Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Kansas City, Llc during CMS and state inspections, most recent first.
Unsafe oxygen storage and improper gait belt transfers: A resident with respiratory failure had an unsecured type E oxygen cylinder on the floor in the room along with additional portable oxygen cylinders, while staff stated oxygen should be secured and extra tanks returned to the closet. In a separate event, staff performed unsafe gait belt transfers for another resident with cognitive impairment, weakness, malnutrition, a sacral pressure ulcer, and falls history by allowing the belt to slide under the arms and by grabbing under the armpit during transfers.
Failure to use EBP and provide proper catheter care: Two residents with indwelling urinary catheters were observed receiving direct care without the required gown-and-glove precautions, and one CNA continued care after touching a trashcan without changing gloves or performing hand hygiene. Staff also reused a disposable cleansing wipe on catheter tubing, and for another resident the catheter bag and tubing touched the floor during emptying. Interviews confirmed staff were unsure of the EBP and catheter-care requirements.
Kitchen Not Kept Clean or in Good Repair: The grill, stove shelf, dish room ceiling, meal trays, hot boxes, steam table knobs, and refrigerator vents were observed with grease, food debris, dust, and damage. Staff stated the grill should be cleaned daily, the kitchen should be clean and in good repair, and maintenance was responsible for repairs, but the water stain in the dish room had not been fixed and no kitchen cleaning/repair policy was provided.
Staff failed to follow EBP and infection control practices for residents with indwelling urinary catheters and wounds. A CNA handled a trashcan and then continued catheter care without changing gloves or using a gown as required, another CNA emptied a catheter bag without a gown and allowed catheter tubing to touch the floor, and an NP placed a resident’s open heel wound directly on the floor during treatment without a barrier.
A resident with heart failure, pneumonia, respiratory failure, and an ADL self-care deficit requiring substantial assistance with bathing and personal hygiene did not receive a shower, bed bath, or shave during a five-day respite stay, despite facility policies requiring at least twice-weekly bathing and assistance with grooming. Observation found the resident in bed with dry, flaky skin, disheveled greasy hair, facial hair, and body odor, and the resident reported staff had repeatedly said they would provide at least a bed bath and trim facial hair but never did, causing the resident to feel self-conscious and uncomfortable. Review of records showed no documentation of a shower, shave, or any refusals, while CNAs, an LPN, the DON, and the Administrator all stated that residents should be offered regular showers, refusals must be documented, and residents requesting shaving should be assisted and kept clean and well groomed.
A resident with diabetes had an order for NovoLOG 4 units before meals, but an LPN checked blood glucose at 11:40 A.M., the meal tray arrived at 12:05 P.M., and the insulin was not given until 12:37 P.M. after the resident had already eaten. Facility policy required staff to follow medication orders and timing parameters, and the DON stated insulin should be administered when the meal is delivered, before the resident eats.
A resident who was dependent for toileting and had bowel and bladder incontinence, impaired cognition, and a Stage III pressure ulcer did not receive complete peri-care during incontinent care. CNAs were observed using wipes with fecal material on them, folding wipes while cleaning stool, and failing to separate and clean all skin folds or fully clean the peri-area; the DON stated staff were expected to clean all areas touched by urine or feces.
A resident with dysphagia, cognitive impairment, and an order for a pureed diet was served lunch items that were thick and contained chunks or particles. Dietary staff prepared the ham and broccoli rice mixture in a food processor, but the food remained sticky, thick, and required chewing; the RD, Dietary Manager, and Administrator all stated pureed food should be smooth, pudding-like, and free of chunks.
A resident was hit in the face by another resident, resulting in a laceration to the lower lip. The incident occurred in the dining room when one resident asked another to move away from the table, leading to frustration and physical aggression. Both residents have moderately impaired cognitive skills and a history of behavioral issues, but neither had previously displayed physical aggression. The facility's abuse policy requires staff education on abuse prevention, but the incident highlights a failure in monitoring and managing resident behaviors.
The facility failed to employ a qualified director of food and nutrition services, affecting all residents receiving meals. The Dietary Manager, promoted nine months ago, lacked necessary qualifications and credentials, including certification and experience. Interviews confirmed the DM was not certified and was still completing a food safety course, with the Registered Dietitian and General Manager acknowledging the deficiency.
