Cycle 1
Health 2025-12-10 · Fire 2025-12-10
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Sugar Land, TX
Ignite Medical Resort Sugar Land, LLC
2-star overall rating with 2-star inspections with $202,589 in total fines with 5 fire-safety deficiencies in the latest cycle
1803 Wescott Avenue, Sugar Land, TX
(713) 325-1717
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ignite Medical Resorts
Operator or chain grouping
Approved since
2015-07-29
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
0.88
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.67
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
0.75
CMS adjusted RN staffing hours
Adjusted total hours
3.24
CMS adjusted total nurse staffing hours
Case-mix index
1.61
Higher values indicate more complex resident acuity
RN turnover
85%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
84%
Annual nurse turnover · state 52% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.81% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 9.28% · Lower 95% interval 6.76% |
| Discharge to community | 51.43% |
50.57%
0.9 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 42.27% · Lower 95% interval 40.73% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 32 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 29 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.56% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 14.29% · Lower 95% interval 4.49% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 73 |
| Staff flu vaccination coverage | 1.34% |
42%
40.7 pts worse
|
Numerator 2 · Denominator 149 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | 90% |
95.95%
6 pts worse
|
Numerator 18 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
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 | 5.0% |
2.7%
2.3 pts worse
|
11.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.0% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
3.3%
1.1 pts worse
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.7% |
18.9%
12.2 pts better
|
19.6%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.3% |
10.8%
5.5 pts better
|
16.7%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.3% · 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 | 9.7% |
16.1%
6.4 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.5% |
0.5%
6 pts worse
|
1.0%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
0.8%
3 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.5% |
15.0%
7.5 pts worse
|
19.8%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.5% |
| Percentage of long-stay residents with pressure ulcers | 10.9% |
4.2%
6.7 pts worse
|
5.1%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
89.7%
5.6 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.8% · Q2 93.2% · Q3 99.0% · Q4 96.8% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
12.0%
4.3 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 8.3% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
88.0%
3.7 pts better
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.1% |
25.9%
2.2 pts worse
|
23.9%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.1% · Observed 36.1% · Expected 30.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-27 · Fire 2024-09-27
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-08-09 · Fire 2023-08-09
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-22
F · Potential for more than minimal harm
2025-12-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-01-22
F · Potential for more than minimal harm
2025-12-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-22
F · Potential for more than minimal harm
2025-12-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-22
E · Potential for more than minimal harm
2025-12-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-01-22
F · Potential for more than minimal harm
2024-09-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-09-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-09-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-04
F · Potential for more than minimal harm
2023-08-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-22
F · Potential for more than minimal harm
2023-08-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-22
F · Potential for more than minimal harm
2023-08-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-22
F · Potential for more than minimal harm
2023-08-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-16
E · Potential for more than minimal harm
2023-08-09
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.
Corrected 2023-08-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-09-27
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 2024-12-27
D · Potential for more than minimal harm
2024-09-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-07
D · Potential for more than minimal harm
2024-09-27
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 2024-11-20
D · Potential for more than minimal harm
2024-09-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-27
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 2024-11-20
D · Potential for more than minimal harm
2024-09-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-27
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-27
J · Immediate jeopardy
2024-08-30
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-09-01
J · Immediate jeopardy
2024-08-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-04
J · Immediate jeopardy
2024-08-30
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 2024-10-04
D · Potential for more than minimal harm
2023-08-09
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 2023-08-17
E · Potential for more than minimal harm
2023-06-26
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-07-25
E · Potential for more than minimal harm
2023-06-26
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 2023-07-25
D · Potential for more than minimal harm
2023-06-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-25
D · Potential for more than minimal harm
2023-06-26
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-07-25
J · Immediate jeopardy
2023-04-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-04-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-03-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-20
D · Potential for more than minimal harm
2023-03-06
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-03-20
Penalties and ownership
What sits behind the stars
$14,433
2024-08-30
Fine
Fine · fine $14,433
Fine
$14,433
2024-08-30
Fine
Fine · fine $14,433
Fine
$83,496
2024-08-30
Fine
Fine · fine $83,496
Fine
$0
2024-08-30
Payment Denial
Payment Denial · denial start 2024-10-01 · 129 days
129 day denial
$4,938
2024-02-20
Fine
Fine · fine $4,938
Fine
$4,938
2024-02-12
Fine
Fine · fine $4,938
Fine
$14,814
2024-01-22
Fine
Fine · fine $14,814
Fine
$4,587
2023-08-07
Fine
Fine · fine $4,587
Fine
$13,762
2023-07-17
Fine
Fine · fine $13,762
Fine
$3,873
2023-06-26
Fine
Fine · fine $3,873
Fine
$3,882
2023-06-20
Fine
Fine · fine $3,882
Fine
$3,529
2023-06-12
Fine
Fine · fine $3,529
Fine
$3,176
2023-06-05
Fine
Fine · fine $3,176
Fine
$2,823
2023-05-30
Fine
Fine · fine $2,823
Fine
$2,470
2023-05-23
Fine
Fine · fine $2,470
Fine
$2,117
2023-05-15
Fine
Fine · fine $2,117
Fine
$21,085
2023-04-28
Fine
Fine · fine $21,085
Fine
$0
2023-04-28
Payment Denial
Payment Denial · denial start 2023-05-26 · 14 days
14 day denial
$4,233
2023-04-24
Fine
Fine · fine $4,233
Fine
Ownership
Ignite Medical Resort Sugar Land, LLC
5% Or Greater Direct 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
Carr, Barry
Operational/Managerial Control · 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 Medical Resort Sugar Land, LLC
Operational/Managerial Control · Organization
Ignite Post Acute Solutions LLC
5% Or Greater Indirect Ownership Interest · Organization
Ignite Sugar Land Jv, LLC
5% Or Greater Indirect Ownership Interest · Organization
Ignite Team Partners LLC
Operational/Managerial Control · Organization
Israel Family Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Prestige Worldwide Sugar Land, LLC
5% Or Greater Indirect Ownership Interest · Organization
Stern Family Investment Tr
5% Or Greater Indirect Ownership Interest · Organization
Washington, Rulkiya
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
The Crescent
Sugar Land, TX
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $128,737 in total fines with 17 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Sugar Land Health Care Center
Sugar Land, TX
3-star overall rating with 3-star inspections with $38,518 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Paradigm At First Colony
Missouri City, TX
1-star overall rating with 1-star inspections with $211,113 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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