Ignite Medical Resort San Antonio, LLC

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 1 treatment carts (TC #1) reviewed for medication storage. The facility failed to ensure the treatment cart in the public area was locked on 3/25/26. This failure could place residents at risk of medication misuse and drug diversion.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to 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 2 of 2 residents (Resident #3 and Resident #5) reviewed for infection control. The facility failed to ensure RN D followed Enhanced Barrier Precautions when providing wound care to Resident # 3 on 3/26/26. The facility failed to ensure RN D followed Enhanced Barrier Precautions when providing wound care to Resident #5 on 3/26/26. The facility failed to ensure RN D followed infection control practices when providing wound care to Resident #3 on 3/26/26. The facility failed to ensure RN D followed infection control practices when providing wound care to Resident #5 on 3/26/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for 1 of 1 facility reviewed for competent staffing. The facility failed to complete annual performance reviews for CNAs employed by the facility for 1/1/2025 through 9/1/2025. This failure could lead to incompetent staff and improper care to residents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the resident environment remained free of accident hazards as is possible for 1 of 1 laundry departments (2 of the 3 dryers) reviewed for fire hazards. The facility failed to clean out the lint from the 2 commercial dryer's interiors for a year. This failure could place residents at risk for a potential fire.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for 3 of 3 LVNs (ADON A, LVN F, and LVN G) reviewed for staff competency. The facility failed to ensure ADON A, LVN F, and LVN G were competent and trained to provide care for Resident #108's PleurX [a catheter placed in the chest cavity for long-term drainage]. This failure could lead to improper care and complications of Residents' medical care.

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 and to help prevent the development and transmission of communicable diseases and infections for 5 of 5 residents (Residents #52, #53, #87, #108, and #121) reviewed for infection control. The facility failed to ensure enhanced-barrier precautions were initiated for Residents #52, #53, #87, and #121. The facility failed to ensure contact isolation precautions were initiated for Resident #108 when she admitted to the facility on antibiotic therapy for blood culture results positive for VRE (a contagious bacterial infection that is resistant to multiple antibiotics). These failures could lead to the spread of infection and illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure at the time each resident is admitted , the facility must have physician orders for the resident's immediate care for 2 of 2 residents (Residents #108 and #148) reviewed for new admissions. The facility failed to ensure Resident #108 had an order in place to drain the PleurX device [a catheter inserted into the chest cavity for long-term drainage of fluid accumulation] after readmission on [DATE]. The facility admitted Resident #148 with the need for a thoracolumbar spine orthosis (TSLO) back brace and did not support the Resident with a physician's order for the TSLO brace. These failures could lead to residents not receiving necessary care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implemented a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the residents that met professional standards of quality care. The baseline care plan was not developed within 48 hours of a resident's admission and did not include the minimum healthcare information necessary to properly care for a resident including for 1 of 8 residents (Resident #148) [TT1] reviewed for a baseline care plan. Resident #148 was admitted on [DATE] at 5:00 PM with the need for a thoracolumbar spine orthosis (TSLO) back brace, the TSLO brace was not addressed in the baseline care plan. This failure could place residents at risk for not receiving care and services.

