident’s left forearm showed red bruising and several puncture wounds at the fistula site, and tubing from the right chest CVC was covered with a white cotton 4x4 pad. The resident stated that dialysis was normally performed through the fistula, that the CVC was used when the fistula was difficult to access, that the facility nurses usually removed the fistula bandage and checked for redness or bruising after dialysis, and that not all nurses checked the fistula every day or used a stethoscope to listen to it. Staff interviews confirmed that the facility did not consistently monitor the dialysis access sites according to a clear protocol, did not document the monitoring consistently, and did not have a care plan that described how the dialysis access site would be monitored.
Delayed Dental Follow-Up and Treatment
Penalty
Summary
The facility failed to ensure follow-up dental appointments were made for one resident with poor dentition and cracked teeth, resulting in delayed dental treatment. The resident was admitted with anemia and cirrhosis of the liver, had a physician order for a dental referral due to poor dentition and cracked teeth, and had a dental consult order already in place. The resident’s care plan identified oral/dental health problems and directed staff to coordinate dental care and monitor for oral symptoms, but the record did not show documentation of follow-up dental appointments or reasons for delay over several months. The resident’s record showed a dental visit in August 2025 with referral for surgery with sedation for edentulation and a pending denture appointment after tooth removal. However, from October 2025 through January 2026, there was no documentation of additional dental follow-up appointments, dental recommendations, or nursing assessments related to ongoing dental pain or discomfort. The resident later developed a dental abscess and was started on clindamycin, with a new order to schedule follow-up with a local hospital oral surgeon. At the time of survey, the resident reported mouth pain involving the gums, tongue, and jaw, difficulty chewing and drinking, and sharp jagged teeth cutting the cheeks. Staff interviews showed the LPN had not assessed the resident for mouth pain and was not aware of the resident’s current complaints, while the Social Services Designee stated the facility lacked documentation from prior dental visits and follow-up recommendations. The Chief Nursing Officer stated the resident should not have had to wait 4-5 months for follow-up dental treatment for ongoing dental issues.
Facility Fails to Maintain Comfortable Environment Due to High Temperatures
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for its residents, as evidenced by room temperatures ranging from 81.8°F to 87.0°F, which exceeded the facility's policy of maintaining temperatures between 71°F and 81°F. The facility's Emergency Operations Plan required action when the heat index inside exceeded 80°F, but the facility did not have a comprehensive monitoring system in place to document air temperatures or conduct random monitoring. This deficiency had the potential to affect all residents in the building, with a census of 116 residents. Observations and interviews revealed that the facility's cooling system, which included a boiler system and air handler/chiller unit, was not effectively maintaining the desired temperature. The Director of Maintenance (DOM) acknowledged that regular temperature logs were not kept unless there was a problem, and the system was running about 20 degrees cooler than outside temperatures. Several wall units were not functioning, and parts were delayed, contributing to the elevated temperatures in resident rooms and common areas. Residents and staff reported discomfort due to the heat, with some residents experiencing difficulty breathing and others using fans to cope with the high temperatures. Staff interviews indicated that the issue had persisted for several days, with some staff members failing to report the problem or take action. The facility's response was delayed, and the air conditioning company was only contacted after the state surveyor's visit, revealing a lack of proactive measures to address the temperature issues.
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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.
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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) |
|---|---|---|---|---|
| Kingswood Senior Living | 0.9 mi | ★★★★★ | 0 | 0 |
| Bridgewood Health Care Center | 1.7 mi | ★★★★★ | 28 | 3 |
| Advanced Health Care Of Overland Park | 2 mi | ★★★★★ | 2 | 0 |
| Hilltop At Blue River, The | 2.3 mi | ★★★★★ | 3 | 0 |
| Overland Park Post Acute | 2.4 mi | ★★★★★ | 5 | 0 |
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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.