The facility failed to provide written notification of hospital transfers for two residents, only giving verbal notices. One resident with intact cognition was transferred twice for medical issues without written notice, while another with moderately impaired cognition was transferred multiple times for serious conditions without documentation of written notice. The facility's management acknowledged the lack of written notifications.
The facility failed to ensure a safe discharge for multiple residents, resulting in significant deficiencies. Residents were discharged without proper orders, medications, or follow-up care. One resident with a heart condition was sent home with incorrect medications, while another lacked necessary medical equipment and dialysis services. The facility's discharge process lacked communication, coordination, and documentation, leading to unsafe transitions.
The facility failed to provide written bed hold notices to two residents during hospital transfers, relying instead on verbal notifications. This deficiency was identified for residents with intact and moderately impaired cognition, who were hospitalized for various medical conditions. The facility's policy lacked details on the cost per day and the requirement for written notices, contributing to the oversight.
The facility failed to conduct ongoing neurological assessments for residents who experienced unwitnessed falls, as required by their policy. A resident with a history of traumatic brain injury had multiple falls without proper evaluations. Another resident reported hitting her head during a fall, but follow-up assessments were not conducted. A third resident also lacked documented follow-up assessments after an unwitnessed fall. Staff interviews revealed inconsistencies in following the facility's protocol for neurological assessments.
The facility failed to document that residents were offered and provided education about influenza and pneumonia vaccines, with no signed declinations or rationales for refusals recorded. Interviews revealed that the facility did not obtain signatures for vaccine refusals and did not document education in the electronic medical record, contrary to the expectations of the Director of Nursing.
A resident with intact cognition requested not to receive care from certain staff members due to perceived rudeness and disrespect. Despite this request and subsequent coaching for the staff involved, the facility failed to ensure these staff members were removed from the resident's care assignments. This oversight violated the resident's right to self-determination and highlighted communication gaps within the facility's management.
A facility failed to maintain ileostomy care orders for a resident with metabolic encephalopathy, ileostomy status, and cirrhosis of the liver. The resident's care plan required ostomy care, but no orders were present in the EMR. The last documented change of the ileostomy wafer and bag was weeks prior, leading to leakage issues that affected the resident's quality of life. Observations showed fecal matter under the ileostomy skin barrier, and the NP confirmed the absence of care orders, noting they might have been lost during hospital visits.
A resident with Alzheimer's and dementia eloped from the facility and was found near a busy roadway. The facility failed to provide adequate supervision and did not follow their elopement policy, resulting in a lack of immediate search and notification to the resident's family. The incident was not documented in the nursing notes, and the family was informed days later. Staff interviews revealed confusion about the incident's documentation and reporting.
Unsafe oxygen storage and improper gait belt transfers
Penalty
Summary
The facility failed to ensure the environment of two sampled residents remained free from accident hazards. For one resident with diagnoses including heart failure, pneumonia, and respiratory failure, the resident used supplemental oxygen and was observed in bed with oxygen applied via nasal cannula while two oxygen concentrators were in the room. One type E oxygen cylinder with the plastic seal over the valve was observed unsecured on the floor, while another full type E cylinder and one empty type E cylinder were stored in oxygen tank holders in the room. The resident stated he/she used oxygen to help breathing and did not know why there were three portable oxygen tanks in the room. Facility staff interviews showed that oxygen tanks should be secured in an oxygen holder and that extra oxygen tanks, whether empty or full, should be returned to the oxygen closet. A CNA and an LPN stated portable oxygen tanks should not be on the floor and that there should not be excessive oxygen not in use in the resident's room. The DON and Administrator both stated oxygen should be secured and not sat on the floor in the resident's room, and both said the resident should not have unsecured oxygen in the room. The facility also failed to provide a safe gait belt transfer for another resident with cognitive impairment, weakness, cardiomyopathy, protein calorie malnutrition, a sacral pressure ulcer, and a history of falls. During observation, CNA B placed the gait belt around the resident's waist, but it slid up under the resident's arm pits during transfers. CNA B also grabbed the resident under the arm during a transfer, and later CNA B and CMT B again used an arm-under-the-armpit technique while transferring the resident into the wheelchair. The resident's care plan did not address gait belt use, and staff interviews confirmed that staff should not place an arm under the resident's arm pits during a gait belt transfer.
