Below 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 St Marys Llc during CMS and state inspections, most recent first.
The facility failed to provide adequate pressure ulcer care and prevention, leading to the development and worsening of pressure ulcers in residents. A resident's pressure ulcer worsened due to inconsistent implementation of interventions and missing documentation. Another resident was admitted with multiple pressure injuries, but the facility did not document a comprehensive wound assessment or consistently document wound care treatments. A third resident had a Stage III pressure ulcer, but daily wound care was not consistently documented, and weekly skin checks were not always completed.
The facility failed to maintain cleanliness and proper food storage standards in the kitchen, with food debris and dust buildup observed in various areas. Milk was stored at an improper temperature, and the Dietary Manager admitted to not instructing staff to check milk temperatures. These issues potentially affected all residents consuming food from the kitchen.
The facility failed to maintain a safe and clean environment, with deficiencies including uncleanable commode risers, dust buildup on fans and vents, unclean floors, missing tiles in a shower room, a loose grab bar, and a broken shower chair. These issues potentially affected at least 30 residents.
The facility failed to ensure timely physician visits for several residents, as required by policy. A resident was not seen by a physician for 10 months, while another had not been seen since admission. Staff were unaware of visit frequency requirements, and there was no monitoring system in place.
The facility failed to ensure timely physician responses to pharmacist recommendations for Gradual Dose Reduction (GDR) of psychotropic medications for two residents. One resident's Bupropion and Duloxetine were not reviewed for GDR, and another resident's Quetiapine dosage was increased without appropriate indications. Additionally, a third resident's Lorazepam dosage was increased without a documented rationale or anxiety diagnosis.
The facility failed to maintain safe temperatures for hot foods and milk on room trays for residents on C and E Hall. Observations showed that hot foods were below the required 120°F, and milk was above the required 41°F. Delays in tray delivery due to CNAs assisting residents contributed to the issue. Staff interviews revealed inconsistent monitoring of tray temperatures, affecting at least 12 residents.
The facility failed to ensure the call system was audible on C Hall, affecting 14 residents with dementia. Observations showed that while call lights were flashing, they were not audible within the hall. The CNO confirmed the issue, and the North Unit Manager noted the lack of a Touch Screen Nurse Console in the area. A CNA also reported being unable to hear the call system from their location.
The facility failed to secure cleanout covers, creating a hazard for residents and staff. On C Hall, a cover moved when stepped on due to a broken cap, as noted by the EVS Director. Similarly, a cover between D Hall and the Rehabilitation Unit Nurse's station was loose, with the EVS Director attributing the issue to accidental damage during carpet removal. This affected 14 residents on C Hall and 19 residents passing through the affected area.
A resident with cognitive impairment and physical limitations was exposed to bystanders during care due to open window curtains. Staff interviews revealed an expectation to maintain privacy, but a CNA admitted forgetting to close the curtains. The ADON and DON acknowledged the oversight.
The facility failed to obtain physician orders and evaluate the ability of two residents to self-administer medications. One resident with COPD was observed using a Ventolin inhaler without staff monitoring or documentation, while another resident with COPD and Pneumonia used a Trelegy inhaler independently without a care plan or evaluation. Staff interviews revealed a lack of awareness and adherence to protocols for self-administration of medication.
The facility failed to promptly address and document skin issues for two residents. One resident had multiple skin integrity concerns upon admission, but treatment orders were delayed, and weekly skin assessments were inconsistently documented. Another resident, at risk for skin issues, had a facility-acquired wound that was not identified or treated in a timely manner. Staff interviews revealed inconsistencies in skin assessment documentation and communication, leading to deficiencies in resident care.
A facility failed to provide proper catheter care for a resident, risking urinary tract infections, by not cleaning the catheter insertion site and not emptying the drainage bag as required. Additionally, the facility did not implement hospital discharge orders for another resident to attempt a voiding trial for catheter removal, failing to assess urinary continence or consult a urologist. Staff interviews revealed misunderstandings and non-compliance with care protocols.
A resident with COPD and dementia had their oxygen tubing improperly stored on the floor, contrary to the facility's policy requiring storage in a labeled bag. Observations over several days showed the tubing remained on the floor, and interviews with staff revealed a lack of awareness and adherence to proper storage practices.
A resident with PTSD and other mental health conditions did not receive trauma-informed care at the facility. The care plan lacked focus on PTSD, and staff were unaware of the diagnosis and potential triggers. The resident and family expressed concerns about the absence of therapy and support services, highlighting a failure to implement the facility's trauma-informed care policy.
