Ignite Medical Resort Round Rock, LLC

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents (Resident #3) reviewed for medication errors. The facility failed to ensure nursing staff administered Resident #3's medication at the scheduled time. These failures could place all 3 residents at risk of their medications not being administered according to Physician's orders, getting their medications late, or not receiving the intended therapeutic benefits of their medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident has the right to secure and confidential personal and clinical records for 2 of 23 residents (Resident #1 and Resident #2) on Kindle Unit of the facility reviewed for Privacy and Confidentiality. The facility failed to ensure Resident #2's clinical records were protected from being viewed by unauthorized persons when the CNA left Resident #2's personal information visible on the computer's screen at unattended charting station on Kindle Unit. The facility failed to ensure Resident #1's clinical records were protected from being viewed by unauthorized persons when the RN left Resident #1's personal information visible on the computer's screen on unattended NC on Kindle Unit. This failure could result in residents' personal information being exposed to unauthorized individuals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident or family group with private space for 1 of 1 resident council meetings reviewed for resident rightsThe facility failed to provide a private space for residents to meet during resident council meetings, exposing residents to loss of privacy. This failure could affect place residents by placing them at risk for loss of privacy and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 5 of 8 residents (Resident #31, Resident #57, Resident #76, Resident #93, and Resident #94) reviewed for quality of life.1. The facility failed to ensure Resident #57, Resident #76, Resident #93, and Resident #94 received regular showers.2. The facility failed to ensure Resident #31, and Resident #94 were offered to have their facial hair removed. These failures placed residents at risk of having poor hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen and food sanitation.1. The facility failed to ensure the [NAME] used proper hand sanitation while preparing pureed foods. 2. The facility failed to ensure the DA D used proper hand sanitation prior to distributing food to residents' rooms. These failures could place residents, who receive food from the kitchen, at risk for food contamination and foodborne illness. Findings Included:An observation and interview on 01/13/2026 at 11:25 a.m., revealed the [NAME] cleaned and disinfected the robot coup blender after finishing a puree of Tamale pie. The [NAME] failed to wash her hands before putting clean gloves on. [...]

Inspectors wroteBased on observations, interviews, 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 of communicable diseases and infections for reviewed for infection control. DA D did not sanitize his hands between each resident when passing meal trays for lunch. This failure could place the residents at risk of transmission of disease and infection.

Inspectors wroteBased on observation and interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 15 residents (Resident #22 and Resident #71) reviewed for resident rights. The facility failed to ensure Resident #22 and Resident #71's rooms were clean. This deficient practice could place residents at risk of feelings dissatisfaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs are stored properly and only authorized persons have access for 1 of 2 medication carts (TC #1) reviewed for pharmacy services. The facility failed to ensure TC #1 was locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff through a communication system that relays the call directly to a staff member or a centralized staff work area from toilet facilities for 1 of 1 resident rooms. (Resident #10's room [ROOM NUMBER]) reviewed for call lights. The facility failed to ensure emergency call lights in Resident #10's room's bathroom were operable. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for one of four residents (Resident #1) reviewed for pharmaceutical services. The facility failed to ensure Resident #1 received her Furosemide (given to help treat fluid retention) on 04/06/25 at 7:00 AM and 04/11/24 at 5:00 pm, Spironolactone (used to treat high blood pressure) on 04/06/25 at 7:00 AM and 05/11/25 at 5:00 PM, alprazolam (used to treat anxiety disorders) on 04/11/25 at 5:00 PM and 04/12/25 at 5:00 PM, Metronidazole (used to treat infections) on 04/11/25 at 5:00 PM, and Midodrine HCl (used to treat low blood pressure) on 04/11/25, 04/14/25, 04/19/25 and 04/20/25 at 5:00 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were free from physical abuse for one (Resident #1) of seven residents reviewed for abuse in that: CNA B forced Resident #1 to have his vitals taken after he refused and used force to push Resident #1 on his back on 01/27/2025. Noncompliance existed from 01/27/2025 to 01/28/2025, but the facility corrected the noncompliance through re-training and assessment of staff, reviews of clinical information, and the immediate suspension of CNA B.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for three (Resident #1, Resident #2, and Resident #3) of five residents reviewed for pressure injuries. The facility failed to: 1.) Ensure Resident #1 had wound care treatments until four days after being admitted . She missed seven wound care treatments in December 2024 and January 2025. 2.) Ensure Residents #2 and #3 had orders for the monitoring of their wound vacs (a negative pressure wound therapy) every shift. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain.