Failure to Use EBP and Provide Proper Catheter Care
Penalty
Summary
The facility failed to ensure appropriate care for residents with indwelling urinary catheters and failed to ensure staff used Enhanced Barrier Precautions (EBP) during direct care. The report states that two of 18 sampled residents were affected. Facility policies reviewed by surveyors addressed catheter care to help prevent urinary tract infections and required EBP for residents with indwelling medical devices, including urinary catheters, during high-contact care activities such as hygiene, toileting, and device care. For one resident with an indwelling urinary catheter and a care plan requiring EBP, a CNA provided catheter care while wearing gloves, picked up a trashcan in the room with the same gloves, and then continued care without changing gloves or performing hand hygiene. The CNA emptied the catheter drainage bag, later removed the gown and gloves, and then put on new gloves without a gown before cleaning the catheter tubing. The CNA used a disposable cleansing wipe more than once by folding it and wiping the tubing again, then carried the trashcan and continued care without changing gloves before applying a new incontinent brief. During interview, the CNA stated he or she should have changed gloves after touching the trashcan, did not know when EBP should have been worn, did not know hand hygiene should occur with every glove change, and believed a disposable cleansing wipe could be used more than once. For a second resident with an indwelling urinary catheter, wounds, and a recent UTI, the care plan required EBP. During observation, a CNA entered the room to empty the catheter drainage bag wearing gloves but no gown. While moving the catheter tubing to collect urine, the catheter bag and tubing touched the floor. The CNA later stated a gown should have been worn and that catheter tubing and drainage bags should never touch the floor. The Infection Preventionist and DON both stated that EBP should be used for direct care of residents with catheters, that hand hygiene should occur between glove changes, and that catheter tubing and drainage bags should not touch the floor.
Kitchen Not Kept Clean or in Good Repair
Penalty
Summary
The kitchen was not maintained in a clean and sanitary manner and was not kept in good repair. On 02/08/26 and again on 02/11/26, observation showed the grill with a thick layer of encrusted grease and food debris, the shelf above the stove with a thick layer of grease and food debris, and the dish room ceiling with a round brown stain the size of a basketball and pieces of ceiling tile hanging down. The facility did not provide a policy on cleaning and repairs in the kitchen. On 02/11/26, additional observation showed the trays residents were served meals on had missing pieces that came off when touched, the wheels and brakes on two hot boxes had grease buildup, dirt, and debris, the knobs on the steam table were covered with food debris, grease, and grime, and the vents on the sides of the refrigerator were caked with dust. During interviews, staff stated the cooks were responsible for cleaning the grill daily, the kitchen should be clean and in good repair, maintenance was responsible for kitchen repairs, and the maintenance log should be used for requests. The Dietary Manager stated the maintenance man had quit two days earlier and knew about the water stain in the dish room but it had not been fixed yet.
Infection Control and Wound Care Lapses
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when staff did not consistently use enhanced barrier precautions (EBP) and did not follow infection control practices during resident care. For a resident with an indwelling urinary catheter and a care plan requiring EBP, a CNA entered the room, sanitized hands, put on gloves, picked up a trashcan, then emptied the catheter with the same gloves. The CNA removed the gown and gloves, washed hands, put on a new pair of gloves without a gown, cleaned the catheter tubing, moved around the bed and picked up the trashcan again, and then placed a new brief on the resident without changing gloves or sanitizing hands. The CNA stated he/she should have changed gloves after picking up the trashcan and did not know when EBP should have been worn. A second resident also had a care plan requiring EBP due to wounds and an indwelling urinary catheter. During observation, a CNA entered the room, put on gloves, and emptied the catheter bag without donning a gown. The catheter tubing touched the floor when the bag was emptied. The CNA stated a gown should have been worn and that catheter tubing and drainage bags should never touch the floor. The Infection Preventionist stated EBP should be worn when providing direct care for residents with catheters, and that hands should be washed or sanitized between glove changes and after picking up a trashcan before providing care. For a third resident with diabetes, limited mobility, and a left heel wound, the wound assessment described an open area with bright red tissue and surrounding redness. During the wound treatment, the NP removed the shoe and sock, found no dressing on the heel, and sat the resident's left heel directly on the floor without a barrier while measuring and examining the wound. The NP stated a barrier should have been placed between the wound and the floor. The wound nurse, Administrator, and Infection Preventionist each stated that an open wound should not touch the floor and that a barrier should be used to protect the wound from the floor.
