Katy, TX

Ignite Medical Resort Katy, LLC

4-star overall rating with 3-star inspections with $51,914 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

1222 Park West Green Drive, Katy, TX

(346) 762-6300

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 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

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Ignite Medical Resorts

Operator or chain grouping

Approved since

2018-09-13

CMS approved date

Coverage

Medicare

Participation flags

Chain footprint

22 facilities

Chain averages 3 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

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

0.70

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.25

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.39

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

4.35

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.95

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

4.15

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.64

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.16

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.54

CMS adjusted RN staffing hours

Adjusted total hours

3.32

CMS adjusted total nurse staffing hours

Case-mix index

1.79

Higher values indicate more complex resident acuity

RN turnover

57%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

75%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,036

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

46.3

Composite VBP score used to determine payment impact.

Payment multiplier

0.9997

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.97

Baseline 26.99% · Performance 21.54% · Measure score 4.97 · Achievement 0 · Improvement 4.97

Healthcare-associated infections

Baseline 5.87% · Performance 4.41% · Measure score 10 · Achievement 10 · Improvement 9

Total nurse turnover

Baseline 63.64% · Performance 76.19% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

3.55

Baseline 3.30 hours · Performance 4.09 hours · Measure score 3.55 · Achievement 3.55 · Improvement 2.68

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.07%	10.72% 1.3 pts worse	No Different than the National Rate · Eligible stays 302 · Observed rate 13.25% · Lower 95% interval 9.27%
Discharge to community	61.91%	50.57% 11.3 pts better	Better than the National Rate · Eligible stays 301 · Observed rate 53.49% · Lower 95% interval 55.54%
Medicare spending per beneficiary	0.93	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 278 · Denominator 278
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 278
Discharge self-care score	68.5%	53.69% 14.8 pts better	Numerator 137 · Denominator 200
Discharge mobility score	65.5%	50.94% 14.6 pts better	Numerator 131 · Denominator 200
Pressure ulcers or injuries, new or worsened	0.72%	2.29% 1.6 pts better	Numerator 2 · Denominator 278 · Adjusted rate 0.51%
Healthcare-associated infections requiring hospitalization	4.41%	7.12% 2.7 pts better	Better than the National Rate · Eligible stays 200 · Observed rate 2% · Lower 95% interval 2.84%
Staff COVID-19 vaccination coverage	100%	8.2% 91.8 pts better	Numerator 123 · Denominator 123
Staff flu vaccination coverage	100%	42% 58 pts better	Numerator 123 · Denominator 123
Discharge function score	75%	56.45% 18.5 pts better	Numerator 150 · Denominator 200
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 86 · Denominator 86
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 185 · Denominator 185
Resident COVID-19 vaccinations up to date	0%	25.2% 25.2 pts worse	Numerator 0 · Denominator 148

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	88.2%	89.7% 1.5 pts worse	81.7% 6.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 72.9% · Q2 97.7% · Q3 91.9% · Q4 89.3% · 4Q avg 88.2%
Percentage of short-stay residents who had an outpatient emergency department visit	6.8%	12.0% 5.2 pts better	12.0% 5.2 pts better	Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 6.5% · Expected 10.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.3%	1.5% 1.2 pts better	1.6% 1.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.3% · Q3 0.6% · Q4 0.3% · 4Q avg 0.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	86.5%	88.0% 1.5 pts worse	79.7% 6.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 86.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.1%	25.9% 0.8 pts better	23.9% 1.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 27.6% · Expected 26.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-08 · Fire 2025-05-08

10 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2024-03-22 · Fire 2024-03-22

11 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Services (2 deficiencies)

Cycle 3 Health 2023-02-02 · Fire 2023-02-02

3 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

4 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-05-08

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-05-30

F · Potential for more than minimal harm 2024-03-22

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-04-19

F · Potential for more than minimal harm 2024-03-22

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-04-19

E · Potential for more than minimal harm 2024-03-22

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-04-19

F · Potential for more than minimal harm 2023-02-02

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-02-03

F · Potential for more than minimal harm 2023-02-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-02-27

E · Potential for more than minimal harm 2023-02-02

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-02-01

E · Potential for more than minimal harm 2023-02-02

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-02-06

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-21

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 2026-02-02

D · Potential for more than minimal harm 2025-12-01

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2026-01-20

D · Potential for more than minimal harm 2025-11-12

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 2025-12-12

D · Potential for more than minimal harm 2025-11-12

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-12-12

E · Potential for more than minimal harm 2025-05-08

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-05-30

D · Potential for more than minimal harm 2025-05-08

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 2025-05-30

D · Potential for more than minimal harm 2025-05-08

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-05-30

D · Potential for more than minimal harm 2025-05-08

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 2025-05-30

D · Potential for more than minimal harm 2025-05-08

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 2025-05-30

D · Potential for more than minimal harm 2025-05-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-30

H · Actual harm 2024-09-11

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2024-10-09

H · Actual harm 2024-09-11

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 2024-10-09

D · Potential for more than minimal harm 2024-09-11

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 2024-10-09

D · Potential for more than minimal harm 2024-09-11

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 2024-10-09

D · Potential for more than minimal harm 2024-09-11

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 2024-10-09

D · Potential for more than minimal harm 2024-09-11

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-09

E · Potential for more than minimal harm 2024-03-22

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2024-04-19

E · Potential for more than minimal harm 2024-03-22

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 2024-04-19

E · Potential for more than minimal harm 2024-03-22

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-04-19

D · Potential for more than minimal harm 2024-03-22

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-04-19

D · Potential for more than minimal harm 2024-03-22

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 2024-04-19

E · Potential for more than minimal harm 2023-02-02

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 2023-02-28

E · Potential for more than minimal harm 2023-02-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-03-01

D · Potential for more than minimal harm 2023-02-02

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 2023-02-28

Penalties and ownership

What sits behind the stars

$35,490 2024-09-11

Fine

Fine · fine $35,490

Fine

$3,387 2024-02-20

Fine

Fine · fine $3,387

Fine

$3,011 2024-02-12

Fine

Fine · fine $3,011

Fine

$6,774 2024-01-22

Fine

Fine · fine $6,774

Fine

$3,252 2023-12-26

Fine

Fine · fine $3,252

Fine

Ownership

Fields, Timothy

5% Or Greater Indirect Ownership Interest · Individual

21% 22 facilities 2025-02-01

Carr, Barry

5% Or Greater Indirect Ownership Interest · Individual

17% 22 facilities 2025-02-01

Ali, Nida