Ignite Medical Resort Round Rock, LLC

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

62.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 328 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 82.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 99 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 1.01 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 70 beds and averages 57.6 residents a day — about 82% occupied, or roughly 12 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.89 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.05 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.77 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.33 hrs/resident/day on weekends vs 4.12 on weekdays — 19% thinner on weekends. RN hours go from 1.18 to 0.73 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

37 citations, most serious first. The 16 most serious are shown; the remaining 21 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-11-14 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 6 residents reviewed for resident rights. 1. The facility failed to notify the MD or NP when Resident #1, who has a diagnosis of stage 5 kidney failure, complained of not being able to urinate. 2. The facility failed to notify the MD or NP when Resident #1, with a BIMS score of 15, began exhibiting erratic behaviors, changes in mental status, confusion, and agitation. 3. The facility failed to notify the MD, NP, or abuse coordinator when Resident #1 presented with bruises on her abdomen, back, legs, arms, and forehead . The failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/13/24 at 2:49 PM. While the IJ was removed on 11/14/24 at 7:19 PM, the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-11-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 1 (Resident #1) of 6 residents reviewed for quality of care. 1. The facility failed to assess the resident or notify the provider when Resident #1, who has a diagnosis of stage 5 kidney failure, complained of not being able to urinate. 2. The facility failed to assess Resident #1, notify the provider or the abuse coordinator when Resident #1, who was taking blood thinners and had a BIMS score of 15, presented with bruises all over her body, and began throwing herself on the floor, hitting herself on the head, yelling, and exhibiting erratic behaviors . 3. The facility failed to follow the care plan and notify the MD of changes in mental status, confusion, and agitation. 4. The facility failed to assist Resident #1 to transfer to the hospital on [DATE], before she called 911 and waited 27 minutes on the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-07-19 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to inform the resident's Physician or Nurse Practitioner when there was a need to alter treatment significantly for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1's scheduled medications were acquired and administered. Resident #1 was not given ceftriaxone (antibiotic used to treat bacterial infections) for a total of 4 times within the dates of 07/09/2024 to 07/11/2024, staff did follow up with the pharmacy for the antibiotics, staff did not communicate with the NP of the lack of antibiotics and missed medications, and staff did not communicate the missed doses to the administration. This failure resulted in the Resident #1's being sent to the hospital to have consistent antibiotic treatment, and to treat Bacteremia (bacteria in the blood stream) and ventriculitis (inflammation of the ventricles in the brain). An IJ was identified on 07/18/2024. The IJ Template was provided to the facility on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-07-19 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide pharmaceutical services, including accurate acquiring, and administering of all drugs and biologicals to meet the needs for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1's scheduled medications were acquired and administered. Resident #1 was not given ceftriaxone (antibiotic used to treat bacterial infections) for a total of 4 times within the dates of 07/09/2024 to 07/11/2024, staff did follow up with the pharmacy for the antibiotics, staff did not communicate with the NP of the lack of antibiotics and missed medications, and staff did not communicate the missed doses to the administration. This failure resulted in the Resident #1's being sent to the hospital to have consistent antibiotic treatment, and to treat Bacteremia (bacteria in the blood stream) and ventriculitis (inflammation of the ventricles in the brain). An IJ was identified on 07/18/2024. The IJ Template was provided to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-07-19 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a resident was free of any significant medication errors for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1's scheduled medications were acquired and administered. Resident #1 was not given ceftriaxone (antibiotic used to treat bacterial infections) for a total of 4 times within the dates of 07/09/2024 to 07/11/2024, staff did follow up with the pharmacy for the antibiotics, staff did not communicate with the NP of the lack of antibiotics and missed medications, and staff did not communicate the missed doses to the administration. This failure resulted in the Resident #1's being sent to the hospital to have consistent antibiotic treatment, and to treat Bacteremia (bacteria in the blood stream) and ventriculitis (inflammation of the ventricles in the brain). An IJ was identified on 07/18/2024. The IJ Template was provided to the facility on [DATE] at 06:35 p.m. While the IJ was removed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-09-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of three residents reviewed for foley catheter care. The facility failed to monitor/document Resident #1's (who has a history of urine retention) urine output for three days (09/11/24 - 09/13/24). On 09/14/24 an I/O catheter removed 700 CCs of urine and he was sent out to the hospital the following day due to swelling to his groin, the foley not draining, and his urine being cloudy with clots of pus. This failure could place residents at risk of UTIs, urine retention, bladder rupture, or hospitalization. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including urinary tract infection, severe sepsis (a serious condition in which the body responds improperly to an infection),…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-01-28 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents (Resident #3) reviewed for medication errors. The facility failed to ensure nursing staff administered Resident #3's medication at the scheduled time. These failures could place all 3 residents at risk of their medications not being administered according to Physician's orders, getting their medications late, or not receiving the intended therapeutic benefits of their medications.Findings included: Record review of Resident #3's order summary report indicated Resident #3 had an order for Carbidopa-Levodopa Oral Tablet Disintegrating 25-100 MG. Give 1.5 tablet by mouth every 8 hours for Parkinson's. Please give at scheduled time. Notify provider if unable to give at scheduled time with start date 01/06/2026. Record review of Resident #3's Medication Administration Record, dated 01/01/2026-01/31/2026, indicated the following scheduled time for administration of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-28 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that each resident has the right to secure and confidential personal and clinical records for 2 of 23 residents (Resident #1 and Resident #2) on Kindle Unit of the facility reviewed for Privacy and Confidentiality. The facility failed to ensure Resident #2's clinical records were protected from being viewed by unauthorized persons when the CNA left Resident #2's personal information visible on the computer's screen at unattended charting station on Kindle Unit. The facility failed to ensure Resident #1's clinical records were protected from being viewed by unauthorized persons when the RN left Resident #1's personal information visible on the computer's screen on unattended NC on Kindle Unit. This failure could result in residents' personal information being exposed to unauthorized individuals. The findings included: Observation on 1/28/2026 at 9:09 a.m. revealed that the computer screen on the CNA's charting station on Kindle Unit…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-01-15 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a resident or family group with private space for 1 of 1 resident council meetings reviewed for resident rightsThe facility failed to provide a private space for residents to meet during resident council meetings, exposing residents to loss of privacy.This failure could affect place residents by placing them at risk for loss of privacy and dignity. the Findings included:Record review of previous Resident Council Meetings Minutes, dated 10/23/2025,11/20/2025, 11/23/2025 revealed that Resident council meetings were regularly held in the facilities dining room.During an interview on 01/13/2026 at 10:00 AM revealed AD F had been trained in Resident Rights and in Abuse, Neglect, and Exploitation. AD F stated, Per the State of Texas Constitution, residents will not be denied their rights and residents should be able to make choices. AD F stated the topics previously addressed in past resident council meetings included: Protecting and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-01-15 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 5 of 8 residents (Resident #31, Resident #57, Resident #76, Resident #93, and Resident #94) reviewed for quality of life.1. The facility failed to ensure Resident #57, Resident #76, Resident #93, and Resident #94 received regular showers.2. The facility failed to ensure Resident #31, and Resident #94 were offered to have their facial hair removed.These failures placed residents at risk of having poor hygiene.Findings included:1. A record review of Resident #31's face sheet dated 1/14/2026 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of congestive heart failure (end-stage heart disease), atrial fibrillation (abnormal heartbeat), chronic kidney disease, anxiety disorder, need for assistance with personal care, hypothyroidism (underactive thyroid),…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-01-15 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to prepare and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen and food sanitation.1. The facility failed to ensure the [NAME] used proper hand sanitation while preparing pureed foods. 