Failure to Provide Assisted Bathing and Grooming for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to dignity and appropriate personal hygiene and grooming. Facility policies on Resident Rights and Bathing required that residents be treated with respect and dignity, be offered baths or showers in accordance with their preferences (or at least twice weekly if no preference was voiced), and receive assistance with grooming. Resident #131’s admission MDS dated 10/20/25 documented no cognitive impairment, substantial assistance needs with showers, bathing, and personal hygiene, and diagnoses including heart failure, pneumonia, and respiratory failure. The resident’s care plan dated 2/8/26 identified an ADL self-care deficit related to limited physical mobility, respiratory impairment related to respiratory failure, and a need for substantial assistance with showers and personal hygiene. From 2/2/26 through 2/9/26, there was no shower sheet or documentation that the resident had received a shower or shave, and no refusal documentation indicating that a shower or shave had been offered and declined. On observation and interview on 2/8/26, the resident was in bed with dry, flaky skin, disheveled and greasy hair, facial hair, and body odor, and reported having been in the facility since Tuesday without receiving a shower, bed bath, or shave, despite staff repeatedly saying they would at least provide a bed bath and trim facial hair. The resident stated they were there because they needed help and had not received the help needed, and that the lack of cleanliness and grooming made them feel self-conscious and uncomfortable. CNAs, an LPN, the DON, and the Administrator all stated that residents should receive at least two showers per week, that refusals must be documented, that residents requesting shaving should receive assistance, and that residents should be clean, dry, and well groomed, and acknowledged that this resident, who was present for five days, should have received at least one shower.
Insulin Not Given Before Meal
Penalty
Summary
The facility failed to ensure Resident #143 received NovoLOG insulin as ordered with meals. The resident’s POS dated 02/11/2026 ordered NovoLOG FlexPen 100 unit/mL, 4 units subcutaneously before meals for diabetes. On 02/11/2026, an LPN obtained the resident’s blood glucose at 11:40 A.M., the meal tray was delivered at 12:05 P.M., and the LPN administered 4 units of insulin at 12:37 P.M., after the resident had already eaten the entire meal. The facility’s policies stated that staff must read medication orders and labels entirely, follow specific timing parameters such as before or after meals, and administer insulin safely and accurately. During interview, the LPN stated he/she was responsible for blood glucose monitoring and insulin administration for two residents each meal. The DON stated that orders should be followed as written, staff should read all orders and medication labels, and insulin should be administered when the meal is delivered, before the resident eats.
Incomplete Perineal Care During Incontinence Assistance
Penalty
Summary
The facility failed to ensure dependent residents received complete perineal care and assistance with activities of daily living when staff did not fully clean the peri-area during incontinent care. The facility policy for perineal care stated that perineal care is done daily and as needed for residents requiring assistance, and that the perineal area should be washed with peri wash and water using a washcloth. Resident #12’s care plan and MDS showed bowel and urinary incontinence, dependence on staff for toileting, substantial to maximum assistance with transfers, moderately impaired cognitive skills, diagnoses of cancer, dementia, and diabetes mellitus, and a Stage III pressure ulcer. During observation of incontinent care, CNA B and CNA C did not separate and clean all areas of the skin folds or fully clean the peri-area when urine and fecal material were present. CNA B wiped the resident’s buttocks and groin with wipes that still had fecal material on them and folded wipes while cleaning fecal material. CNA C also wiped the rectal area with wipes that had a smear of fecal material and did not separate and clean all areas of the skin folds. In interview, CNA B stated all areas touched by urine or feces should have been cleaned and that wipes should not have been folded when cleaning fecal material. The DON stated staff were expected to separate and clean all areas of skin where urine or feces had touched and should not fold the wipe when cleaning fecal material.
Pureed Diet Food Prepared With Chunks and Incorrect Consistency
Penalty
Summary
The facility failed to ensure that pureed foods were prepared in a form designed to meet the needs of a resident ordered a pureed diet. Resident #115 had moderate cognitive impairment, supervision with eating, dysphagia, diabetes, asthma, and a physician order for a pureed diet. The resident’s care plan and dietitian evaluation both documented the need for a pureed diet related to swallowing problems. During lunch meal preparation, dietary staff processed the broccoli rice mixture and baked ham with broth, but the foods remained thick and contained visible chunks or particles. The Regional Dietary Manager instructed staff to remake the pureed ham after it was found to be thick and sticky, but the second preparation was still thick. The resident was then served a meal that was thick and had chunks in it. Surveyor observation confirmed the pureed ham and broccoli rice mixture were thick, allowed a spoon to remain standing, and contained particles that required chewing. Staff, including the dietary aide, Dietary Manager, Registered Dietitian, and Administrator, stated that pureed food should be smooth, pudding-like, and contain no chunks or particles.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from abuse when they were hit in the face by another resident, resulting in a laceration to the lower lip. The incident occurred in the dining room, where the resident was sitting at a table and was approached by another resident who was asked to move away. The second resident, feeling frustrated, hit the first resident in the face. This incident was witnessed by another resident who heard the exchange and saw the aftermath. The first resident involved in the incident has a history of mild cognitive impairment and has displayed behaviors such as refusing care and medications, and occasionally being physically aggressive. The second resident also has moderately impaired cognitive skills and a history of potential behaviors, including being sexually inappropriate and yelling at other residents. Both residents have adequate hearing and clear speech, and neither had previously displayed physical aggression while residing at the facility. The facility's abuse policy, dated November 2018, outlines the prohibition of abuse and the requirement for staff education on abuse prevention. However, the incident highlights a failure in monitoring and managing resident behaviors, as neither resident was identified as high risk for physical aggression prior to the incident. The facility's investigation revealed that staff did not witness the incident, and the residents involved had not previously exhibited such behaviors, indicating a gap in the facility's ability to anticipate and prevent resident-to-resident abuse.
Facility Lacks Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, which had the potential to affect all 87 residents receiving meals from the facility's kitchen. The Dietary Manager (DM), who was hired in September 2018, was promoted to the position of dietary manager nine months prior to the survey but lacked the necessary qualifications and credentials. The DM's job description required a Food Service Sanitation certification, but the employee file did not contain documentation of any training course. During interviews, the DM confirmed she was not a certified dietary manager and did not possess other qualifying credentials, although she was currently enrolled in a food safety and management course. The General Manager and the Registered Dietitian (RD) corroborated that the DM was not a certified dietary manager and lacked two or more years of experience in the role of director of food and nutrition services in a healthcare setting. The RD also confirmed that neither the DM nor the assistant DM had the required experience, and the DM had not yet completed the food safety and management course. This deficiency in staffing qualifications was identified through interviews and record reviews, highlighting the facility's failure to meet regulatory requirements for food and nutrition service management.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification of facility-initiated transfers to the hospital for two residents, R38 and R19, as required by their policy. For Resident R38, who had intact cognition, the facility did not provide written notice of transfer on two occasions, despite the resident being sent to the hospital for issues such as stomach pain, vomiting, dizziness, and critical lab results indicating a UTI and failed antibiotic treatment. The General Manager confirmed that only verbal notices were given, and no written documentation was provided to the resident or their representative. Similarly, Resident R19, who had moderately impaired cognition, was transferred to the hospital multiple times for conditions including acute ischemic encephalopathy, seizures, pneumonia, and a blood clot. However, there was no documentation in the facility's records that R19 or his representative received written notice of these transfers. The Administrator acknowledged that only verbal notifications were given, and there was a lack of paper documentation to support the transfers.
