Cycle 1
Health 2024-07-17 · Fire 2024-07-17
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
23 fire-safety deficiencies
Top issue: Emergency Preparedness (11 deficiencies)
Overland Park, KS
Ignite Medical Resort Overland Park LLC
1-star overall rating with 2-star inspections with $6,942 in total fines with 14 recent health deficiencies with 23 fire-safety deficiencies in the latest cycle
11901 Rosewood Street, Overland Park, KS
(913) 345-1745
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
96
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ascension Living
Operator or chain grouping
Approved since
1989-03-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.29
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.17
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
1.71
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.17
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.28
CMS adjusted RN staffing hours
Adjusted total hours
3.07
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,357
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9844
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.04
Baseline 19.97% · Performance 20.95% · Measure score 1.04 · Achievement 1.04 · Improvement 0
Healthcare-associated infections
4.64
Baseline 8.51% · Performance 6.70% · Measure score 4.64 · Achievement 3.78 · Improvement 4.64
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
2.43
Baseline 3.74 hours · Performance 3.77 hours · Measure score 2.43 · Achievement 2.43 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.29% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 10.34% · Lower 95% interval 6.97% |
| Discharge to community | 49.18% |
50.57%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 37.04% · Lower 95% interval 35.79% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 103 · Denominator 103 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 103 |
| Discharge self-care score | 60% |
53.69%
6.3 pts better
|
Numerator 36 · Denominator 60 |
| Discharge mobility score | 43.33% |
50.94%
7.6 pts worse
|
Numerator 26 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 0.97% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 103 · Adjusted rate 0.92% |
| Healthcare-associated infections requiring hospitalization | 6.7% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 6.67% · Lower 95% interval 3.39% |
| Staff COVID-19 vaccination coverage | 1.12% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 89 |
| Staff flu vaccination coverage | 79.34% |
42%
37.3 pts better
|
Numerator 96 · Denominator 121 |
| Discharge function score | 65% |
56.45%
8.5 pts better
|
Numerator 39 · Denominator 60 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 38 · Denominator 38 |
| Transfer of health information to patient | 97.5% |
96.28%
1.2 pts better
|
Numerator 39 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 39.44% |
25.2%
14.2 pts better
|
Numerator 28 · Denominator 71 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.9 |
1.8
2.1 pts worse
|
1.9
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 3.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.7% |
91.8%
11.1 pts worse
|
93.4%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 89.0% · Q3 81.9% · Q4 57.3% · 4Q avg 80.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.5% |
95.5%
5 pts worse
|
95.5%
5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
4.4%
2.7 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.4% · Q3 0.0% · Q4 1.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.1% |
5.6%
10.5 pts worse
|
11.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 10.4% · Q3 23.9% · Q4 20.3% · 4Q avg 16.1% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
5.0%
2 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 10.5% · Q3 9.8% · Q4 4.7% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.4% |
23.2%
3.2 pts worse
|
19.6%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 27.6% · Q3 28.6% · Q4 20.9% · 4Q avg 26.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.9% |
19.8%
5.1 pts worse
|
16.7%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 25.0% · Q3 23.6% · Q4 24.5% · 4Q avg 24.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.7% |
18.4%
4.7 pts better
|
16.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 16.2% · Q3 18.3% · Q4 7.3% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.8% |
18.8%
8 pts better
|
14.9%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 8.8% · Q3 6.6% · Q4 13.1% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.8%
1.3 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.1% |
3.1%
1 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 1.4% · Q3 0.0% · Q4 5.6% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.9% |
23.2%
10.3 pts better
|
19.8%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 7.2% · Q3 13.0% · Q4 20.6% · 4Q avg 12.9% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
4.6%
2.2 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 7.9% · Q3 4.5% · Q4 9.1% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 37.5% |
75.6%
38.1 pts worse
|
81.7%
44.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 52.6% · Q2 46.2% · Q3 31.0% · Q4 27.2% · 4Q avg 37.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
11.7%
0.2 pts better
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 13.5% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
2.2%
1.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.6% · Q4 0.9% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 41.5% |
73.5%
32 pts worse
|
79.7%
38.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 41.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
23.0%
1.2 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 29.2% · Expected 28.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-20 · Fire 2023-03-20
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-08-02 · Fire 2021-08-02
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-17
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-07-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-07-17
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-07-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-07-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-07-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-18
F · Potential for more than minimal harm
2023-03-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-06
F · Potential for more than minimal harm
2023-03-20
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-03-06
F · Potential for more than minimal harm
2023-03-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-06
E · Potential for more than minimal harm
2023-03-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-03-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-06
F · Potential for more than minimal harm
2021-08-02
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-08-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-08-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-08-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-08-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-08-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-08-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-09-17
E · Potential for more than minimal harm
2021-08-02
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-09-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-08-29
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-20
G · Actual harm
2024-07-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-07-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-07-17
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-07-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-17
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-17
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-17
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-17
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-17
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-08-12
C · Minimal harm
2024-07-17
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-08-12
G · Actual harm
2023-11-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-08
E · Potential for more than minimal harm
2023-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-20
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-20
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-20
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-20
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-04-13
E · Potential for more than minimal harm
2021-08-02
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-08-27
E · Potential for more than minimal harm
2021-08-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-08-27
E · Potential for more than minimal harm
2021-08-02
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-08-27
D · Potential for more than minimal harm
2021-08-02
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-08-27
D · Potential for more than minimal harm
2021-08-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-08-27
Penalties and ownership
What sits behind the stars
$6,942
2024-07-17
Fine
Fine · fine $6,942
Fine
$0
2023-11-20
Payment Denial
Payment Denial · denial start 2023-12-12 · 27 days
27 day denial
Ownership
Carr, Barry
Operational/Managerial Control · Individual
Carr, Jared
Operational/Managerial Control · Individual
Chuku, Brandy
Operational/Managerial Control · Individual
Fields, Timothy
Operational/Managerial Control · Individual
Gillis, Karen
Operational/Managerial Control · Individual
Ignite Team Partners LLC
Operational/Managerial Control · Organization
Jablonski, Nicole
Operational/Managerial Control · Individual
Mcfarlane, John
Operational/Managerial Control · Individual
Middlemas, Melissa
Operational/Managerial Control · Individual
Rogers, Dylan
Operational/Managerial Control · Individual
Rose, Marc
Operational/Managerial Control · Individual
Thengil, Mathew
Operational/Managerial Control · Individual
White, Jim
Operational/Managerial Control · Individual
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