2. The facility failed to ensure the DA D used proper hand sanitation prior to distributing food to residents' rooms. These failures could place residents, who receive food from the kitchen, at risk for food contamination and foodborne illness.Findings Included:An observation and interview on 01/13/2026 at 11:25 a.m., revealed the [NAME] cleaned and disinfected the robot coup blender after finishing a puree of Tamale pie. The [NAME] failed to wash her hands before putting clean gloves on. [NAME] completed a puree of refried beans, removed her gloves, and cleaned and sanitized the robot coup. [NAME] did not wash her hands between cleaning of robot coup and puree of rice. The [NAME] put gloves on and pureed rice and no handwashing after rice was pureed and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-01-15 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for reviewed for infection control.DA D did not sanitize his hands between each resident when passing meal trays for lunch. This failure could place the residents at risk of transmission of disease and infection.Findings included:Observation on 01/13/2026 at 12:50 PM of staff passing lunch trays to the resident rooms on the 100 Hall revealed DA D did not hand hygiene when leaving Resident #59's room. He took a tray from the cart to Resident #26's room, and no hand hygiene was conducted. DA D then returned to the cart and took a tray to Resident #38's room, and no hand hygiene was conducted. He returned to the cart and took a tray to Resident 67's room, and no hand hygiene was conducted. An interview on 01/13/2026 at 1:14 PM with DA D, who stated he had been trained to clean his hands…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 15 residents (Resident #22 and Resident #71) reviewed for resident rights. The facility failed to ensure Resident #22 and Resident #71's rooms were clean.This deficient practice could place residents at risk of feelings dissatisfaction.The findings were:Record review of Resident #22's face sheet, dated 01/14/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #22 had diagnoses which included embolism and thrombosis (blood clots in blood vessels), atrial fibrillation (abnormal heart rhythm), dementia (memory, thinking, difficulty), need for assistance with personal care, muscle weakness, history of falls and unsteadiness on feet. Record review of Resident #22's MDS assessment, dated 01/05/2026, revealed Resident #22 had a BIMS score of 13 which indicated intact cognitive responses. Record…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-15 · tag F0761 — failed to label and store drugs safely — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure drugs are stored properly and only authorized persons have access for 1 of 2 medication carts (TC #1) reviewed for pharmacy services.The facility failed to ensure TC #1 was locked, medications secured, and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings included:An initial walkthrough observation of the facility on 01/13/2026 at 09:01 a.m., revealed TC#1 was unlocked and unattended outside of a resident's room. A nurse was inside a resident's room with her back turned away from the treatment cart. The resident's door was cracked open about two inches. Residents were walking by the unlocked treatment cart. TC #1 contained residents prescribed creams. On top of the treatment cart was a bottle of wound cleaner solution and two packages of black foam wound dressings. One foam dressing was opened. LVN C came out of the room, introduced herself,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-08 · tag F0919 — failed to provide a working call system — isolated
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff through a communication system that relays the call directly to a staff member or a centralized staff work area from toilet facilities for 1 of 1 resident rooms. (Resident #10's room [ROOM NUMBER]) reviewed for call lights.The facility failed to ensure emergency call lights in Resident #10's room's bathroom were operable.This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.Findings include:Record review of Resident #10's face sheet dated 10/05/25 indicated Resident #10 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included low back pain, pain in the right leg, and age-related osteoporosis (bone disease that occurs because of the aging process). Record review of Resident #10's annual MDS assessment has not been completed yet. Resident #10 required total assistance with toileting, personal…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-05-03 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for one of four residents (Resident #1) reviewed for pharmaceutical services. The facility failed to ensure Resident #1 received her Furosemide (given to help treat fluid retention) on 04/06/25 at 7:00 AM and 04/11/24 at 5:00 pm, Spironolactone (used to treat high blood pressure) on 04/06/25 at 7:00 AM and 05/11/25 at 5:00 PM, alprazolam (used to treat anxiety disorders) on 04/11/25 at 5:00 PM and 04/12/25 at 5:00 PM, Metronidazole (used to treat infections) on 04/11/25 at 5:00 PM, and Midodrine HCl (used to treat low blood pressure) on 04/11/25, 04/14/25, 04/19/25 and 04/20/25 at 5:00 PM. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, which could result in worsening or…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$63,733 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $18,295 — penalty dated 2024-10-16
• $8,018 — penalty dated 2024-09-24
• $37,420 — penalty dated 2024-07-19
• Medicare payment denial — starting 2024-08-20 for 10 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to IGNITE MEDICAL RESORTS — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 54 rows in the source record cover these 30 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

12 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX