Austin, TX

Ignite Medical Resort Round Rock, LLC

2-star overall rating with 1-star inspections with $84,696 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

16219 Ranch Road 620 North, Austin, TX

(512) 520-1834

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

3 / 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

2018-02-21

CMS approved date

Coverage

Medicare

Participation flags

Chain footprint

22 facilities

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

Changed ownership

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

1.00

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.52

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.89

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

4.41

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

2.52

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.87

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.56

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.24

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.88

CMS adjusted RN staffing hours

Adjusted total hours

3.87

CMS adjusted total nurse staffing hours

Case-mix index

1.56

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

68%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,509

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

Performance score

11.89

Composite VBP score used to determine payment impact.

Payment multiplier

0.9810

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 21.35% · Performance 23.50% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 5.33% · Performance 8.25% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

3.56

Baseline 90.36% · Performance 63.77% · Measure score 3.56 · Achievement 0 · Improvement 3.56

Adjusted total nurse staffing

1.20

Baseline 5.07 hours · Performance 3.42 hours · Measure score 1.20 · Achievement 1.20 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.88%	10.72% 1.2 pts worse	No Different than the National Rate · Eligible stays 315 · Observed rate 12.38% · Lower 95% interval 9.21%
Discharge to community	62.61%	50.57% 12 pts better	Better than the National Rate · Eligible stays 328 · Observed rate 57.32% · Lower 95% interval 57.73%
Medicare spending per beneficiary	1.02	1.02 About the same
Drug regimen review with follow-up	99.47%	95.27% 4.2 pts better	Numerator 187 · Denominator 188
Falls with major injury	1.06%	0.77% 0.3 pts worse	Numerator 2 · Denominator 188
Discharge self-care score	72.48%	53.69% 18.8 pts better	Numerator 79 · Denominator 109
Discharge mobility score	55.96%	50.94% 5 pts better	Numerator 61 · Denominator 109
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 188 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	8.25%	7.12% 1.1 pts worse	No Different than the National Rate · Eligible stays 183 · Observed rate 9.84% · Lower 95% interval 5.78%
Staff COVID-19 vaccination coverage	100%	8.2% 91.8 pts better	Numerator 97 · Denominator 97
Staff flu vaccination coverage	37.17%	42% 4.8 pts worse	Numerator 42 · Denominator 113
Discharge function score	75.23%	56.45% 18.8 pts better	Numerator 82 · Denominator 109
Transfer of health information to provider	98.61%	95.95% 2.7 pts better	Numerator 71 · Denominator 72
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 100 · Denominator 100
Resident COVID-19 vaccinations up to date	31.58%	25.2% 6.4 pts better	Numerator 30 · Denominator 95

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	77.7%	89.7% 12 pts worse	81.7% 4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 69.4% · Q2 67.1% · Q3 81.4% · Q4 92.5% · 4Q avg 77.7%
Percentage of short-stay residents who had an outpatient emergency department visit	9.3%	12.0% 2.7 pts better	12.0% 2.7 pts better	Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 11.1% · Expected 13.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.0%	1.5% 0.5 pts better	1.6% 0.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.1% · Q3 1.3% · Q4 0.8% · 4Q avg 1.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	54.0%	88.0% 34 pts worse	79.7% 25.7 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 54.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.5%	25.9% 2.4 pts better	23.9% 0.4 pts better	Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 33.3% · Expected 33.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-16 · Fire 2024-10-16

9 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2023-08-25 · Fire 2023-08-25

21 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2022-06-09 · Fire 2022-06-09