Inspectors wroteBased on interviews and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 6 residents reviewed for resident rights. 1. The facility failed to notify the MD or NP when Resident #1, who has a diagnosis of stage 5 kidney failure, complained of not being able to urinate. 2. The facility failed to notify the MD or NP when Resident #1, with a BIMS score of 15, began exhibiting erratic behaviors, changes in mental status, confusion, and agitation. 3. The facility failed to notify the MD, NP, or abuse coordinator when Resident #1 presented with bruises on her abdomen, back, legs, arms, and forehead . [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 1 (Resident #1) of 6 residents reviewed for quality of care. 1. The facility failed to assess the resident or notify the provider when Resident #1, who has a diagnosis of stage 5 kidney failure, complained of not being able to urinate. 2. The facility failed to assess Resident #1, notify the provider or the abuse coordinator when Resident #1, who was taking blood thinners and had a BIMS score of 15, presented with bruises all over her body, and began throwing herself on the floor, hitting herself on the head, yelling, and exhibiting erratic behaviors . 3. The facility failed to follow the care plan and notify the MD of changes in mental status, confusion, and agitation. 4. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 4 residents reviewed for quality of care. 1. The facility did not prevent the development of one facility acquired Stage II pressure injury for Resident #3. 2. The facility failed to complete weekly skin assessments according to their policy for Residents # 1, 2, 3, and 4. These failures could place residents at risk for developing pressure ulcers or wounds.

Inspectors wroteBased on interviews and record review the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 2 (Resident #1 and Resident #2) of 6 residents who were reviewed for administration. 1. The facility failed to accurately document the administration of Resident #1's anticoagulant medication from 10/28/24 through 11/05/24. 2. The facility failed to transcribe a wound care order 10/30/24 for Resident #2. These failures could place residents at risk of lack of desired effect of medications and treatments, and lack of wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infection for 1 of 3 residents (Resident #2) reviewed for infection prevention and control. The facility failed to place Resident #2 on Enhanced Barrier Precautions when admitted on [DATE] with a surgical wound. The facility failed to ensure they made PPE available near or outside resident's rooms who were on EBP. These failures could place residents at risk for infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, and distribute food in accordance with professional standards for the facility's only kitchen reviewed for food service safety. 1. The facility failed to properly seal, label, and date foods stored in the kitchen's freezer, refrigerator , activity room snack bar, and walk-in cooler. 2. The facility failed to clean and sanitize the kitchen's only industrial can opener. 3. The HC failed to wear effective hair restraint while preparing food. This failure could have placed residents at risk of ingesting food borne pathogens, ingesting adulterated foods, and becoming ill. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide, based on the comprehensive assessment and care plan and preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for 3 of 7 Residents (Resident #32, Resident #152, and Resident #154) reviewed for facility activities. 1. The facility failed to post the activity schedule in a prominent location, visible to residents and responsible parties. 2. The facility failed to hold activities that were on the activity schedule. 3. The facility failed to complete Resident #152's Activity Assessment. 4. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 1 of 7 Residents (Resident #33) reviewed for ADL care. The facility failed to provide grooming services, in the form of nail care, for Resident #33. This failure could have placed residents at risk of scratches, infections, or lowered self-esteem. Findings Included: Record review of Resident #33's AR, dated 10/14/2024, reflected an [AGE] year-old woman, who admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for 2 of 2 residents (Residents #37 and Resident #42) reviewed for accidents and supervision. The facility failed to ensure Resident #37, and Resident #42 were provided safety when facility staff were directing the residents to going outside to smoke in the roadway without supervision. Findings Included: Record review of Resident #37's face sheet reflected a [AGE] year-old male with an admission date of 09/04/24. Resident #37 had diagnoses which included fall subsequent encounter, generalized muscle weakness and need for assistance with personal care. Resident #37's admission MDS assessment dated [DATE] reflected he had a BIMS Score of 12, and moderate cognitive impairment. Resident #37 used a wheelchair for mobility. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to establish policies regarding smoking for 2 of 2 (Resident #37 and Resident #42) residents reviewed for smoking. 1. The facility failed to enforce the no smoking policy for Resident #37 and #42. 2. The facility failed to ensure that the residents did not have their cigarettes and lighters in their rooms. This failure could place all residents at risk of injury, burns, and unsafe environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of three residents reviewed for foley catheter care. The facility failed to monitor/document Resident #1's (who has a history of urine retention) urine output for three days (09/11/24 - 09/13/24). On 09/14/24 an I/O catheter removed 700 CCs of urine and he was sent out to the hospital the following day due to swelling to his groin, the foley not draining, and his urine being cloudy with clots of pus. This failure could place residents at risk of UTIs, urine retention, bladder rupture, or hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure that medical records were accurately documented for three (Resident #2, Resident #3, and Resident #4) of six residents reviewed for accurate medical records. The facility failed to document nursing notes in Residents #2's, #3's, and #4's EMRs when they were discharged from the facility. This deficient practice could result in errors in care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 3 residents (Residents #1) reviewed for infection control, as indicated by: CNA A and LVN B failed to wash hands and change dirty gloves while handling clean items while providing pericare to Resident #1. This failure could place the residents at risk of transmission of diseases and infection.

