Ignite Medical Resort Webster, LLC

In the surveyor’s words

From the most serious findings on record at Ignite Medical Resort Webster, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF604Mar 22, 2023

  Based on observation, interview and record review, the facility failed to ensure that residents were free from physical restraints imposed for the purposes of convenience, and not required to treat the resident's medical symptoms for 1 of 8 residents (Resident #40) reviewed for physical restraints. -The facility failed to ensure that physical restraints were not used on Resident #40 during medication administration via G- tube (a tube inserted through the belly that brings nutrition directly to the stomach), which resulted in Resident #40 suffering from emotional distress and increased behaviors. On 03/17/23 at 12:35 PM and Immediate Jeopardy (IJ) was identified. […]

• Immediate jeopardy, isolatedF742Mar 22, 2023

  Based on observations, interviews, and record reviews, the facility failed to ensure a resident who displays or was diagnosed with a mental illness or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 8 Residents (Resident #40) reviewed for behavioral services. - The facility failed to appropriately treat Resident #40's behaviors by staff restraining the resident during G-tube medication administration. This use of restraints resulted in the resident experiencing acute emotional distress. […]

• No harm, potential for more than minimal, patternF565Mar 22, 2023

  Based on interview, and record review, the facility failed to ensure residents had a right to organize and participate in resident groups in the facility for 5 of 5 residents (#16, #31, #17, #37, and #7) reviewed for resident rights, in that: -The facility failed to organize and allow Residents #16, #31, #17, #37, and #7 to participate in monthly resident council meeting. This failure could place residents who reside at the facility at risk of not being able to voice their concerns without staff being present, overhearing their concerns, and to conduct resident council meetings without interference. Findings included: Resident #16 Record review of the face sheet for Resident #16 dated 03/17/2023 revealed an [AGE] year-old female admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF755Mar 22, 2023

  Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 8 residents (Resident #109, CR #1) reviewed for pharmacy services. - The facility failed to ensure that Resident #109 received her full dose of medications by not leaving the medication at the resident's bedside. - The facility failed to ensure that the Kindle Medication Room did not contain expired IV medications. These failures could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications. […]

• No harm, potential for more than minimal, patternF842Mar 22, 2023

  Based on observation, interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, which were complete and accurately documented for 8 of 15 residents (Resident # 40, Resident #7, Resident #10, Resident #24, Resident #29, Resident #31, Resident #54 and Resident #308 ) whose records were reviewed. - Nursing staff failed to properly document Resident #40's behaviors. - LVN A documented administration of Glucerna (a nutritional supplement) to Resident #40 on 03/15/23 even though it was not performed - The facility failed to ensure their system of documenting weights for residents was accurate. […]