Webster, TX

Ignite Medical Resort Webster, LLC

5-star overall rating with 5-star inspections with $42,280 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

16130 Galveston Rd, Webster, TX

(832) 426-7030

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 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

68

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Ignite Medical Resorts

Operator or chain grouping

Approved since

2019-01-25

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

0.72

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.43

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.09

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

4.24

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

2.15

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.84

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.48

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.29

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.56

CMS adjusted RN staffing hours

Adjusted total hours

3.30

CMS adjusted total nurse staffing hours

Case-mix index

1.76

Higher values indicate more complex resident acuity

RN turnover

63%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

44%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,988

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

Performance score

37.85

Composite VBP score used to determine payment impact.

Payment multiplier

0.9910

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 21.14% · Performance 22.39% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

9.45

Baseline 5.69% · Performance 5.01% · Measure score 9.45 · Achievement 9.45 · Improvement 9

Total nurse turnover

4.55

Baseline 65.67% · Performance 45.07% · Measure score 4.55 · Achievement 4.55 · Improvement 4.55

Adjusted total nurse staffing

1.13

Baseline 4.68 hours · Performance 3.4 hours · Measure score 1.13 · Achievement 1.13 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.94%	10.72% 0.8 pts better	No Different than the National Rate · Eligible stays 568 · Observed rate 9.68% · Lower 95% interval 8.27%
Discharge to community	72.43%	50.57% 21.9 pts better	Better than the National Rate · Eligible stays 601 · Observed rate 63.06% · Lower 95% interval 67.51%
Medicare spending per beneficiary	1.15	1.02 0.1 pts worse
Drug regimen review with follow-up	98.81%	95.27% 3.5 pts better	Numerator 414 · Denominator 419
Falls with major injury	0.72%	0.77% 0.1 pts better	Numerator 3 · Denominator 419
Discharge self-care score	74.9%	53.69% 21.2 pts better	Numerator 182 · Denominator 243
Discharge mobility score	55.56%	50.94% 4.6 pts better	Numerator 135 · Denominator 243
Pressure ulcers or injuries, new or worsened	1.43%	2.29% 0.9 pts better	Numerator 6 · Denominator 419 · Adjusted rate 1.39%
Healthcare-associated infections requiring hospitalization	5.01%	7.12% 2.1 pts better	Better than the National Rate · Eligible stays 355 · Observed rate 3.94% · Lower 95% interval 3.33%
Staff COVID-19 vaccination coverage	2.6%	8.2% 5.6 pts worse	Numerator 4 · Denominator 154
Staff flu vaccination coverage	68.88%	42% 26.9 pts better	Numerator 135 · Denominator 196
Discharge function score	56.79%	56.45% 0.3 pts better	Numerator 138 · Denominator 243
Transfer of health information to provider	99.48%	95.95% 3.5 pts better	Numerator 192 · Denominator 193
Transfer of health information to patient	99.1%	96.28% 2.8 pts better	Numerator 221 · Denominator 223
Resident COVID-19 vaccinations up to date	1.29%	25.2% 23.9 pts worse	Numerator 3 · Denominator 233

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	89.7% 9.9 pts better	81.7% 17.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 99.2% · Q3 99.6% · Q4 100.0% · 4Q avg 99.6%
Percentage of short-stay residents who had an outpatient emergency department visit	8.2%	12.0% 3.8 pts better	12.0% 3.8 pts better	Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 8.3% · Expected 11.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.5%	1.5% 1 pts better	1.6% 1.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.0% · Q3 0.3% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	89.0%	88.0% 1 pts better	79.7% 9.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 89.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.4%	25.9% 4.5 pts better	23.9% 2.5 pts better	Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 24.0% · Expected 26.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-11 · Fire 2025-06-11

2 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-05-08 · Fire 2024-05-08

0 health deficiencies

No concentrated health issue counts in this cycle.

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-03-22 · Fire 2023-03-22

9 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

3 fire-safety deficiencies

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

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-06-11

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-06-26

E · Potential for more than minimal harm 2025-06-11

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-06-26

E · Potential for more than minimal harm 2025-06-11

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-06-26

E · Potential for more than minimal harm 2025-06-11

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2025-06-26

F · Potential for more than minimal harm 2023-03-22

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-03-24

E · Potential for more than minimal harm 2023-03-22

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-03-24

E · Potential for more than minimal harm 2023-03-22

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-03-24

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-06-11

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 2025-07-11

D · Potential for more than minimal harm 2025-06-11

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 2025-07-11

G · Actual harm 2023-03-22

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2023-03-24

G · Actual harm 2023-03-22

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 2023-03-24

E · Potential for more than minimal harm 2023-03-22

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2023-03-24

E · Potential for more than minimal harm 2023-03-22

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 2023-03-24

E · Potential for more than minimal harm 2023-03-22

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 2023-03-24

D · Potential for more than minimal harm 2023-03-22

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 2023-03-24

D · Potential for more than minimal harm 2023-03-22

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 2023-03-24

D · Potential for more than minimal harm 2023-03-22

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-03-24

D · Potential for more than minimal harm 2023-03-22

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2023-03-24

Penalties and ownership

What sits behind the stars

$42,280 2023-03-22

Fine

Fine · fine $42,280

Fine

Ownership

Fields, Timothy

5% Or Greater Indirect Ownership Interest · Individual

20% 22 facilities 2022-04-01

Carr, Barry

5% Or Greater Indirect Ownership Interest · Individual

16% 22 facilities 2022-04-01

Carr, Barry