Ignite Medical Resort San Antonio, LLC

Inspection findings

1. Apr 3, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected May 18, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 18, 2026 · CMS health inspection

2. Dec 8, 2025 Health · 16 findings
   • Not serious Scope/severity D

     F0635 Resident Assessment and Care Planning Deficiencies

     Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

     Corrected Jan 18, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Jan 18, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Jan 18, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 18, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     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 Jan 18, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Jan 18, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0726 Nursing and Physician Services Deficiencies

     Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

     Corrected Jan 18, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0730 Nursing and Physician Services Deficiencies

     Observe each nurse aide's job performance and give regular training.

     Corrected Jan 18, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Jan 18, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Jan 18, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Jan 18, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 18, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Oct 24, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Oct 21, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Oct 31, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Oct 10, 2025 · CMS fire safety

3. May 19, 2025 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Jun 30, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Jun 30, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0908 Environmental Deficiencies

     Keep all essential equipment working safely.

     Corrected Jul 3, 2025 · CMS health inspection

4. Mar 17, 2025 Health · 5 findings
   • Not serious Scope/severity E Complaint

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Apr 21, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Apr 21, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Apr 21, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Mar 28, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Apr 21, 2025 · CMS health inspection

5. Aug 15, 2024 Health · 7 findings
   • Not serious Scope/severity E Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Sep 29, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Sep 29, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Sep 29, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 29, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0919 Environmental Deficiencies

     Make sure that a working call system is available in each resident's bathroom and bathing area.

     Corrected Sep 29, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Sep 29, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Sep 4, 2024 · CMS fire safety

6. Jul 18, 2024 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Aug 19, 2024 · CMS health inspection

7. Jan 23, 2024 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Mar 8, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Mar 8, 2024 · CMS health inspection

8. Jul 13, 2023 Health · 9 findings
   • Not serious Scope/severity E

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Aug 27, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Aug 27, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Aug 27, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Aug 27, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0808 Nutrition and Dietary Deficiencies

     Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

     Corrected Aug 27, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Aug 27, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Aug 4, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Aug 11, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Aug 27, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BERGER, AVIVA — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 07/01/2025
• BERGER, MENACHEM — managing control - governing body, NOT APPLICABLE, since 04/01/2022
• CARR, BARRY — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• CARR, BARRY — adp of the snf, NOT APPLICABLE, since 04/01/2022
• CARR, BARRY — managing control - governing body, NOT APPLICABLE, since 04/01/2022
• CARR, JARED — operational/managerial control, NOT APPLICABLE, since 01/01/2025
• CARR, JARED — adp of the snf, NOT APPLICABLE, since 01/01/2025
• CARR, JARED — indirect ownership interest, NOT APPLICABLE, since 01/01/2025
• FIELDS, TIMOTHY — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• FIELDS, TIMOTHY — adp of the snf, NOT APPLICABLE, since 04/01/2022
• FIELDS, TIMOTHY — managing control - governing body, NOT APPLICABLE, since 04/01/2022
• GILLIS, KAREN — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• GILLIS, KAREN — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• GILLIS, KAREN — adp of the snf, NOT APPLICABLE, since 04/01/2022
• GOBST, RYAN — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• ISRAEL, BENJAMIN — managing control - governing body, NOT APPLICABLE, since 04/01/2022
• ISRAEL, YEHUDIS — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 07/01/2025
• JABLONSKI, NICOLE — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• JABLONSKI, NICOLE — adp of the snf, NOT APPLICABLE, since 04/01/2022
• JABLONSKI, NICOLE — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• MCFARLANE, JOHN — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• MCFARLANE, JOHN — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• MCFARLANE, JOHN — adp of the snf, NOT APPLICABLE, since 04/01/2022
• MUSHTAQ, UZAIR — adp of the snf, NOT APPLICABLE, since 05/01/2022
• MUSHTAQ, UZAIR — operational/managerial control, NOT APPLICABLE, since 05/01/2022
• ROSE, MARC — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• ROSE, MARC — adp of the snf, NOT APPLICABLE, since 04/01/2022
• ROSE, MARC — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• SHEARER, RACHEL — adp of the snf, NOT APPLICABLE, since 04/01/2022
• SHEARER, RACHEL — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• SHEARER, RACHEL — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• STERN, TODD — managing control - governing body, NOT APPLICABLE, since 04/01/2022
• THENGIL, MATHEW — adp of the snf, NOT APPLICABLE, since 04/01/2022
• THENGIL, MATHEW — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• THENGIL, MATHEW — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• THEUS, MICHELLE — adp of the snf, NOT APPLICABLE, since 01/01/2023
• THEUS, MICHELLE — operational/managerial control, NOT APPLICABLE, since 01/01/2023
• THEUS, MICHELLE — indirect ownership interest, NOT APPLICABLE, since 01/01/2023
• WHITE, JIM — adp of the snf, NOT APPLICABLE, since 04/01/2022
• WHITE, JIM — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• WHITE, JIM — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• BERGER FAM TR UA 06252014 — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• BLUE PEARL FINANCIAL LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• GOLD PEARL, LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• IGNITE POST ACUTE SOLUTIONS LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• IGNITE SAN ANTONIO JV, LLC — direct ownership interest, NOT APPLICABLE, since 04/01/2022
• IGNITE TEAM PARTNERS LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• IGNITE TEAM PARTNERS LLC — adp of the snf, NOT APPLICABLE, since 06/25/2025
• IGNITE-VILLA HOLDCO LLC — direct ownership interest, NOT APPLICABLE, since 04/01/2022
• ISRAEL FAMILY INVESTMENT TRUST — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• ISRAEL INVESTMENT TR — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• PRESTIGE WORLDWIDE SAN ANTONIO, LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• SPARK THERAPY LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• SPARK THERAPY LLC — adp of the snf, NOT APPLICABLE, since 06/25/2025
• STERN FAMILY INVESTMENT TR — indirect ownership interest, NOT APPLICABLE, since 04/01/2022