Ignite Medical Resort Fort Worth, 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.

66.3% 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 418 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 75.8% 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 91 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 1.05 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 9% 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 48.2 residents a day — about 69% occupied, or roughly 22 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.36 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.93 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 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 3.90 hrs/resident/day on weekends vs 4.54 on weekdays — 14% thinner on weekends. RN hours go from 1.06 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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.

43 citations, most serious first. The 19 most serious are shown; the remaining 24 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-05-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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, interviews, and record reviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for pressure ulcers, in that: 1. The facility failed to provide preventive care, consistent with professional standards of practice, to Resident#1 who was at risk for pressure injury development. On 04/24/25, Resident #1's admission progress note revealed skin integrity concerns that included, Resident #1 had redness to bilateral heels, Eschar (a hardened, dry, black, or brown dead tissue that forms a scab-like covering over deep wounds) to the left big toe, redness to the groin area, and redness to the buttock and coccyx (tailbone) area. 2. The facility failed to consult the Wound Medical Doctor (WMD) or implement additional pressure relieving devices for Resident #1 to prevent skin…

  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 · Kcited before2024-06-28 · tag F0697 — failed to manage pain — pattern
  Provide safe, appropriate pain management for a resident who requires such services.
  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 pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 9 residents (Resident #1, #2, and #3) reviewed for pain management. 1. The facility failed to provide medication oxycodone Oral tablet 10 MG per doctor's order for Resident #1 on 6-5-2024 after Resident #1 complained of continued pain and requested medication. Resident #1 admitted to the facility on [DATE] at 3:30 PM and only received Acetaminophen Capsule 500 MG for pain at 11:55 PM. Resident #1 did not receive oxycodone oral tablet 10 MG until 6-6-2024 at 1:20 AM, at which time Resident #1's pain level was at an 8. 2. The facility failed to provide effective medication for Resident #2 who admitted to the facility on [DATE] and received Tramadol oral tablet 50 MG per order starting on 5-13-2024 at 8:56 PM and Oxycodone…

  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 · J2023-11-02 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  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 residents had the right to be free from abuse and neglect for 2 of 5 residents reviewed (Resident # 7's and Resident # 26) for abuse and neglect. The facility failed to: 1. Respond and assist Resident #7 after a fall and constantly yelling out for help on 10/27/23. The resident was found by EMT, lying in feces and with partially dried blood to laceration on her head requiring 10 sutures. LVN F ignored the pleas for help according to the EMT. Resident #26 had to call 911 and guided the EMTs to Resident #7's room. 2. (Non IJ in IJ) Provide Resident #26 ostomy care during shift on 10/31/23 leaving the bag soiled that was connected due to him emptying independently. According to the EMT, on 10/27/23, they observed Resident #26 with a heavily soiled ostomy bag that was leaking. An Immediate Jeopardy (IJ) was identified on 11/01/23. The IJ template was provided to the facility on [DATE] at 4:30 PM. While the IJ was removed on 11/02/23, 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-11-02 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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 implement written policies and procedures that prohibit and prevent abuse and neglect establish policies and procedures to investigate any such allegations for 2 (Resident 7 and Resident #26) of 5 residents reviewed for abuse and neglect in that: The facility failed to implement their abuse and neglect policy because Resident #7 and #26 were not free from abuse/neglect and failed to: 1. Respond and assist Resident #7 after a fall and constantly yelling out for help. on 10/27/23. The resident was found by EMT, lying in feces and with partially dried blood to laceration on her head requiring 10 sutures. LVN F ignored the pleas for help according to the EMT. Resident #26 had to call 911 and guided the EMTs to Resident #7's room. 2. (Non IJ in IJ) Provide Resident #26 ostomy care during shift on 10/31/23 leaving the bag soiled that was connected due to him emptying independently. According to the EMT Resident #26 on 10/27/23 observed Resident…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2026-02-07 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  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 required dialysis received such services, consistent with professional standards of practice for 1 (Resident #1) of 1 resident reviewed peritoneal dialysis.The facility failed to ensure nursing staff received training to administer, monitor and intervene for Resident #1 who required PD (During peritoneal dialysis, a cleansing fluid flows through a tube into part of the stomach area, also called the abdomen. The inner lining of the abdomen, known as the peritoneum, acts as a filter and removes wastes from blood. After a set amount of time, the fluid with the filtered waste flows out of the abdomen and is thrown away). Resident #1 was admitted to the hospital with peritonitis (bacteria into the peritoneum).The facility failed to ensure Resident #1 had dialysis supplies available on 01/25/26 and 01/26/26 to perform PD. Resident #1 was not dialyzed on 01/25/26 and 01/26/26 because she did not have supplies (cycler) available. This…