A resident with major depressive disorder in an LTC facility did not receive adequate social services support, as evidenced by a lack of documented supportive visits or counseling services. Despite the resident's expressed feelings of depression and desire to return home, staff interviews revealed inconsistent engagement with the resident's mental health needs. The facility's leadership expected social services to provide support, but there was no documentation of such actions being taken.
The facility failed to ensure physicians documented their rationale for disagreeing with pharmacists' recommendations for two residents. One resident continued using a medication as-needed despite a recommendation for routine use, and another resident was on a risky medication combination without documented rationale for continuing it. The facility's policy did not address the need for physician documentation, contributing to the deficiency.
The facility failed to ensure pureed sausage was smooth, affecting six residents on pureed diets. Observations revealed the sausage was grainy, confirmed by dietary staff. The dietary staff did not taste the sausage after pureeing it, contrary to expectations.
The facility did not comply with its Visitor's Food Policy, as observed in the resident unit refrigerator where several food items were improperly labeled or not labeled at all. This included a fruit tray without a name or date, cans of soda with names but no dates, and a foam cup with a date but no name. The Rehab Unit Manager acknowledged the requirement for all food and drink to be labeled with a date and resident's name, highlighting a failure in policy adherence that potentially affected several residents.
The facility failed to ensure the outdoor dumpster was in good repair, with a 15-inch crack in the lid and trash accumulating on the ground around it. The EVS Director was unaware of the crack and noted that employees sometimes miss when placing trash in the dumpster.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention, resulting in the development and worsening of pressure ulcers in several residents. Resident #74 was admitted with a Stage I pressure ulcer and was at high risk for further skin integrity issues. Despite having orders for a low air loss mattress and Prevalon boots, these interventions were not consistently implemented, and documentation of wound care was often missing. Observations revealed that the resident's pressure ulcer worsened, with an increase in size and necrotic tissue, indicating a lack of proper care and monitoring. Resident #1 was admitted with multiple pressure injuries, including Stage IV ulcers, but the facility did not document a comprehensive wound assessment upon admission. There was a lack of initial wound measurements and detailed descriptions, and wound care treatments were not consistently documented. The resident's wounds were not properly assessed or documented by the facility's nursing staff, leading to inadequate monitoring and care. Resident #62 had a Stage III pressure ulcer on the right ankle, but the facility failed to document daily wound care consistently. Weekly skin checks were ordered but not always completed, and there was a lack of comprehensive wound assessments. The facility's failure to adhere to physician orders and document wound care interventions contributed to the inadequate management of the resident's pressure ulcer.
Kitchen Cleanliness and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage standards in the kitchen, as observed during a survey. There was a buildup of food debris under the shelves in the dry goods storage room and under the six-burner stove, deep fat fryer, and convection oven. Additionally, dust accumulation was noted on the sprinkler heads over the baking preparation area and on the utensil rack. The Dietary staff admitted to not having moved the appliances for cleaning in a few days due to being short-staffed. The Dietary Manager also acknowledged not having notified the Maintenance Department about cleaning the sprinkler heads. Further observations revealed that the milk in a serving container in the dining room was at a temperature of 63°F, which is above the recommended 41°F. Dust was also found on the self-closing fixture and the top of the door between the main kitchen and the galley. The Dietary Manager admitted to not having instructed the dietary staff to check the temperature of the milk during meals and stated that they would ask the maintenance department to clean the top of the door. These deficiencies potentially affected all residents who consumed food from the kitchen, with the facility census being 84 residents.