Inadequate Discharge Process Leads to Unsafe Transitions
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for five out of six sampled residents, leading to significant deficiencies in the discharge process. Residents were discharged without proper orders, medications, home health services, dialysis services, and follow-up appointments. For instance, one resident was discharged with a heart condition and pneumonia but was not provided with necessary home health care or follow-up appointments. The resident was sent home with incorrect medications belonging to other residents, leading to confusion and a lack of medication adherence until an emergency in-home visit was conducted. Another resident was discharged without any medications or necessary medical equipment, such as a bed and lift, which were promised by the facility but not delivered. The resident also required dialysis services, which the facility failed to arrange. The resident and their family were not provided with discharge instructions or education on medication management, leaving them to arrange home health services independently. Additional deficiencies were noted with other residents, including one who left the facility against medical advice and found that their prescriptions had not been sent to the pharmacy as claimed by the facility. Another resident was discharged to the hospital without proper documentation or provider orders. Overall, the facility's discharge process was inadequate, lacking in communication, coordination, and proper documentation, resulting in unsafe transitions for the residents involved.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents and their representatives during hospital transfers, as required by regulations. This deficiency was identified for two residents, R38 and R19, out of a sample of 28. The facility's policy on bed hold and therapeutic leave, revised in November 2018, did not include the cost per day or specify that the notice must be written, which contributed to the oversight. Resident R38, who had intact cognition as indicated by a BIMS score of 15 out of 15, was transferred to the hospital on two occasions, once for stomach pain and vomiting and another time for a urinary tract infection and failed antibiotic treatment. Despite these transfers, there was no documentation in the electronic medical record (EMR) that a written notice of the bed hold policy was provided to R38 or their representative. The General Manager confirmed that only verbal notices were given, acknowledging the need for improvement in this area. Similarly, Resident R19, who had moderately impaired cognition with a BIMS score of 11 out of 15, was hospitalized multiple times for conditions including acute ischemic encephalopathy, seizures, pneumonia, and a blood clot. The facility's EMR lacked documentation of written notices regarding the bed hold policy for any of these hospital transfers. The Administrator admitted that neither R19 nor their representative received the necessary bed hold papers, indicating that the facility relied on verbal notifications instead of the required written documentation.
Failure to Conduct Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to perform ongoing neurological assessments for residents who experienced unwitnessed falls, which could have resulted in head trauma. This deficiency was identified for three residents out of a sample of 28. The facility's policy required that neurological assessments be conducted for any unwitnessed fall or if there was any indication of head injury. However, the facility did not consistently follow this protocol, as evidenced by the lack of completed neurological evaluations for several falls experienced by the residents. Resident 19, who had a history of traumatic brain injury and repeated falls, experienced multiple unwitnessed falls. Despite the facility's policy, neurological evaluations were not completed for all of these incidents. The facility's documentation was inconsistent, with some falls lacking any neurological assessments and others having only partially completed checklists. Interviews with staff revealed a lack of adherence to the facility's protocol, with some nurses not completing the required assessments or documentation. Similarly, Resident 222 reported an unwitnessed fall where she hit her head, but follow-up neurological assessments were not conducted as required. The initial evaluation was completed, but the ongoing assessments were not documented. Resident 226 also experienced an unwitnessed fall, and while an initial neurological evaluation was conducted, no follow-up assessments were documented. Interviews with the DON and nursing staff highlighted discrepancies in the understanding and implementation of the facility's neurological assessment protocol, contributing to the deficiency.
Failure to Document Vaccine Education and Declinations
Penalty
Summary
The facility failed to document that residents were offered and provided education about the influenza and pneumonia vaccines. Specifically, two residents were not documented as having been offered education about the influenza vaccine, and four residents were not documented as having been offered education about the pneumonia vaccine. This lack of documentation could potentially prevent residents or their representatives from making informed decisions regarding immunizations, which could lead to illness. The facility's Immunization Policy, revised in May 2023, requires that all admissions be offered the pneumovax injection as recommended by the CDC, and that each resident's immunization status be documented in their clinical record. However, the facility did not document any history of pneumonia vaccines for the residents reviewed, nor did they document signed declinations or rationales for refusals. Additionally, there was no documentation of education provided to residents who declined the vaccines. Interviews with the Infection Preventionist and the Director of Nursing revealed that the facility did not obtain signatures for vaccine refusals and did not document education provided to residents in the electronic medical record. The Director of Nursing expected that the electronic medical record would contain reasons for vaccine declinations and any education provided, but this was not the case for the residents reviewed.
