Ignite Medical Resort Katy, LLC

Inspectors wroteBased on interview, and record review the facility failed to ensure the assessment accurately reflected the status for 1 (CR#1) of 6 residents reviewed for accuracy of assessments. The facility failed to ensure CR#1's admission MDS assessment accurately reflected he had a Foley catheter. The failure could place residents at risk of receiving inadequate care and services due to inaccurate assessments. Record review of CR#1's face sheet dated 6/26/2026 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and discharge on [DATE]. His diagnoses included hypertension (high blood pressure), hyperlipidemia (high level of fat in the blood), chronic kidney disease stage V (damage kidney that cannot filter blood properly), acute kidney failure (a sudden loss of kidney function that happens a few hours a day). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for 3 out of 7 residents (Resident #1, Resident #2, and Resident #5) reviewed for ADLs.- The facility failed to provide scheduled showers and/or bed baths three times a week for Resident #1, Resident #2, and Resident #5, for the weeks of 1/12/26-1/16/26 and 1/19/26-1/23/26. This failure could place residents at risk of skin breakdown, infection, and reduced feelings of self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (CR #1) reviewed for pressure ulcer treatment. The facility failed to ensure CR#1 with a documented sacral pressure injury (sustained force applied to the sacrum, the triangular bone at the base of the spine) received necessary wound treatment and monitoring. This failure could place the residents at risk of worsening wounds, infection, and hospitalization. Record review of CR #1's face sheet, dated 11/30/2025, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 11/16/2025. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment such as services that are to be furnished to attain or maintain the resident's highest practicable physical well-being for 1 (Resident #5) of 5 residents reviewed for care plans.-Resident #5's care plan failed to include weights as part of their diagnosis of CHF and as a resident requiring dialysis. This failure could cause residents to not have their individualized needs met and lead to a decline in function that is not documented and treated. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure each resident had acceptable parameters of nutritional status such as usual body weight or desirable body weight range for 1 (Residents #2) of 5 residents reviewed for weights. -The facility failed to weigh Resident #2 on 10/4/2025 per physician orders. This failure has the potential to affect other residents requiring weight management, especially those who have weight loss and weight gain and who could be at risk of serious harm due to poor nutrition and weight loss. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free of significant medications errors for 1 resident (Resident #20) of 8 resident for medication errors in that: - The facility was unable to locate a current order for Resident #20 for the medication Brilinta (blood thinner/antiplatelet {medication that prevents blood clots}) 90mg oral 1 tablet in the morning and at bedtime. Resident #20 received the medication from 05/01/25 at 9:00PM to 05/07/25 at 9:00PM. This failure placed resident at risk for increase in bleeding and unwanted hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 resident (Resident #101) reviewed for pharmaceutical services. The facility failed to ensure RN A followed the physician's orders for administering Mycophenolic Acid, which was used for preventing organ rejection, to Resident #101 on 05/07/25. This failure could put residents at risk of not receiving their medications as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. The facility had a medication error rate of 17% based on 6 errors for 34 opportunities. The errors effected2 resident (Resident #101,Resident #20) of 4 residents reviewed for medication administration. -Two medications, Ascorbic Acid tablet 250 mg (used to treat supporting tissue growth and repair, boosting immunity and acting as an antioxidant) and Doxycycline Hyclate oral tablet 100 mg (use to treat infections) for Resident #20 were not dispensed or administered. - Four medications: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of three medication carts and one of two medication room reviewed for drug for drug labeling and storage, in that: The 200 medication cart reviewed contained heparin 50,000 USP unit per 10 ml 1 vial open not dated (medication used to prevent blood clots). The medication room had 8 cartons of Nurten 2.0 (calorically dense complete nutrition unflavored) that were expired. These failures placed residents at risk for receiving biologicals and medications which were ineffective and/or not safe.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened/prepared discarded after used date of 2 - 3 days per facility policy. 2. The facility failed to store personal food items outside of the kitchen area. 3. The facility failed to ensure food items were sealed and secure. These failures could place residents at risk of food borne illness and disease. Findings Included: In an observation on 05/06/2025 at 08:16 a.m., of the 1 of 1 facility walk-in refrigerators revealed the following: 2-personal fruit trays containing black grapes, not labeled, or dated. 2-Hamburger buns in a bag, used and not labeled. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission and communicable disease and infections for 2 (Resident #35, Resident #36) of 8 residents whose care was reviewed in that: -The facility failed to label and store resident care items (toothbrush, wash basins, and body cleanser) to prevent cross contamination. They resided in the same room; Resident #35 was bed B and Resident # 36 was bed A. This failure placed residents at risk for infections and decrease in quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 4 (Resident #1) reviewed for pain management. -The facility failed to ensure that as a resident with cancer of the esophagus Resident #1's pain medications (Lyrica 75mg and Tramadol HCl 50mg) were available at the facility after he was admitted from a cancer treatment hospital. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 (Resident #1) residents reviewed. -The facility failed to ensure that as a resident with cancer of the esophagus Resident #1's Lyrica and Tramadol were available for administration from 09/04/2024 at 10pm to 09/06/2024 at 2pm according to Physician Orders started on 09/04/2024 when Resident #1's nurses knew the pharmacy did not have the prescription for the pain medications but the nurses did not intervene even after Resident #1's representatives requested his pain medications This deficient practice could place residents at risk for adverse effects by not receiving the therapeutic effects of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect for one (Resident #1) of one resident reviewed for dignity. The facility failed to ensure Resident #1's foley bag had a privacy bag covering it on 09/06/2024 while he sat in his wheelchair in his room. This failure could place residents in the facility at risk of feeling uncomfortable and disrespected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #1) reviewed for incontinent care. 1. The facility failed to ensure Resident #1 foley tubing was not touching the floor on 09/06/2024 while Resident was seated in his wheelchair. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings, for 1 (Resident #1) of 2 resident that was reviewed for feeding tubes, in that: -The facility failed to ensure RN A appropriately verified placement, RN A should have listened to the bowel sounds, then checked the residual and water flush the tube before feeding for Resident #1 during a enteral bolus tube feeding on 09/06/2024. The water for the flush should be room temperature, not cold. RN A used cold water to flush after the enteral bolus feeding. This failure could place residents at risk for adverse reactions, inadequate therapy, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention control program that included standard and transmission-based precautions to be followed to prevent spread of infections and hand hygiene procedures to be followed by 2 of 4 staff (CNA A and RN A) involved in direct resident contact. 1. CNA A left a waste bag on the floor outside a resident's room without disposing of it in a hygienic manner on 08/19/2024. 2. The facility failed to ensure RN A followed proper infection control and hand washing procedure during G - tube bolus feeding for Resident #1 on 09/06/2024 3. The facility failed to ensure Resident #1 Foley tubing was not touching the floor during observations on 09/06/2024 This failure could affect all residents by causing spread of disease in a facility due to not following infection control procedures.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer parenteral fluids consisitent with professional with professional standards of practice and care plans for 1 of 8 residents (Resident #26) reviewed for parenteral intravenous (IV) antibiotic care and services through a peripherally inserted catheter (PICC) therapy. -The facility failed to change Resident #26's PICC line dressing once a week . -RN T failed to maintain sterile technique when changing Resident #26's PICC line dressing change . -The facility failed to date Resident #26's IV tubing. These failures could place residents at risk for infections, unwanted hospitalization, and decrease in quality of life.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure expired foods were not discarded 2. The facility failed to ensure foods were labeled and dated. These failures could place residents at risk of food borne illness and disease. who ate food from the kitchen and place them at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 03/19/24 at 8:10 AM revealed the following leftover foods were not discarded prior to the use by date. 1. A Plastic Container of American Cheese was dated 3/07/24. 2. A Plastic Container of Cubed Cheese had no label and was not dated. 3. A Plastic Container of Cubed Cheese was dated 2/23/24 4. [...]

Inspectors wroteBased on observation and interview the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for Food and Nutrition Services. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a comfortable and homelike environment for 2 of 8 residents (Resident #10 and Resident #16) whose environment was reviewed in that: -The facility failed to properly store residents personal care item (toothbrush) to prevent cross contamination . This failure could place residents at risk for unwanted infections, and decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a residents' medical, nursing, and mental and psychosocial needs, that were identified in the comprehensive assessment for 1 of 5 residents (Resident #26) reviewed for care plans. The facility failed to develop a care plan to address Resident #26's for having a PICC line . This failure could place residents at risk for dislodgement, infections, and unwanted hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 3 of 4 residents (Residents #s 1, 2, and 3) reviewed for ADLs. -The facility failed to provide showers/baths for Residents #1, #2, and #3 in accordance with resident's shower schedules. This failure could place residents at risk for infection, skin breakdown, and body odor.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 4 Staff (Housekeeper E, LVN D, and CNA A) reviewed for infection control. -The facility failed to ensure Housekeeper E followed proper use of PPE and infection control procedure while cleaning the nursing station, clean utility room, restroom and cubby station in 200 hall. -The facility failed to ensure LVN D followed proper infection control on disinfecting equipment before and after it was used on Resident #234. -The facility failed to ensure Resident # 234 Foley bag and tubing from touching the floor. -The facility failed to ensure LVN D followed proper hygiene after she provided care for Resident #234. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #234) reviewed for incontinent care. -The facility failed to ensure Resident #234's Foley catheter tubing (tubing inserted into the bladder to drain urine) was secured to her leg to prevent stress or pulling on the catheter site. -The facility failed to ensure LVN D and CNA A followed proper infection control procedure by prevented Resident # 234 Foley bag and tubing from touching the floor. These failures could place residents at risk for pain, infection, injury and hospitalization.