Facility Maintenance Deficiencies Affect Resident Safety and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by multiple deficiencies observed during a survey. Commode risers in several resident rooms, including A110, A105, A102, B104, C106, C104, C102, E107, E108, G104, and D107, were found to be not easily cleanable, which could potentially affect the safety and hygiene of the residents using them. Additionally, a buildup of dust was observed on the fan blades in resident room B105, and a heavy buildup of dust was found inside the ceiling vent in resident room A101. The floor in resident rooms A105 and C109 was not maintained clean, with an old spill and a buildup of dust and powder, respectively. Further deficiencies included missing tile pieces from the countertop in the A Hall shower room, which could potentially cause skin damage, and a grab bar in the restroom of resident room B106 that was not securely affixed to the wall. The shower chair in the restroom of D105 was also found to be broken. These deficiencies indicate a lack of proper maintenance and oversight in ensuring the safety and cleanliness of the facility's environment, potentially affecting at least 30 residents who resided in or used those areas.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility's physician failed to conduct timely face-to-face visits with several residents, as required by the facility's policy. Specifically, the physician did not visit Resident #8 at least once every 30 days for the first 90 days after admission, nor did the physician visit Residents #25, #38, #41, #62, and #15 every 60 days thereafter. The facility's policy mandates that residents must be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter, with visits considered timely if they occur no later than 10 days after the required date. Resident #25, who was admitted with multiple diagnoses including dementia, depression, and diabetes, was seen by a nurse practitioner monthly, but the last documented physician visit was on 10/30/23, indicating a 10-month gap without a physician's visit. Similarly, Resident #8, admitted with dementia and other conditions, had not been seen by the facility's physician since admission, as noted in the nurse practitioner's encounter notes. Resident #41, with a history of stroke and seizures, was only seen by the facility's physician once in 11 months, despite being seen by nurse practitioners multiple times. The facility staff, including LPNs and ADONs, were unaware of the required frequency of physician visits, and there was no system in place to monitor compliance with the visit schedule. This lack of awareness and monitoring contributed to the failure to ensure that the physician conducted the necessary visits, as evidenced by the absence of physician progress notes in the residents' medical records. The DON acknowledged the expectation for physician visit progress notes and the requirement for physicians to visit each resident every 60 days, alternating with nurse practitioner visits, but was unsure who was responsible for monitoring this compliance.
Failure to Ensure Timely Physician Response to GDR Recommendations
Penalty
Summary
The facility failed to ensure timely physician responses to pharmacist recommendations for Gradual Dose Reduction (GDR) of psychotropic medications for two residents. For Resident #25, the pharmacist recommended a GDR for Bupropion and Duloxetine, but there was no documented response from the physician regarding these recommendations. Although Quetiapine was discontinued, the lack of documentation for the other medications indicates a failure to follow up on the pharmacist's suggestions. The resident's medical records did not show any rationale for not attempting a GDR, despite the psychiatrist's follow-up visits and medication reviews. Resident #50 experienced multiple falls, and the facility increased the dosage of Quetiapine without documented behaviors or appropriate indications for the antipsychotic medication. The pharmacist's review noted the absence of an appropriate diagnosis for Quetiapine, yet the physician agreed to continue the medication without providing comments. The facility did not document any behaviors that would justify the increase in Quetiapine, and there was no evidence of behavior monitoring or rationale for the medication adjustments. For Resident #62, the facility did not provide a rationale for the physician's decision to increase Lorazepam dosage despite a pharmacist's recommendation for a GDR. The resident's records lacked a diagnosis of anxiety, which was the stated reason for the medication. The facility's failure to document the physician's rationale for not following the GDR recommendation and the absence of an anxiety diagnosis highlight a lack of compliance with medication management protocols.
Failure to Maintain Safe Food Temperatures on Room Trays
Penalty
Summary
The facility failed to maintain appropriate temperatures for hot foods and milk on room trays for residents on C and E Hall. Observations revealed that hot foods on room trays were not kept at or close to the required temperature of 120°F, with eggs and bacon measuring at 108.1°F and 102.2°F, respectively. Additionally, milk was not maintained at the required temperature of 41°F, with measurements showing 63.9°F and 53.2°F. These deficiencies were observed during the room tray delivery process, where delays occurred as CNAs had to assist residents, causing trays to sit on the cart longer than necessary. Interviews with staff indicated a lack of regular monitoring and evaluation of the room tray delivery procedure. The Chief Nursing Officer acknowledged not having reviewed the room tray service, and the Dietary Manager admitted to checking tray temperatures randomly rather than regularly. This lack of consistent oversight and adherence to the facility's policy on food temperatures potentially affected at least 12 residents who received room trays towards the end of the delivery time, compromising the safety and quality of their meals.
Inaudible Call System on C Hall
Penalty
Summary
The facility failed to ensure the audible portion of the call system was operational at the Nurse's area on C Hall, which is a unit with residents who had some level of dementia. This deficiency affected 14 residents residing on C Hall. Observations revealed that while the call light was flashing and alarming outside of C Hall, it was not audible within the hall itself. During an interview, the Chief Nursing Officer confirmed that the alarm did not sound on that unit, and the North Unit Manager acknowledged that the installers of the call light system did not consider placing a Touch Screen Nurse Console at the nurse's area on C Hall. Further observations showed that the call light in a resident's room was activated, and the sound was only heard at the North Unit Nurse's Station, which was located outside of C Hall. A Certified Nursing Assistant (CNA) stated that they could not hear the call system from their location at the nurse's area. The Administrator later acknowledged that placing a Touchscreen Console on C Hall would make the call system more audible on that hall.