  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
• Actual harm · Gcited before2024-09-04 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  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 review, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of six residents (Resident #1) reviewed for pain management. The facility failed to administer Resident #1's pain medication Acetaminophen 1000 mg and/or Tramadol 100 mg for pain before wound care. This failure could place residents at risk for increased pain due to not having their pain medication when it was available. Findings included: Resident #1 Review of Resident #1's admission record dated 09/04/2024, revealed a [AGE] year-old male who was readmitted to the facility on [DATE] with an initial admission date of 08/20/2024 . His diagnoses included abscess of the liver (this is a mass in the liver filled with pus), Type 2 diabetes mellitus (uncontrolled blood sugar), Parkinsonism (a progressive nervous system…

  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
• Actual harm · G2023-09-18 · 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 interview, and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was an accident involving the resident which results in injury and has the potential for requiring physician intervention for one of 16 residents (Resident #50) reviewed for physician notification. 1. The facility failed to notify the physician of Resident #50's fall with acute hip fracture. The failure could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. Findings included : Record review of face sheet dated 8/24/23 revealed Resident #50 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included orthostatic hypotension (low blood pressure when standing), age related physical debility with an admitting diagnosis of fracture of unspecified part of neck of right femur, subsequent encounter for closed…

  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
• Actual harm · Gcited before2023-09-18 · 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 interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of 16 residents (Resident #50) reviewed for quality of care. The facility failed to notify the physician of Resident #50's fall with acute hip fracture and failed to follow-up on x-ray results which would require physician intervention or timely transport to the hospital. The failure could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. Findings included : Record review of face sheet dated 8/24/23 revealed Resident #50 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included orthostatic hypotension (low blood pressure when standing), age related physical debility with an admitting diagnosis of fracture 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-09-18 · tag F0777 — isolated
  Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
  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 promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for one of 16 residents (Resident ##50) reviewed for x-ray results. The facility failed to follow-up on x-ray results for Resident #50 which indicated an acute hip fracture, preventing the resident from being sent out timely to the hospital. The failure could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. Findings included: Record review of face sheet dated 8/24/23 revealed Resident #50 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included orthostatic hypotension (low blood pressure when standing), age related physical debility with an admitting diagnosis of fracture 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-02-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
  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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen in that: The facility failed to ensure food items, placed in the refrigerator, were sealed, dated, and labeled appropriately.The facility failed to ensure food items, placed in the dry storage area, were sealed and kept off the floor. These failures could place residents at risk for food-borne illnesses. Findings included: In an observation on 2-10-2026 at 8:22 AM, revealed the facility's only walk-in refrigerator had a box of lettuce opened, unsealed, scattered outside the box, and on the floor, a plastic container of potato salad, unlabeled and undated, and 11 plastic containers of chocolate pudding undated and unlabeled. The dry storage area had a pack of 17 Styrofoam cups unsealed on the floor, 1-96 oz plastic jar of amber honey, with a cracked lid, which leaked onto the floor, and an orange on the floor underneath the storage shelves. The reach-in refrigerator had a…

  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 · F2026-02-12 · tag F0814 — failed to dispose of garbage properly — widespread
  Dispose of garbage and refuse properly.
  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 keep garbage storage receptacles in a sanitary condition according to professional standards: 1. The facility failed to keep the outside garbage storage area clean.2. The facility failed to ensure garbage receptacles in the kitchen had lids on them, when trash was in the containers, not being used. These failures could place residents at risk of attracting rodents, insects, and contracting food-borne illnesses.Findings included: In an observation on 2-10-2026 at 8:25 AM, revealed the facility's only kitchen was observed having a large trash can, with a liner containing trash, open and unsealed. A smaller closed trash can, next to the handwashing sink, was observed to have an open-box full of trash on top of it. A third smaller trash can was observed with the lid propped up containing trash. On 2-10-2026 at 8:30 AM, an observation was made of the facility's only outside trash dumpster area. The trash dumpster was full, had two sliding doors that were open, and trash bags hanging outside the doors. Various…

  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 before2026-02-12 · tag F0761 — failed to label and store drugs safely — pattern
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of four medication carts (Med Cart A), One of two treatment carts (Treatment cart B) and 1 of 7 residents (Resident #94) reviewed for medication storage. 1.The facility failed to ensure Nurses Treatment Cart B was not left unlocked and unattended in the corridor by room [ROOM NUMBER] on 02/10/26. 2. LVN G failed to ensure the medication cart (Med Cart B) was not left unlocked and did not have a cup of medication left on top of the cart while out of view. 3. LVN G failed to ensure medications were not left at Resident #94's bedside while she was out of the resident's room. These failures could place residents at risk of lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications Findings…

  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 · E2026-02-12 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  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 each resident received, and the facility provided food that was palatable and attractive, for five of twenty-four residents (Residents #81, #83, #88, #93, and #95) reviewed for food and nutrition services. The facility failed to provide attractive and palatable regular diet items for the main and alternate regular diet meals for lunch on 02/11/26. This failure could place residents at risk for not enjoying meals and experiencing weight loss. Findings include: 1. Review of Resident #81's admission record, dated 02/12/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #81 had diagnoses which included infection and inflammatory reaction due to internal right knee (knee infection surgery became infected), protein-calorie malnutrition (lack of sufficient intake of protein and/or calories, which can interfere with muscle healing, and make the body more vulnerable to infection), type 2 diabetes (a type…

