Cycle 1
Health 2024-11-07 · Fire 2024-11-07
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fort Worth, TX
Ignite Medical Resort Fort Worth, LLC
2-star overall rating with 1-star inspections with $155,085 in total fines with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
6301 Oakmont Blvd, Fort Worth, TX
(682) 312-8577
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ignite Medical Resorts
Operator or chain grouping
Approved since
2018-06-21
CMS approved date
Coverage
Medicare
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.01
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.44
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.54
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.99
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.46
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.44
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
3.08
CMS adjusted total nurse staffing hours
Case-mix index
1.77
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,296
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.99
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.20% · Performance 22.03% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.01% · Performance 9.99% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.23
Baseline 80.52% · Performance 54.17% · Measure score 4.23 · Achievement 2.33 · Improvement 4.23
Adjusted total nurse staffing
0.96
Baseline 4.73 hours · Performance 3.35 hours · Measure score 0.96 · Achievement 0.96 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.41% |
10.72%
2.7 pts worse
|
Worse than the National Rate · Eligible stays 415 · Observed rate 14.94% · Lower 95% interval 11.3% |
| Discharge to community | 66.35% |
50.57%
15.8 pts better
|
Better than the National Rate · Eligible stays 418 · Observed rate 59.57% · Lower 95% interval 60.8% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 75.69% |
95.27%
19.6 pts worse
|
Numerator 137 · Denominator 181 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 181 |
| Discharge self-care score | 70.64% |
53.69%
17 pts better
|
Numerator 77 · Denominator 109 |
| Discharge mobility score | 62.39% |
50.94%
11.5 pts better
|
Numerator 68 · Denominator 109 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 181 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.99% |
7.12%
2.9 pts worse
|
Worse than the National Rate · Eligible stays 234 · Observed rate 11.54% · Lower 95% interval 7.26% |
| Staff COVID-19 vaccination coverage | 86.76% |
8.2%
78.6 pts better
|
Numerator 118 · Denominator 136 |
| Staff flu vaccination coverage | 85.52% |
42%
43.5 pts better
|
Numerator 124 · Denominator 145 |
| Discharge function score | 66.06% |
56.45%
9.6 pts better
|
Numerator 72 · Denominator 109 |
| Transfer of health information to provider | 93.5% |
95.95%
2.5 pts worse
|
Numerator 115 · Denominator 123 |
| Transfer of health information to patient | 88.89% |
96.28%
7.4 pts worse
|
Numerator 48 · Denominator 54 |
| Resident COVID-19 vaccinations up to date | 6.25% |
25.2%
18.9 pts worse
|
Numerator 5 · Denominator 80 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
89.7%
5.2 pts better
|
81.7%
13.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 92.8% · Q3 97.7% · Q4 99.1% · 4Q avg 94.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
12.0%
3.9 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 9.2% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.1% |
1.5%
1.4 pts better
|
1.6%
1.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.6% |
88.0%
8.4 pts worse
|
79.7%
0.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.2% |
25.9%
3.3 pts worse
|
23.9%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 37.3% · Expected 30.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-18 · Fire 2023-09-18
16 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-07-14 · Fire 2022-07-14
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-15
F · Potential for more than minimal harm
2024-11-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-15
F · Potential for more than minimal harm
2024-11-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-15
E · Potential for more than minimal harm
2024-11-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-15
E · Potential for more than minimal harm
2024-11-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-15
F · Potential for more than minimal harm
2023-09-18
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-10-15
F · Potential for more than minimal harm
2023-09-18
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-10-15
F · Potential for more than minimal harm
2023-09-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-15
F · Potential for more than minimal harm
2023-09-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-15
F · Potential for more than minimal harm
2023-09-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-15
F · Potential for more than minimal harm
2023-09-18
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2023-10-15
E · Potential for more than minimal harm
2023-09-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-15
E · Potential for more than minimal harm
2023-09-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-09-18
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-09-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-15
F · Potential for more than minimal harm
2022-07-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-08-20
F · Potential for more than minimal harm
2022-07-14
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-08-20
F · Potential for more than minimal harm
2022-07-14
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2022-08-20
E · Potential for more than minimal harm
2022-07-14
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-08-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-08
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 2025-12-11
D · Potential for more than minimal harm
2025-12-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-11
D · Potential for more than minimal harm
2025-12-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-11
D · Potential for more than minimal harm
2025-07-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-25
J · Immediate jeopardy
2025-05-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-01
E · Potential for more than minimal harm
2025-05-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-31
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-31
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-02-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-28
E · Potential for more than minimal harm
2024-11-07
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 2024-12-15
D · Potential for more than minimal harm
2024-11-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-15
D · Potential for more than minimal harm
2024-11-07
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-12-15
G · Actual harm
2024-09-04
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-09-04
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-09-04
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-09-04
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 2024-09-30
D · Potential for more than minimal harm
2024-09-04
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 2024-09-30
D · Potential for more than minimal harm
2024-09-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-30
K · Immediate jeopardy
2024-06-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-08-02
E · Potential for more than minimal harm
2024-03-14
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 2024-04-15
J · Immediate jeopardy
2023-11-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-20
J · Immediate jeopardy
2023-11-02
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-11-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-11-02
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-01
G · Actual harm
2023-09-18
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-15
G · Actual harm
2023-09-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-15
G · Actual harm
2023-09-18
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-10-15
F · Potential for more than minimal harm
2023-09-18
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 2023-10-15
E · Potential for more than minimal harm
2023-09-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-15
E · Potential for more than minimal harm
2023-09-18
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-09-18
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-09-18
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-07-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-05-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-16
Penalties and ownership
What sits behind the stars
$19,115
2026-02-07
Fine
Fine · fine $19,115
Fine
$19,120
2025-05-31
Fine
Fine · fine $19,120
Fine
$0
2025-05-31
Payment Denial
Payment Denial · denial start 2025-06-28 · 27 days
27 day denial
$12,048
2024-09-04
Fine
Fine · fine $12,048
Fine
$80,760
2024-06-28
Fine
Fine · fine $80,760
Fine
$14,518
2023-10-24
Fine
Fine · fine $14,518
Fine
$9,524
2023-09-18
Fine
Fine · fine $9,524
Fine
Ownership
Fields, Timothy
5% Or Greater Indirect Ownership Interest · Individual
Carr, Barry
5% Or Greater Indirect Ownership Interest · Individual
Carr, Barry
Operational/Managerial Control · Individual
Carr, Jared
Operational/Managerial Control · Individual
Fields, Timothy
Operational/Managerial Control · Individual
Gillis, Karen
Operational/Managerial Control · Individual
Ignite Team Partners LLC
Operational/Managerial Control · Organization
Jablonski, Nicole
Operational/Managerial Control · Individual
Mcfarlane, John
Operational/Managerial Control · Individual
Niles, Richard
Operational/Managerial Control · Individual
Norris, John
Operational/Managerial Control · Individual
Rose, Marc
Operational/Managerial Control · Individual
Shearer, Rachel
Operational/Managerial Control · Individual
Spark Therapy LLC
Operational/Managerial Control · Organization
Thengil, Mathew
Operational/Managerial Control · Individual
White, Jim
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Wedgewood Nursing Home
Fort Worth, TX
2-star overall rating with 1-star inspections with $31,778 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Cityview Nursing and Rehabilitation Center
Fort Worth, TX
2-star overall rating with 1-star inspections with abuse icon flag with $234,014 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Garden Terrace Healthcare Center Of Fort Worth
Fort Worth, TX
3-star overall rating with 2-star inspections with $34,405 in total fines with 7 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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