Inspectors wroteBased on observation, interview, and record review, 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 1 residents (Resident #87) reviewed for ADLs. The facility failed to ensure Resident #87 received routine bathing assistance after admitting to the facility in September 2025. These failures could lead to skin breakdown, infection, or psychosocial harm.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to ensure for a resident who enters the facility with an indwelling catheter or subsequently receives one had a clinical condition that demonstrates catheterization is necessary for 1 of 3 residents (Resident # 50) reviewed for indwelling urinary catheterization necessity, in that: Resident #50 did not have a physician's order for an indwelling catheter. This deficient practice could affect residents in the facility who have an indwelling or external catheter and place them at risk for infection and improper care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 residents (Resident #108) reviewed for respiratory care. The facility failed to ensure Resident #108's long-term indwelling chest catheter, known by the brand name PleurX, was drained per physician order and by competent staff. These failures could result in infection and/or complications to a resident's respiratory or cardiovascular systems.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 25 medication administration opportunities with 2 errors resulting in a 8% medication error rate, for 2 of 8 residents (Resident #25 and Resident #126) reviewed for medication administration. 1. LVN K administered to Resident #126 his prescribed insulin aspart after breakfast contrary to the physician's orders. 2. ADON LVN A attempted to administer Resident #25 his prescribed insulin aspart after breakfast contrary to the physician's orders. These failures could place residents at risk for not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access, for 1 of 6 medication carts (200-hall medication cart), reviewed for security. LVN G left the 200-hall west medication cart unattended and unlocked. This failure could place residents at risk for having their medications accessible to unauthorized people.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 2 of 2 elevators reviewed for essential equipment. The facility failed to ensure elevators #1 and #2 were functioning properly. This failure could place residents at risk of not having functional and safe mode of travel from floor to floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological's were stored properly in the cart for 1 (100 hallway med aide cart) of 2 medication carts reviewed, in that: The facility failed to ensure Resident #5's Lyrica (pregabalin), a DEA controlled substance, was stored appropriately in a double locked container. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 5 residents reviewed for medical records. The facility failed to ensure LVN A documented Resident #1's medication at the correct time the medication was administered. This failure placed resident at risk for delayed or inaccurate medication administration which could result in decline in health and well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect the confidentiality of personal and medical records for 14 (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15) of 14 residents and involving one (LPN A) of six staff observed for confidentiality of records. The facility failed to ensure LPN A would not leave a Vital Signs Flow Sheet Report on a 200-East Hall medication cart exposing 200-East Hall residents' personal information. This failure could affect residents by placing them at risk for loss of privacy and dignity.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of care within 48 hours of a resident's admission for three (Resident #1, Resident #2, and Resident #3) of four residents reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission that addressed the services that were being provided for Resident #1, Resident #2, and Resident #3. This failure could place newly admitted residents at risk for not receiving the care, services, and continuity of care to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were stored in locked compartments for three (Cart 200-East Hall, Cart 200-West Hall, and Cart 300-West Hall) of six reviewed for drug storage. The facility failed to ensure medication carts, 200-East Hall and 200-West Hall on the second floor and 300-West Hall on the third floor were secured when unattended on 03/12/2025. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversion.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for one (Resident #2) of four residents reviewed for physician orders for treatments. The facility failed to follow physician orders and obtain Resident #2's weight during night shift every Tuesday per physician order schedule. This failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, to promote healing, prevent infection, and prevent new pressure ulcers from developing for one (Resident #2) of four residents reviewed for pressure ulcers. In three observations over three days, the facility failed to follow physician orders and apply Prevelon boots (cushioned boots, also known as heel protectors, designed to lift the heel off the bed and help prevent heel pressure injures and provide pressure relief) as ordered for Resident #2. This failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition.

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 the kitchen. The facility failed to ensure osmolite (a tube feeding formula) was disposed of after its best-by date. The facility failed to ensure staffs facial hair was covered by a hair restraint. The facility failed to ensure trays, insulated plate lids, and insulated plate bases were air dried prior to stacking them with water droplets resulting in being wiped dry with a hand towel during meal prep. The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on interviews and record reviews, the facility failed to deliver the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being for 3 of 30 Residents (Resident # 201, Resident # 67, and Resident # 203 who were reviewed for call light response in that: The facility failed to deliver timely call light response for Resident #201, Resident # 67, and Resident # 203. This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement baseline care plans that included the instructions needed to provide effective and person-centered care within 48 hours of admission for 8 of 25 residents (Residents #77, #99, #100, #102, #106, #149, #150, and #199) that were reviewed for baseline care plans in that: The facility failed to complete (Residents #77, #99, #100, #102, #106, #149, #150, and #199) baseline care plans within 48 hours. This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care.