Loose Cleanout Covers Pose Hazard
Penalty
Summary
The facility failed to maintain the covers of cleanouts in a secure manner, creating a potential hazard for residents and staff. On C Hall, the cleanout cover was observed to move when stepped on, with the blue tape that previously secured it broken. The Environmental Services (EVS) Director explained that the cap into which the screw of the cover fits was broken, causing the cover to be loose. Similarly, in the area between D Hall and the Rehabilitation Unit Nurse's station, another cleanout cover was found to move when stepped on. The Rehabilitation Unit Manager was unaware of how long this cover had been loose, and the EVS Director noted that the cap was accidentally broken during carpet removal. This issue potentially affected 14 residents on C Hall and 19 residents who passed through the area between D Hall and the Rehabilitation Unit.
Failure to Ensure Privacy and Dignity During Resident Care
Penalty
Summary
The facility failed to provide dignity and privacy during the care of a resident, specifically during activities of daily living and perineal care. The resident, who had a history of cognitive impairment, depression, and physical limitations, was exposed to bystanders outside the window during care procedures. On two separate occasions, the window curtains were left open while care was being administered, allowing bystanders to view the resident, thus compromising the resident's privacy and dignity. Interviews with staff members, including CNAs and the ADON, revealed that there was an expectation to maintain privacy by closing curtains and blinds during personal care. However, it was admitted by CNA J that they forgot to close the curtains during the care of the resident. The ADON and DON also acknowledged the importance of ensuring privacy and dignity for residents and admitted that the window curtains should have been closed during the care of the resident.
Failure to Obtain Physician Orders and Evaluate Self-Administration of Medication
Penalty
Summary
The facility failed to obtain a physician's order for self-administration of medication at bedside and did not evaluate or document the ability of two residents to self-administer their medications. Resident #343, who was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), did not have a physician's order for self-administration of medication or an evaluation completed prior to the survey. The resident was observed with a Ventolin inhaler at the bedside, which was used without staff monitoring or documentation. The resident, who had a left arm amputation, self-administered the inhaler but was unaware if staff monitored or documented the administration. Resident #345, admitted with diagnoses of Pneumonia and COPD, also did not have a care plan or evaluation for self-administration of medication. The resident was observed with a Trelegy inhaler at the bedside and reported using it independently. The inhaler was not found in the medication cart during a medication administration observation, indicating it was left at the bedside without a physician's order. Interviews with staff, including a Certified Medication Technician (CMT), Licensed Practical Nurse (LPN), Assistant Directors of Nursing (ADONs), and the Director of Nursing (DON), revealed a lack of awareness and adherence to protocols for self-administration of medication. Staff acknowledged the need for a physician's order and evaluation for self-administration, as well as the requirement to monitor and document the administration of medications by residents.
Failure to Address and Document Skin Issues Timely
Penalty
Summary
The facility failed to act promptly on skin issues identified during the initial skin assessment for Resident #47. Upon admission, the resident had several skin integrity concerns, including redness and inflammation in various areas, and an open area on the coccyx. Despite these findings, there were no documented physician's orders for treatment of the resident's skin issues. The resident's medical record lacked timely documentation of treatment orders, and weekly skin assessments were not consistently completed or documented, leading to a delay in addressing the resident's skin conditions. Additionally, the facility did not ensure timely documentation and follow-up on a change in skin condition for Resident #62. The resident was at risk for skin integrity issues and had a physician's order for weekly skin checks. However, there were gaps in the documentation of skin observations, and a wound on the resident's buttocks was not identified or treated during perineal care. The wound was later discovered to be facility-acquired, indicating a failure in the facility's monitoring and documentation processes. Interviews with facility staff, including the Administrator, ADONs, and the DON, revealed inconsistencies in the completion and documentation of skin assessments. The facility's nursing staff were responsible for conducting weekly skin assessments, but there were lapses in communication and documentation, leading to unaddressed skin issues. The facility's policies and procedures for skin integrity were not adequately followed, resulting in deficiencies in the care provided to the residents.
Deficiencies in Catheter Care and Discharge Order Implementation
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling Foley catheter, which put the resident at risk for urinary tract infections. The resident, who was cognitively intact and required total assistance for toileting, had diagnoses including quadriplegia, neurogenic bladder, and pressure injuries. During an observation, a CNA did not clean around the catheter insertion site and surrounding skin, which is a critical part of catheter care. The CNA also failed to empty the drainage bag, which contained dark tea-colored urine and a white/yellowish substance, as required by the facility's policy. Interviews with staff revealed a lack of adherence to the facility's catheter care policy, which mandates cleaning the insertion site and surrounding skin every shift. Another deficiency involved the failure to transcribe and implement hospital discharge orders for a resident who was supposed to undergo a voiding trial to remove a urinary catheter. The resident, who had diagnoses of high blood pressure, renal failure, and benign prostatic hyperplasia, was not assessed for urinary continence or catheter removal. Despite hospital orders to attempt a voiding trial within a week of discharge, the facility did not conduct the trial or consult with a urologist. Interviews with facility staff, including the DON and ADON, indicated a misunderstanding of the discharge orders and a lack of assessment for catheter removal, attributing the continued use of the catheter to the resident's BPH diagnosis. The facility's failure to adhere to catheter care protocols and discharge orders resulted in deficiencies in the care provided to residents with indwelling urinary catheters. The staff did not perform necessary assessments or follow through with physician orders, leading to potential risks for the residents involved. The facility's policies and staff training did not ensure compliance with catheter care standards, as evidenced by the observations and interviews conducted during the survey.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to ensure proper infection control practices for storing oxygen equipment for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD), unspecified chronic bronchitis, and dementia. The resident's care plan indicated a potential for altered respiratory status, but did not specify the route or amount of oxygen used. Observations over several days showed that the resident's oxygen concentrator was left on with the tubing on the floor, even when the resident was not in the room. The facility's policy required oxygen equipment to be stored in a labeled bag, but this was not followed. Interviews with staff, including a CNA, the ADON, the DON, the MDS Coordinator, and an LPN, revealed a lack of awareness and adherence to the facility's policy on oxygen equipment storage. The CNA and other staff members acknowledged that the oxygen tubing should not be on the floor and should be stored in a labeled bag. However, they were unaware of the tubing's condition in the resident's room. The staff expected CNAs to notice and replace the tubing if necessary, but this expectation was not met, leading to the deficiency.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD), among other mental health conditions. The resident was admitted with diagnoses including unspecified dementia, major depressive disorder, insomnia, anxiety disorder, and borderline personality disorder. Despite these diagnoses, the resident's care plan lacked focus or interventions related to PTSD or trauma-informed care. Observations noted the resident exhibiting signs of distress, such as taking sharp, quick breaths and expressing feelings of upset and worry, particularly about not receiving medications on time. Interviews with facility staff revealed a lack of awareness and action regarding the resident's PTSD diagnosis. The Social Services Designee was unaware of the diagnosis and had not completed an initial trauma screening. The Certified Nursing Assistant (CNA) and other staff members were also unaware of the resident's PTSD and any potential triggers. The Assistant Director of Nursing and the Director of Nursing acknowledged the diagnosis but noted that the resident had not received psychiatric services, and there was a lack of communication and documentation regarding trauma-informed care. Family members and the resident expressed concerns about the lack of therapy and support services offered. The resident's family, who held the Durable Power of Attorney, indicated that the facility had not discussed psychiatric services, and they believed therapy would benefit the resident. The facility's policy on trauma-informed care was not implemented effectively, as evidenced by the absence of a trauma assessment and the lack of individualized care planning for the resident's PTSD.
Failure to Provide Medically Related Social Services for Depressed Resident
Penalty
Summary
The facility failed to provide medically related social services to a resident diagnosed with major depressive disorder. The resident, who was cognitively intact, expressed feelings of depression, hopelessness, and a desire to return home. Despite these indicators, there was no documentation of social services supportive visits or counseling services in the resident's electronic medical record. The resident's care plan included the need for staff to allow the resident to verbalize feelings and initiate referrals for counseling and psychiatric services as needed, but these actions were not documented as being carried out. Interviews with staff revealed a lack of consistent engagement with the resident's mental health needs. Certified Nurses Assistants (CNAs) reported that the resident often stayed in bed and expressed a desire to go home, but there was no indication that these observations were followed up with appropriate social services interventions. The Social Services Designees (SSDs) acknowledged the resident's depressive symptoms and stated that they would request psychiatric evaluations, but there was no evidence of ongoing supportive visits or the use of behavioral health services. The facility's leadership, including the Assistant Directors of Nursing (ADONs) and the Director of Nursing (DON), expected the SSDs to provide supportive visits and arrange counseling services for residents with mood concerns. However, the SSDs admitted to not documenting their interactions with the resident and were in the process of developing a plan to implement behavioral health services. This lack of documentation and follow-through on the care plan's directives contributed to the deficiency in providing necessary social services to the resident.
