Cycle 1
Health 2024-06-06 · Fire 2024-06-06
20 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
El Paso, TX
Ignite Medical Resort El Paso, LLC
1-star overall rating with 2-star inspections with 20 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3421 Joe Battle Boulevard, El Paso, TX
(915) 599-5500
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ignite Medical Resorts
Operator or chain grouping
Approved since
2017-10-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 3 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
11,269
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.89
Baseline 23.54% · Performance 20.68% · Measure score 3.89 · Achievement 1.63 · Improvement 3.89
Healthcare-associated infections
0
Baseline 6.66% · Performance 9.10% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 53.73% · Performance 68.29% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.08
Baseline 3.38 hours · Performance 3.95 hours · Measure score 3.08 · Achievement 3.08 · Improvement 1.90
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.49% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 104 · Observed rate 16.35% · Lower 95% interval 9.14% |
| Discharge to community | 59.32% |
50.57%
8.8 pts better
|
No Different than the National Rate · Eligible stays 103 · Observed rate 49.51% · Lower 95% interval 49.21% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 9.76% |
95.27%
85.5 pts worse
|
Numerator 8 · Denominator 82 |
| Falls with major injury | 1.22% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 82 |
| Discharge self-care score | 65.31% |
53.69%
11.6 pts better
|
Numerator 32 · Denominator 49 |
| Discharge mobility score | 36.73% |
50.94%
14.2 pts worse
|
Numerator 18 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 1.22% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 82 · Adjusted rate 1.09% |
| Healthcare-associated infections requiring hospitalization | 9.1% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 14.81% · Lower 95% interval 5.47% |
| Staff COVID-19 vaccination coverage | 2.97% |
8.2%
5.2 pts worse
|
Numerator 3 · Denominator 101 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 111 · Denominator 111 |
| Discharge function score | 51.02% |
56.45%
5.4 pts worse
|
Numerator 25 · Denominator 49 |
| Transfer of health information to provider | 83.87% |
95.95%
12.1 pts worse
|
Numerator 26 · Denominator 31 |
| Transfer of health information to patient | 95.92% |
96.28%
0.4 pts worse
|
Numerator 47 · Denominator 49 |
| Resident COVID-19 vaccinations up to date | 20.41% |
25.2%
4.8 pts worse
|
Numerator 10 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
97.1%
1 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.2% |
2.7%
7.5 pts worse
|
11.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.2% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.8% |
18.9%
9.9 pts worse
|
19.6%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.7% |
10.8%
11.9 pts worse
|
16.7%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.8% |
16.1%
9.3 pts better
|
14.9%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.9% |
15.0%
5.9 pts worse
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 20.7% |
4.2%
16.5 pts worse
|
5.1%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.1% |
89.7%
20.6 pts worse
|
81.7%
12.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 66.0% · Q2 47.7% · Q3 68.8% · Q4 88.4% · 4Q avg 69.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
12.0%
0.6 pts worse
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 13.9% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.2% · Q3 1.1% · Q4 1.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.9% |
88.0%
37.1 pts worse
|
79.7%
28.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
25.9%
4.8 pts better
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 25.0% · Expected 28.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-14 · Fire 2023-04-14
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2022-02-16 · Fire 2022-02-16
11 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-01
F · Potential for more than minimal harm
2024-06-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-01
F · Potential for more than minimal harm
2023-04-14
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-14
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-14
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-14
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-14
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-14
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-08-01
C · Minimal harm
2023-04-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-10
F · Potential for more than minimal harm
2022-02-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-02-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-03-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Not marked corrected
D · Potential for more than minimal harm
2025-12-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Not marked corrected
D · Potential for more than minimal harm
2025-12-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
F · Potential for more than minimal harm
2025-12-04
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2026-01-19
E · Potential for more than minimal harm
2025-12-04
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2026-01-19
E · Potential for more than minimal harm
2025-12-04
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-19
E · Potential for more than minimal harm
2025-12-04
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2026-01-19
D · Potential for more than minimal harm
2025-12-04
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-01-19
C · Minimal harm
2025-12-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-01-19
D · Potential for more than minimal harm
2025-12-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-17
F · Potential for more than minimal harm
2025-03-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-03
D · Potential for more than minimal harm
2024-07-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-26
E · Potential for more than minimal harm
2024-06-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-06
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-06
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-03
E · Potential for more than minimal harm
2024-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-06-06
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-06-06
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-07-03
D · Potential for more than minimal harm
2023-09-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-04-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-10
E · Potential for more than minimal harm
2023-04-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-14
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-14
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-14
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-14
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-05-10
E · Potential for more than minimal harm
2022-02-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-02-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-02-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-02-16
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-02-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-02-16
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-02-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-02-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-02-16
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2022-03-10
Penalties and ownership
What sits behind the stars
Ownership
Ignite Medical Resort El Paso, LLC
5% Or Greater Direct Ownership Interest · Organization
Ab Investment Trust U/A/D 1/3/23
5% Or Greater Indirect Ownership Interest · Organization
Berger Fam Tr Ua 06252014
5% Or Greater Indirect Ownership Interest · Organization
Blue Pearl Financial LLC
5% Or Greater Indirect Ownership Interest · Organization
Carr, Barry
5% Or Greater Indirect Ownership Interest · Individual
Fields, Timothy
5% Or Greater Indirect Ownership Interest · Individual
Fields, Timothy
Operational/Managerial Control · Individual
Gold Pearl, LLC
5% Or Greater Indirect Ownership Interest · Organization
Ignite El Paso Jv, LLC
5% Or Greater Indirect Ownership Interest · Organization
Ignite Medical Resort El Paso, LLC
Operational/Managerial Control · Organization
Ignite Post Acute Solutions LLC
5% Or Greater Indirect Ownership Interest · Organization
Ignite Team Partners LLC
Operational/Managerial Control · Organization
Ignite-Villa Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Israel Family Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Israel Investment Tr
5% Or Greater Indirect Ownership Interest · Organization
Israel, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
Prestige Worldwide El Paso, LLC
5% Or Greater Indirect Ownership Interest · Organization
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#3
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