17 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

5 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-10-16

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Corrected 2025-03-24

F · Potential for more than minimal harm 2023-08-25

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-09-25

E · Potential for more than minimal harm 2023-08-25

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-09-25

F · Potential for more than minimal harm 2022-06-09

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2022-07-08

F · Potential for more than minimal harm 2022-06-09

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2022-07-08

E · Potential for more than minimal harm 2022-06-09

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-07-08

E · Potential for more than minimal harm 2022-06-09

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-09

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 2022-07-08

Inspection history

Recent health citations

E · Potential for more than minimal harm 2026-01-28

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Not marked corrected

D · Potential for more than minimal harm 2026-01-28

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Not marked corrected

D · Potential for more than minimal harm 2025-12-08

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2025-12-09

E · Potential for more than minimal harm 2025-05-03

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 2025-06-03

D · Potential for more than minimal harm 2025-01-29

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 2025-01-28

E · Potential for more than minimal harm 2025-01-15

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-01-31

J · Immediate jeopardy 2024-11-14

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 2024-12-12

J · Immediate jeopardy 2024-11-14

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-12-12

E · Potential for more than minimal harm 2024-11-14

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-12-12

E · Potential for more than minimal harm 2024-11-14

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 2024-12-12

E · Potential for more than minimal harm 2024-11-14

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-12

F · Potential for more than minimal harm 2024-10-16

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 2024-11-20

E · Potential for more than minimal harm 2024-10-16

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2024-11-20

D · Potential for more than minimal harm 2024-10-16

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 2024-11-20

D · Potential for more than minimal harm 2024-10-16

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 2024-11-20

D · Potential for more than minimal harm 2024-10-16

F926 · Environmental Deficiencies

Health

Have policies on smoking.

Corrected 2024-11-20

G · Actual harm 2024-09-24

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 2024-10-13

E · Potential for more than minimal harm 2024-09-24

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 2024-10-13

D · Potential for more than minimal harm 2024-07-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-15

J · Immediate jeopardy 2024-07-19

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 2024-08-30

J · Immediate jeopardy 2024-07-19

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 2024-08-30

J · Immediate jeopardy 2024-07-19

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-08-30

E · Potential for more than minimal harm 2023-11-03

F660 · Resident Assessment and Care Planning Deficiencies

Health

Plan the resident's discharge to meet the resident's goals and needs.

Corrected 2023-12-08

F · Potential for more than minimal harm 2023-08-25

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 2023-09-28

E · Potential for more than minimal harm 2023-08-25

F941 · Administration Deficiencies

Health

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Corrected 2023-09-28

E · Potential for more than minimal harm 2023-08-25

F942 · Resident Rights Deficiencies

Health

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Corrected 2023-09-28

E · Potential for more than minimal harm 2023-08-25

F944 · Administration Deficiencies

Health

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Corrected 2023-09-28

E · Potential for more than minimal harm 2023-08-25

F946 · Administration Deficiencies

Health

Provide training in compliance and ethics.

Corrected 2023-09-28

E · Potential for more than minimal harm 2023-08-25

F949 · Administration Deficiencies

Health

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Corrected 2023-09-28

D · Potential for more than minimal harm 2023-08-25

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-09-28

C · Minimal harm 2023-08-25

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2023-09-28

J · Immediate jeopardy 2023-07-11

F742 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected 2023-08-07

E · Potential for more than minimal harm 2023-07-11

F837 · Administration Deficiencies

Health

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Corrected 2023-08-07

D · Potential for more than minimal harm 2023-07-11

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 2023-08-07

E · Potential for more than minimal harm 2023-03-13

F694 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-04-07

E · Potential for more than minimal harm 2022-06-09

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 2022-07-08

E · Potential for more than minimal harm 2022-06-09

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2022-07-08

E · Potential for more than minimal harm 2022-06-09

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 2022-07-08

E · Potential for more than minimal harm 2022-06-09

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2022-07-08

E · Potential for more than minimal harm 2022-06-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-09

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 2022-07-08

D · Potential for more than minimal harm 2022-06-09

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-09

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-09

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 2022-07-08

D · Potential for more than minimal harm 2022-06-09

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-09

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-09

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 2022-07-08

Penalties and ownership

What sits behind the stars

$18,295 2024-10-16

Fine

Fine · fine $18,295

Fine

$8,018 2024-09-24

Fine

Fine · fine $8,018

Fine

$37,420 2024-07-19

Fine

Fine · fine $37,420

Fine

$0 2024-07-19

Payment Denial

Payment Denial · denial start 2024-08-20 · 10 days

10 day denial

$20,963 2023-07-11

Fine

Fine · fine $20,963

Fine

Ownership

Fields, Timothy

5% Or Greater Indirect Ownership Interest · Individual

21% 22 facilities 2022-04-01

Carr, Barry

5% Or Greater Indirect Ownership Interest · Individual

17% 22 facilities 2022-04-01

Carr, Barry