  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 · D2026-02-12 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  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 the resident had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options to choose the alternative or option he or she preferred for one of three residents (Resident #101) reviewed for consent to receive psychotropic medications. The facility failed to obtain a written consent form for Resident #101 before starting the medications alprazolam (for treating anxiety), bupropion (for treating depression), hydrocodone-acetaminophen (an opiate pain killer), and zolpidem tartrate (to aid in sleeping). This failure could place residents at risk of being unable to exercise their rights to make informed decisions regarding their treatment.Findings include: Review of Resident #101's admission record, dated 02/12/26, reflected a [AGE]…

  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 · D2026-02-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each 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 observation, interview, and record review, the facility failed to ensure the resident received reasonable accommodation of needs and preferences, for 1 of 17 Residents (Resident #62) reviewed for accommodations of needs. The facility failed to ensure Resident #62 had a call light within her reach. This failure could place residents at risk of not getting their needs met and diminishing their quality of life.Findings included: A record review of Resident #62's face sheet dated 2-10-2026 revealed a [AGE] year-old female who re-admitted to the facility on [DATE] with a primary diagnosis of encounter for orthopedic aftercare following surgical amputation and secondary diagnoses of absence of right leg above knee, sepsis (a life-threatening medical emergency occurring when the body's immune system overreacts to an infection, causing widespread inflammation, tissue damage, and organ failure), type 2 diabetes mellitus(disorder where the body develops insulin resistance and cannot use insulin properly), 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 · Dcited before2026-02-12 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  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 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 two of six residents (Residents #8 and #81) reviewed for infection control. 1. The facility failed to ensure LVN E wore a gown for EBP before accessing an indwelling catheter (foley) to collect urine from Resident #8 on 02/10/26. 2.The facility failed to ensure LVN D wore a gown for EBP before accessing Resident #81's Central Venous Catheter (this is a flexible tube inserted in the vein for intravenous medication therapy) IV to administer intravenous antibiotics on 02/11/26. These failures could place residents at risk of Multidrug-resistant Organisms infections. Findings included:1. Record review of Resident #8's admission record, dated 02/12/26, reflected an [AGE] year-old female with an initial admission 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-12-08 · tag F0761 — failed to label and store drugs safely — pattern
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with state and federal laws in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 Residents reviewed for medication storage. LVN-C failed to ensure Resident #1's PICC line medication was secured in a locked compartment. This failure could place residents at risk for consuming or tampering with medications that could result in adverse medication reactions.Record review of Resident #1's face sheet dated 10/23/2025, reflected he was an [AGE] year-old male that was admitted on [DATE] with diagnosis including: infection and inflammatory reaction due to internal left knee prothesis, subsequent encounter (infection of other causes). Record review of Resident #1's quarterly MDS Assessment, dated 10/09/2025, reflected the resident BIMS score was 15 indicating his cognition was in-tact. Resident #1's ADL functioning…

  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 F0641 — isolated
  Ensure each resident receives an accurate assessment.
  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 the assessment accurately reflected the resident's status for 3 (Resident #1, Resident #9, and Resident #22) of 4 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1, Resident #9, and Resident #22 MDS were coded for BiPAP/CPAP treatments.The facility staff failed to ensure that Resident #9 was coded for a PICC line per MD orders. This failure could place residents at risk of receiving the incorrect care and treatments. During an observation and interview with Resident # 1 on 10/23/2025 at 1:15 PM his BIPAP/CPAP mask was on the floor on the left side of his bag. Resident #1 stated that he used the mask at night. Resident#1 said while he was s patient at the facility, he has not observed staff cleaning or bagging his CPAP mask. He does receive treatments from the machine at night. Resident #1 stated that he could not move or stand, due to surgery on his knee, and he could not have put the mask on the floor.…

  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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  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 needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 4 of 10 (Resident #1, Resident #9, Resident #14, and Resident #22) residents reviewed for respiratory care. The facility failed to ensure:Resident #1's, Resident #9's, and Resident #22's BiPAP/CPAP mask were stored properly when it was not in use, per facility protocol for sanitation. Resident #14's NC (a medical device that delivers supplemental oxygen through a flexible tube with two prongs that rest in the nostrils.) was discarded properly when changed, and dating the new NC tubing was installed.These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. Resident #1 During an observation and interview with Resident…

  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

“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

$141,703 in federal fines across 6 penalties.

• $12,425 — penalty dated 2026-02-07
• $12,428 — penalty dated 2025-05-31
• $12,048 — penalty dated 2024-09-04
• $80,760 — penalty dated 2024-06-28
• $14,518 — penalty dated 2023-10-24
• $9,524 — penalty dated 2023-09-18

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 $2.5M paid to related parties — landlords or management companies under common ownership — equal to about 19% 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