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 of communicable diseases and infection for 2 of 11 residents (Residents #89 and #204) reviewed for infection control and for residents who eat in their rooms in halls, in that: 1. RN-E did not sanitize glucometer in between uses with Residents #204 and #89, or after leaving Resident's #89 room, who was on droplet precautions. 2. RN-E failed to wash or sanitize his hands between glove changes before administering medications to Resident #204 and Resident #89. RN-E failed to wash or sanitize his hands when entering or exiting Resident #89's room, who was on droplet precautions. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities, for 1 of 30 residents (Resident #79) reviewed for call light accessibility and functionality, in that: On 07/09/2024 at 01:00 PM Resident #79 utilized his call light which did not illuminate the nurse call light directly outside of and above of his room door. This failure could place residents at risk for harm by not receiving care and attention when their nurse call light system malfunctions and or is out of reach.

Inspectors wroteBased on interview, and record review the facility failed to provide pharmaceutical services (including procedures that assist the accurate acquiring, receiving, dispensing ,and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents(Resident #1) reviewed for pharmacy services. The facility failed to acquire and administer Resident #1's scheduled dose of Dexamethasone (a corticosteroid that prevents the release of substances in the body that cause inflammation.) on 7/7/2024 and 7/8/2024. This failure could place residents at risk for pain and poor quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 4 of 4 residents (Residents #1, #2, #3 and #4) reviewed for quality of care in that: The facility failed to ensure Residents #1, #2, #3 and #4 received their scheduled wound care as ordered by the physician. This deficient practice could place residents at risk for worsening skin conditions and infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments in 2 of 9 medication carts (third floor treatment cart and medication cart) reviewed for medication storage, in that: The facility failed to ensure the third-floor treatment cart and medication cart were locked when left unattended in the hallway. This deficient practice could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, for 2 of 8 Residents (Residents #236 and #238) reviewed for base line care plans, in that: 1. The facility failed to develop and implement a baseline care plan to support Resident #236's needs for hypotension, low blood pressure, with prescribed medications meant to raise blood pressure, oxygen use, prescribed opioid use for pain, and support interventions for a fractured hip. 2. The facility failed to develop and implement a baseline care plan to support Resident #238's needs for communication in Arabic. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5%. The facility error rate was 10.7% based on 3 errors out of 28 opportunities for 2 of 5 residents (Resident #256 and #257) reviewed for medication administration: 1. LVN M administered a late medication for Resident #256. The medication was scheduled for 07:30 AM administration, the medication was administered at 08:44 AM. 2. MA N administered late medications for Resident #257. The medications were scheduled for administration any time between 07:00 AM and 10:00 AM. The medications were administered at 11:54 AM. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents are free of any significant medication errors, for 2 of 5 residents (Resident #236 and Resident #256) reviewed for medication administration, in that: 1. MA N administered midodrine (a drug prescribed to raise blood pressure) while Resident #236 was experiencing high blood pressure. 2. LVN M administered Resident #256's insulin late. These failures could place residents at risk for not receiving therapeutic effects of their medications to include a diminished health status.

Inspectors wroteBased on observations, interview and record review revealed the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens in that: The DM used a white towel from the sanitizer bucket under the holding food cart as a sanitizer thermometer testing in between food items. This failure could place residents at risk of cross contamination and food borne illness.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 8 Residents (Resident #47) reviewed for storage of medications. Resident #47's triamcinolone cream [a cream used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions], was stored in his room at his bedside. This deficient practice could place residents at risk for harm due to improper storage.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were provide the therapeutic diets as prescribed by the attending physician for 1 of 8 residents (#71) reviewed in that: Resident # 71 did not receive his sugar free health shake lunch meal as ordered by physician. This failure could affect residents with diet needs and could result in a decrease in calories and potential weight loss.