Ignite Medical Resort Carondelet: Pain Med Delay - MO
The medication was Tramadol, a controlled substance. Under the process the facility uses, a pharmacist cannot dispense a controlled medication until a physician has signed off. The physician had not done that. The prescription sat unsigned.
A nurse practitioner interviewed by inspectors on April 30 was direct about what had happened and what it meant. The NP said the resident does well when pain is controlled. She also acknowledged she normally stays out of situations involving controlled medication orders, and that she knew the pharmacy could not send the drug until the physician signed.
The physician had the authority to sign. He or she did not.
The inspection cited minimal harm or potential for actual harm, and noted only a few residents were affected. But for the resident waiting on Tramadol, the gap between a signed order and an unsigned one was the gap between controlled pain and uncontrolled pain.
The NP's account offered no explanation for why the physician had not signed. Inspectors did not record one. The report does not say how long the resident waited, or whether the order was eventually signed and the medication delivered.
What the record shows is a nurse practitioner who understood the requirement, acknowledged the physician had not met it, and described herself as someone who does not normally get involved when controlled medications are at issue. Nobody, by the account inspectors documented, closed that gap before it became a complaint.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ignite Medical Resort Carondelet LLC from 2026-04-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
IGNITE MEDICAL RESORT CARONDELET LLC in KANSAS CITY, MO was cited for violations during a health inspection on April 29, 2026.
The medication was Tramadol, a controlled substance.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.