Inspectors wroteBased on interviews and record reviews, the facility failed to inform the resident's Physician or Nurse Practitioner when there was a need to alter treatment significantly for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1's scheduled medications were acquired and administered. Resident #1 was not given ceftriaxone (antibiotic used to treat bacterial infections) for a total of 4 times within the dates of 07/09/2024 to 07/11/2024, staff did follow up with the pharmacy for the antibiotics, staff did not communicate with the NP of the lack of antibiotics and missed medications, and staff did not communicate the missed doses to the administration. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide pharmaceutical services, including accurate acquiring, and administering of all drugs and biologicals to meet the needs for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1's scheduled medications were acquired and administered. Resident #1 was not given ceftriaxone (antibiotic used to treat bacterial infections) for a total of 4 times within the dates of 07/09/2024 to 07/11/2024, staff did follow up with the pharmacy for the antibiotics, staff did not communicate with the NP of the lack of antibiotics and missed medications, and staff did not communicate the missed doses to the administration. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident was free of any significant medication errors for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1's scheduled medications were acquired and administered. Resident #1 was not given ceftriaxone (antibiotic used to treat bacterial infections) for a total of 4 times within the dates of 07/09/2024 to 07/11/2024, staff did follow up with the pharmacy for the antibiotics, staff did not communicate with the NP of the lack of antibiotics and missed medications, and staff did not communicate the missed doses to the administration. This failure resulted in the Resident #1's being sent to the hospital to have consistent antibiotic treatment, and to treat Bacteremia (bacteria in the blood stream) and ventriculitis (inflammation of the ventricles in the brain). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 6 of 6 residents (Residents #1, 2, 3, 4, 5, and 6). The facility failed to fully involve residents and/or their responsible parties in the discharge planning process prior to their discharge. This failure placed residents at risk of anxiety, disenfranchisement, and rehospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure frozen food items were sealed and dated in the freezer in 2 of 2 freezers. The facility failed to ensure refrigerated food items were dated when opened or prepared in 2 of 2 refrigerators. The facility failed to ensure vegetables were disposed when expired in 1 of 2 refrigerators. The facility failed to ensure grilling equipment in the kitchen was clean and free of food debris. The facility failed to ensure pureed meals when prepared were free of risk of contamination. These failures could place resident who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to provide effective communications mandatory training for 10 of 12 employees (DON, ADON, CNA F, CMA G, RN I, RN J, LVN K, LVN L, PT M, OT N) reviewed for training, in that: The facility failed to ensure DON, ADON, CNA F, CMA G, RN I, RN J, LVN K, LVN L, PT M, OT N completed effective communication training. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its resident for 10 of 12 employees (DON, ADON, CNA F, CMA G, RN I, RN J, LVN K, LVN L, PT M, OT N) reviewed for training, in that: The facility failed to ensure DON, ADON, CNA F, CMA G, RN I, RN J, LVN K, LVN L, PT M, OT N completed resident rights training within the previous year. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 10 of 12 employees (Cook D, CNA E, CNA F, CMA G, RN I, RN J, LVN K, LVN L, PT M, OT N) reviewed for training, in that: The facility failed to ensure [NAME] D, CNA E, CNA F, CMA G, RN I, RN J, LVN K, LVN L, PT M, OT N completed QAPI training within the last year. These failures could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide the required compliance and ethics training for 12 of 12 employees (DON, ADON, [NAME] D, CNA E, CNA F, CMA G, RN I, RN J, LVN K, LVN L, PT M, OT N) reviewed for training, in that: The facility failed to ensure DON, ADON, [NAME] D, CNA E, CNA F, CMA G, RN I, RN J, LVN K, LVN L, PT M, OT N completed compliance or ethics within the previous year. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective behavioral health training for 10 of 12 employees (DON, ADON, CNA F, CMA G, RN I, RN J, LVN K, LVN L, PT M, OT N) reviewed for training, in that: The facility failed to ensure DON, ADON, CNA F, CMA G, RN I, RN J, LVN K, LVN L, PT M, OT N completed behavioral health training within the previous year. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 residents (Residents #117) reviewed for respiratory care, in that: The facility failed to ensure Resident #117's humidifier for her oxygen was dated. This deficient practice could place residents who received oxygen therapy at risk for incorrect oxygen support being delivered and an increase in respiratory complications.

Inspectors wroteBased on observation and interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for 1 of 4 days (8/22/23), reviewed for daily staff posting. The facility failed to post the required daily staff posting on 8/22/23. This failure could result in residents and visitors being unaware of daily staffing levels.