Failure to Honor Resident's Request for Specific Care Providers
Penalty
Summary
The facility failed to honor a resident's request to not have certain staff members provide care, which compromised the resident's right to self-determination. The resident, identified as R26, had an intact cognitive status and was dependent on staff for care. Despite having expressed concerns about the behavior of two staff members, CNA2 and LPN4, whom the resident found rude and disrespectful, the facility continued to assign these staff members to provide care to R26. This was contrary to the facility's policy on self-determination, which emphasizes supporting resident choice in care providers. The resident's complaints were documented during a care plan conference in July 2024, and coaching sessions were conducted for the staff members involved. However, the facility's management failed to ensure that these staff members were removed from R26's care assignments. The General Manager and Staffing Coordinator were unaware that CNA2 continued to provide care to R26 in September 2024, despite the resident's request and the coaching sessions that had taken place earlier. Interviews with facility staff revealed a lack of communication and follow-through regarding the resident's request. The General Manager and Director of Nursing were not fully informed about the ongoing involvement of the staff members in R26's care, and the Staffing Coordinator was not aware of the full extent of the resident's complaints. This oversight resulted in the continued involvement of CNA2 and LPN4 in R26's care, contrary to the resident's expressed wishes and the facility's policy on resident rights.
Lack of Ileostomy Care Orders for Resident
Penalty
Summary
The facility failed to ensure that orders for ileostomy care were in place for a resident who required such services. The resident, who had diagnoses including metabolic encephalopathy, ileostomy status, and cirrhosis of the liver, was observed to have no physician orders for ileostomy care in their electronic medical record. The resident's care plan indicated the need for ostomy care as per provider's orders, but these orders were missing. The resident's treatment administration record showed that the last documented change of the ileostomy wafer and bag was several weeks prior, indicating a lack of consistent care. Observations and interviews revealed that the resident experienced issues with their ileostomy, including leakage that affected their quality of life and potentially their skin integrity. The resident reported not getting out of bed much due to the leakage, and fecal matter was observed under the ileostomy skin barrier during a wound assessment. The nurse practitioner confirmed that the leakage could negatively impact wound healing and acknowledged the absence of ileostomy care orders. It was noted that the orders might have been lost during the resident's recent hospital visits, and the admission nurse was responsible for ensuring the orders were present upon the resident's return.
Resident Elopement Due to Inadequate Supervision and Communication
Penalty
Summary
The facility failed to provide protective oversight for a resident with Alzheimer's disease, dementia, cognitive communication deficit, difficulty walking, and a history of falls. The resident eloped from the facility and was found by a motorist lying in the grass near a busy roadway. Facility staff were unaware of the resident's absence, and the incident was not documented in the nursing notes. The facility's policy on elopement, which requires immediate search and notification of the resident's responsible party, was not followed. The resident's care plan identified them as at risk for elopement and wandering, yet no specific goals or interventions were listed. The care plan also noted the resident's need for supervision and frequent reminders due to impaired cognition. Despite these documented risks, the facility did not implement adequate measures to prevent the resident's elopement or ensure their safety. Interviews with staff and family members revealed a lack of communication and documentation regarding the incident. The resident's family was not informed of the elopement until several days later, and there was confusion among staff about whether the incident had been properly recorded or reported. The Director of Nursing and Interim Administrator claimed that the facility followed their elopement policy, but there was no documentation to support this claim.
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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) |
|---|---|---|---|---|
| Northland Rehabilitation & Health Care Center | 2.1 mi | ★★★★★ | 2 | 0 |
| Linden Woods Village | 2.4 mi | ★★★★★ | 0 | 0 |
| Pleasant Valley Manor Care Center | 3.1 mi | ★★★★★ | 16 | 2 |
| Mccrite Plaza At Briarcliff Skilled Facility | 4.2 mi | ★★★★★ | 4 | 0 |
| Pinnacle Point Wellness & Rehabilitation | 5.1 mi | ★★★★★ | 13 | 0 |
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