Ignite Medical Resort Overland Park LLC
11901 Rosewood Street, Overland Park, KS 66209 · Johnson County · 102 certified beds · avg 100 residents/day · certified since Mar 20, 1989
Part of chain: IGNITE MEDICAL RESORTS (22 facilities, chain avg rating 2.7★)
2/5
Health inspection rating (on-site)
2
Serious findings on record
$6,942
Fines, last 3 years
3.46
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jul 17, 2024 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 27, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 20, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 8, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (36)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 17, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. · from a complaint |
| Aug 29, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. · from a complaint |
| Aug 29, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Jul 17, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 17, 2024 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Jul 17, 2024 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jul 17, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 17, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Jul 17, 2024 | C · Minimal risk, facility-wide | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Nov 20, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 20, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Mar 20, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Aug 2, 2021 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Aug 2, 2021 | E · Potential for harm, repeated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Aug 2, 2021 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 2, 2021 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Aug 2, 2021 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (13 → 14).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 5 | 0 | E |
| 2023 | 14 | 1 | G ▲ |
| 2024 | 16 | 1 | G ▲ |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $6,942, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jul 17, 2024 | Fine | $6,942 |
| Nov 20, 2023 | Payment Denial | 27 days from Dec 12, 2023 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Kansas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.46 | 4.58 | 3.95 | bottom 15% in Kansas; bottom 35% in the U.S. |
| Registered Nurse hours | 0.47 | 0.81 | 0.69 | bottom 14% in Kansas; bottom 33% in the U.S. |
| Weekend total nurse staffing | 3.32 | 4.05 | 3.50 | bottom 26% in Kansas; bottom 48% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.52 | 0.49 | 0.48 | top 36% in Kansas; top 30% in the U.S. |
| Total nursing staff turnover (%) | 53.5 | 48.1 | 45.8 | bottom 34% in Kansas; bottom 28% in the U.S. |
| RN turnover (%) | 70.0 | 42.0 | 42.9 | bottom 15% in Kansas; bottom 12% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.66, RN 0.50, weekend 3.51. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Blue Pearl Financial LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Carr, Barry | Individual | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Carr, Jared | Individual | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Chuku, Brandy | Individual | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Gillis, Karen | Individual | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Gold Pearl, LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Ignite Overland Park JV LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Ignite Post Acute Solutions LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Ignite-Villa Holdco LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Israel Family Investment Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Israel Investment Tr | Organization | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Jablonski, Nicole | Individual | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| McFarlane, John | Individual | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Prestige Worldwide Overland Park LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Rogers, Dylan | Individual | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Rose, Marc | Individual | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Stern Family Investment Tr | Organization | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Thengil, Mathew | Individual | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| White, Jim | Individual | Indirect Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Berger Fam Tr Ua 06252014 | Organization | ADP of the SNF | NOT APPLICABLE | 08/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you handle room assignments and roommate requests, and do residents get advance written notice before any move?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Village Shalom INC | 1.1 mi | Overland Park, KS | ★★★★☆ | 2/5 | |
| Tallgrass Creek, INC | 1.4 mi | Overland Park, KS | ★★★★★ | 5/5 | |
| The Healthcare Resort of Leawood - Iron Horse HLTH | 1.5 mi | Leawood, KS | ★★☆☆☆ | 2/5 | |
| Brookdale Overland Park | 1.6 mi | Overland Park, KS | ★★★★☆ | 4/5 | |
| Advanced Health Care of Overland Park | 3.2 mi | Overland Park, KS | ★★★★★ | 3/5 | |
| Overland Park Post Acute | 3.6 mi | Overland Park, KS | ★☆☆☆☆ | 1/5 | |
| Swan Health at Overland Park | 3.7 mi | Overland Park, KS | ★☆☆☆☆ | 1/5 | |
| Ignite Medical Resort Carondelet LLC | 3.9 mi | Kansas City, MO | ★☆☆☆☆ | 2/5 | |
| Bridgewood Health Care Center | 4.0 mi | Kansas City, MO | ★☆☆☆☆ | 1/5 | abuseSFF |
| Stratford Commons Rehab & Health Care Center | 4.4 mi | Overland Park, KS | ★★★☆☆ | 3/5 | |
| Kingswood Senior Living | 4.7 mi | Kansas City, MO | ★★★☆☆ | 3/5 | |
| Colonial Village | 4.8 mi | Overland Park, KS | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 175183.