Cycle 1
Health 2025-12-08 · Fire 2025-12-08
20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
San Antonio, TX
Ignite Medical Resort San Antonio, LLC
3-star overall rating with 2-star inspections with 20 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
6035 Eckhert Rd, San Antonio, TX
(210) 642-5300
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
105
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ignite Medical Resorts
Operator or chain grouping
Approved since
2018-06-12
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
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
1.62
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.80
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.12
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.32
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
1.66
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,946
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.96
Composite VBP score used to determine payment impact.
Payment multiplier
0.9827
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.23
Baseline 23.92% · Performance 20.66% · Measure score 4.23 · Achievement 1.66 · Improvement 4.23
Healthcare-associated infections
0
Baseline 6.52% · Performance 7.70% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.56
Baseline 46.58% · Performance 45.05% · Measure score 4.56 · Achievement 4.56 · Improvement 0.20
Adjusted total nurse staffing
0
Baseline 4.30 hours · Performance 3.03 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.06% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 412 · Observed rate 12.38% · Lower 95% interval 9.59% |
| Discharge to community | 66.37% |
50.57%
15.8 pts better
|
Better than the National Rate · Eligible stays 452 · Observed rate 60.62% · Lower 95% interval 61.07% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.39% |
95.27%
2.1 pts better
|
Numerator 373 · Denominator 383 |
| Falls with major injury | 1.31% |
0.77%
0.5 pts worse
|
Numerator 5 · Denominator 383 |
| Discharge self-care score | 68% |
53.69%
14.3 pts better
|
Numerator 170 · Denominator 250 |
| Discharge mobility score | 57.2% |
50.94%
6.3 pts better
|
Numerator 143 · Denominator 250 |
| Pressure ulcers or injuries, new or worsened | 1.57% |
2.29%
0.7 pts better
|
Numerator 6 · Denominator 383 · Adjusted rate 1.57% |
| Healthcare-associated infections requiring hospitalization | 7.7% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 263 · Observed rate 7.98% · Lower 95% interval 5.11% |
| Staff COVID-19 vaccination coverage | 84.9% |
8.2%
76.7 pts better
|
Numerator 163 · Denominator 192 |
| Staff flu vaccination coverage | 49.71% |
42%
7.7 pts better
|
Numerator 85 · Denominator 171 |
| Discharge function score | 64.8% |
56.45%
8.3 pts better
|
Numerator 162 · Denominator 250 |
| Transfer of health information to provider | 99.42% |
95.95%
3.5 pts better
|
Numerator 342 · Denominator 344 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 4.39% |
25.2%
20.8 pts worse
|
Numerator 9 · Denominator 205 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 14.9% |
89.7%
74.8 pts worse
|
81.7%
66.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 5.1% · Q3 14.5% · Q4 35.0% · 4Q avg 14.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
12.0%
4.6 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 7.2% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.5% · Q3 1.1% · Q4 0.9% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 31.0% |
88.0%
57 pts worse
|
79.7%
48.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 31.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
25.9%
1 pts better
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 27.9% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2024-08-15
6 health deficiencies
Top issue: Environmental (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-07-13 · Fire 2023-07-13
12 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Not marked corrected
F · Potential for more than minimal harm
2025-12-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Not marked corrected
F · Potential for more than minimal harm
2025-12-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Not marked corrected
E · Potential for more than minimal harm
2025-12-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
E · Potential for more than minimal harm
2024-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-29
E · Potential for more than minimal harm
2024-08-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-04
F · Potential for more than minimal harm
2023-07-13
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-08-27
E · Potential for more than minimal harm
2023-07-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-07-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-08
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2026-01-18
E · Potential for more than minimal harm
2025-12-08
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 2026-01-18
E · Potential for more than minimal harm
2025-12-08
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 2026-01-18
E · Potential for more than minimal harm
2025-12-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-18
E · Potential for more than minimal harm
2025-12-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-18
D · Potential for more than minimal harm
2025-12-08
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2026-01-18
D · Potential for more than minimal harm
2025-12-08
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 2026-01-18
D · Potential for more than minimal harm
2025-12-08
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 2026-01-18
D · Potential for more than minimal harm
2025-12-08
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 2026-01-18
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 2026-01-18
D · Potential for more than minimal harm
2025-12-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-01-18
D · 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 2026-01-18
E · Potential for more than minimal harm
2025-05-19
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-05-19
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 2025-06-30
D · Potential for more than minimal harm
2025-05-19
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 2025-06-30
E · Potential for more than minimal harm
2025-03-17
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-21
E · Potential for more than minimal harm
2025-03-17
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 2025-04-21
E · Potential for more than minimal harm
2025-03-17
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 2025-04-21
D · Potential for more than minimal harm
2025-03-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-28
F · Potential for more than minimal harm
2024-08-15
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 2024-09-29
E · Potential for more than minimal harm
2024-08-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-29
E · Potential for more than minimal harm
2024-08-15
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 2024-09-29
E · Potential for more than minimal harm
2024-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-29
D · Potential for more than minimal harm
2024-08-15
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-09-29
E · Potential for more than minimal harm
2024-07-18
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 2024-08-19
E · Potential for more than minimal harm
2024-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-01-23
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 2024-03-08
E · Potential for more than minimal harm
2023-07-13
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 2023-08-27
E · Potential for more than minimal harm
2023-07-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-27
E · Potential for more than minimal harm
2023-07-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-27
E · Potential for more than minimal harm
2023-07-13
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 2023-08-27
D · Potential for more than minimal harm
2023-07-13
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 2023-08-27
D · Potential for more than minimal harm
2023-07-13
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 2023-08-27
D · Potential for more than minimal harm
2023-03-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-04-16
D · Potential for more than minimal harm
2023-03-02
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2023-04-16
D · Potential for more than minimal harm
2023-03-02
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 2023-04-16
D · Potential for more than minimal harm
2023-03-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-16
Penalties and ownership
What sits behind the stars
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
Mushtaq, Uzair
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
Theus, Michelle
Operational/Managerial Control · Individual
White, Jim
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Huebner Creek Health & Rehabilitation Center
San Antonio, TX
2-star overall rating with 2-star inspections with $14,327 in total fines with 19 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Mesa Vista Inn Health Center
San Antonio, TX
2-star overall rating with 3-star inspections with $8,160 in total fines with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Northgate Health And Rehabilitation Center
San Antonio, TX
1-star overall rating with 2-star inspections with $39,165 in total fines with 23 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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