Failure to Document Physician Rationale for Disagreeing with Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that physicians documented a rationale for disagreeing with pharmacists' recommendations in a timely manner for two residents. For Resident #25, the pharmacist recommended changing the use of Nystatin-Triamcinolone Ointment from as-needed to routine, as it was not appropriate for as-needed use. The physician disagreed with this recommendation but did not provide a rationale for the decision. This lack of documentation persisted over several months, with the pharmacist not continuing to address the recommendation in subsequent reviews. Resident #62 was receiving a combination of medications that posed potential risks, including the concurrent use of Omeprazole and Clopidogrel, which could decrease the effectiveness of Clopidogrel and increase the risk of cardiovascular events. The pharmacist recommended replacing Omeprazole with Pepcid or considering Rabeprazole if PPI therapy was necessary. The physician disagreed with the recommendation but did not document a rationale. Additionally, the resident was receiving Esomeprazole at a higher than recommended dose, and the pharmacist suggested a dose reduction, which the physician also disagreed with, again without providing a rationale. The facility's Pharmacy Services policy did not address the requirement for physicians to document their rationale for not following pharmacists' recommendations. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that there was an expectation for physicians to document their rationale, but it was unclear if the current Nurse Practitioner was aware of this requirement. The lack of documentation and follow-up on pharmacists' recommendations contributed to the deficiency identified in the facility's practices.
Failure to Ensure Proper Texture of Pureed Sausage
Penalty
Summary
The facility failed to ensure that pureed sausage was prepared to a smooth consistency, affecting six residents on pureed diets. During an observation, the pureed sausage was found to be grainy, indicating the presence of small particles. Dietary staff, including Dietary [NAME] (DC) A and the Dietary Manager (DM), confirmed the grainy texture upon tasting the sausage. DC A admitted to not tasting the sausage after pureeing it earlier that morning and before placing it on the steam table. The DM stated that dietary staff are expected to taste pureed food to ensure proper texture.
Failure to Follow Visitor's Food Policy
Penalty
Summary
The facility failed to adhere to its Visitor's Food Policy, which mandates proper labeling and storage of food items brought in by residents, family members, or other visitors. During an observation, it was noted that the resident unit refrigerator contained several items that were not labeled according to the policy. Specifically, a fruit tray was found without a name or date, cans of soda were labeled with names but lacked dates, and a foam cup in the freezer had a date but no name. These observations indicate a failure to ensure that all food items were appropriately labeled with the resident's name, content, date, and room number as required by the policy. The policy also requires that nursing staff evaluate and label food items to ensure they are stored under proper sanitation conditions. However, the observed deficiencies suggest that this process was not consistently followed. The Rehab Unit Manager confirmed that all food and drink should be labeled with a date and the resident's name, and that specific items like nutrition supplemental drinks should have designated sections within the refrigerator. This lapse in following the established policy potentially affected between 3-5 residents in a facility with a census of 84 residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the outdoor dumpster in proper condition, as observed on 8/22/24. The dumpster lid had a 15-inch crack, and there was a significant amount of debris and trash on the ground surrounding the dumpster. During an interview, the Environmental Services (EVS) Director acknowledged the need to notify the dumpster company for a replacement container and admitted to being unaware of the crack in the lid. The EVS Director also mentioned that employees sometimes miss when placing trash in the dumpster, resulting in trash accumulating on the ground around it.
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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 Blue Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blue Springs Wellness & Rehabilitation | 0.9 mi | ★★★★★ | 2 | 0 |
| Ignite Medical Resort Blue Springs | 4.2 mi | ★★★★★ | 0 | 0 |
| Monterey Park Rehabilitation & Health Care Center | 4.5 mi | ★★★★★ | 13 | 0 |
| Jackson Creek Post Acute | 5 mi | ★★★★★ | 21 | 0 |
| Sunterra Springs Independence | 5.4 mi | ★★★★★ | 0 | 0 |
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