Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
IGNITE MEDICAL RESORT ST MARYS LLC
BLUE SPRINGS, MO · 130 certified beds · Last Life Safety survey August 27, 2024
CMS Certification Number 265759 · first certified July 2003
Ownership
Operated by IGNITE MEDICAL RESORTS · For profit - Limited Liability company
- Ownership changed November 1, 2020 (change of ownership)from CARONDELET LONG TERM CARE FACILITIES INC
Position within MO
50 citations — more than 98% of the 487 certified nursing homes in MO. Compared within MO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 22 citations; the earlier surveys in the window averaged 14. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (October 2025 to May 2026), and past the point by which nine in ten MO facilities have been surveyed. This facility’s last Life Safety survey was August 2024. Facilities in MO are typically surveyed 14–21 months after the last one (median 17), measured over 567 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
14 of the 50 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 50 Life Safety citations above. The Physical Environment Index
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in MO, and nationally. Surveyors differ markedly between states, so the MO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 50 |
| Median facility in MO | 18 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 14, 2020 | 6 |
| October 25, 2022 | 22 |
| August 27, 2024 | 22 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2022-10-25 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 2 | 2024-08-27 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-08-27 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2024-08-27 |
| K-0281 | Install proper backup exit lighting. | 2 | 2024-08-27 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 2 | 2022-10-25 |
| K-0293 | Have properly located and lighted "Exit" signs. | 2 | 2024-08-27 |
| K-0161 | Use approved construction type or materials. | 2 | 2024-08-27 |
What the citations cover
- Emergency Preparedness Deficiencies 14
- Smoke Deficiencies 14
- Egress Deficiencies 9
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Other 8
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 14 |
| Smoke Deficiencies | 14 |
| Egress Deficiencies | 9 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Miscellaneous Deficiencies | 5 |
| Construction Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 27, 2024 — 22 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (October 10, 2024) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (October 10, 2024) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (October 10, 2024) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (October 10, 2024) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (October 10, 2024) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (October 10, 2024) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0227 | Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has plan of correction (October 14, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0500 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (October 10, 2024) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (October 10, 2024) |
October 25, 2022 — 22 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (December 9, 2022) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (December 9, 2022) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (December 9, 2022) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (December 9, 2022) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (December 9, 2022) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (December 9, 2022) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0222 | 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. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0300 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (December 9, 2022) |
January 14, 2020 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (February 27, 2020) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (February 27, 2020) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (February 27, 2020) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 14, 2020) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (February 27, 2020) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 27, 2020) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.