Ignite Medical Resort Fort Worth, LLC

Penalties

• Feb 7, 2026 — Fine ($12,425)
• May 31, 2025 — Fine ($12,428)
• Sep 4, 2024 — Fine ($12,048)
• Jun 28, 2024 — Fine ($80,760)
• Oct 24, 2023 — Fine ($14,518)
• Sep 18, 2023 — Fine ($9,524)

Inspection findings

1. Feb 12, 2026 Fire Safety · 13 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Mar 12, 2026 · CMS fire safety

   • Not serious Scope/severity F

     E0037 Emergency Preparedness Deficiencies

     Establish staff and initial training requirements.

     Corrected Mar 12, 2026 · CMS fire safety

   • Not serious Scope/severity D

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected Mar 12, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Mar 12, 2026 · CMS health inspection

   • Not serious Scope/severity E

     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 12, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Mar 12, 2026 · 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 Mar 12, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Mar 12, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 12, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

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

     Corrected Mar 29, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 12, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Mar 12, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0901 Electrical Deficiencies

     Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

     Corrected Mar 12, 2026 · CMS fire safety

2. Feb 7, 2026 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected Feb 10, 2026 · CMS health inspection

3. Dec 8, 2025 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Dec 11, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Dec 11, 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 Dec 11, 2025 · CMS health inspection

4. Jul 10, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 25, 2025 · CMS health inspection

5. May 31, 2025 Health · 4 findings
   • Not serious Scope/severity E Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Jun 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

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

     Corrected Jun 27, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Jun 1, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     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 Jun 27, 2025 · CMS health inspection

6. Feb 5, 2025 Health · 3 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 Feb 28, 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 Feb 28, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Feb 28, 2025 · CMS health inspection

7. Nov 7, 2024 Health · 8 findings
   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Dec 15, 2024 · 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 Dec 15, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0909 Environmental Deficiencies

     Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

     Corrected Dec 15, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Dec 15, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

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

     Corrected Dec 15, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Dec 15, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

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

     Corrected Dec 15, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Dec 15, 2024 · CMS fire safety

8. Sep 4, 2024 Health · 6 findings
   • Not serious Scope/severity D Complaint

     F0691 Quality of Life and Care Deficiencies

     Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

     Corrected Sep 30, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0693 Quality of Life and Care Deficiencies

     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 Sep 30, 2024 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0697 Quality of Life and Care Deficiencies

     Provide safe, appropriate pain management for a resident who requires such services.

     Corrected Sep 30, 2024 · CMS health inspection

   • 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 Sep 30, 2024 · 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 Sep 30, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 30, 2024 · CMS health inspection

9. Jun 28, 2024 Health · 1 finding
   • Serious Scope/severity K Complaint

     F0697 Quality of Life and Care Deficiencies

     Provide safe, appropriate pain management for a resident who requires such services.

     Corrected Aug 2, 2024 · CMS health inspection

10. Mar 14, 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 Apr 15, 2024 · CMS health inspection

11. Nov 2, 2023 Health · 4 findings
    • Serious Scope/severity J Complaint

      F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

      Corrected Nov 20, 2023 · CMS health inspection

    • Serious Scope/severity J Complaint

      F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Develop and implement policies and procedures to prevent abuse, neglect, and theft.

      Corrected Nov 20, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

      Corrected Nov 20, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0691 Quality of Life and Care Deficiencies

      Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

      Corrected Nov 20, 2023 · CMS health inspection

12. Oct 24, 2023 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Dec 1, 2023 · CMS health inspection

13. Sep 18, 2023 Fire Safety · 18 findings
    • Not serious Scope/severity F

      E0020 Emergency Preparedness Deficiencies

      Establish policies and procedures including evacuation.

      Corrected Oct 15, 2023 · CMS fire safety

    • Not serious Scope/severity F

      E0023 Emergency Preparedness Deficiencies

      Establish policies and procedures for medical documentation.

      Corrected Oct 15, 2023 · CMS fire safety

    • Serious Scope/severity G Complaint

      F0580 Resident Rights Deficiencies

      Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

      Corrected Oct 15, 2023 · CMS health inspection

    • Serious Scope/severity G Complaint

      F0684 Quality of Life and Care Deficiencies

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

      Corrected Oct 15, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      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 Oct 15, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0694 Quality of Life and Care Deficiencies

      Provide for the safe, appropriate administration of IV fluids for a resident when needed.

      Corrected Oct 15, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0700 Quality of Life and Care Deficiencies

      Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

      Corrected Oct 15, 2023 · CMS health inspection

    • Not serious Scope/severity D

      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 Oct 15, 2023 · CMS health inspection

    • Serious Scope/severity G Complaint

      F0777 Administration Deficiencies

      Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.

      Corrected Oct 15, 2023 · 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 Oct 15, 2023 · CMS health inspection

    • Not serious Scope/severity F

      K0211 Egress Deficiencies

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

      Corrected Oct 15, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0222 Egress Deficiencies

      Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

      Corrected Oct 15, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Oct 15, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0355 Smoke Deficiencies

      Properly select, install, inspect, or maintain portable fire extinguishes.

      Corrected Oct 15, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0363 Smoke Deficiencies

      Install corridor and hallway doors that block smoke.

      Corrected Oct 15, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0372 Smoke Deficiencies

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

      Corrected Oct 15, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0712 Miscellaneous Deficiencies

      Have simulated fire drills held at unexpected times.

      Corrected Oct 15, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0900 Miscellaneous Deficiencies

      Meet Health Care Facilities Code mechanical requirements.

      Corrected Oct 15, 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 07/17/2025
• BERGER, MENACHEM — managing control - governing body, NOT APPLICABLE, since 04/01/2022
• CARR, BARRY — adp of the snf, NOT APPLICABLE, since 04/01/2022
• CARR, BARRY — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• CARR, BARRY — managing control - governing body, NOT APPLICABLE, since 04/01/2022
• CARR, JARED — adp of the snf, NOT APPLICABLE, since 01/01/2025
• CARR, JARED — operational/managerial control, 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 — adp of the snf, 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
• 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 06/25/2025
• JABLONSKI, NICOLE — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• JABLONSKI, NICOLE — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• JABLONSKI, NICOLE — adp of the snf, 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
• NILES, RICHARD — operational/managerial control, NOT APPLICABLE, since 02/21/2023
• NILES, RICHARD — adp of the snf, NOT APPLICABLE, since 02/21/2023
• NORRIS, JOHN — adp of the snf, NOT APPLICABLE, since 11/17/2025
• NORRIS, JOHN — operational/managerial control, NOT APPLICABLE, since 11/17/2025
• ROSE, MARC — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• ROSE, MARC — adp of the snf, NOT APPLICABLE, since 04/01/2022
• ROSE, MARC — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• SHEARER, RACHEL — operational/managerial control, 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
• STERN, TODD — managing control - governing body, 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
• THENGIL, MATHEW — adp of the snf, NOT APPLICABLE, since 04/01/2022
• WHITE, JIM — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• WHITE, JIM — adp of the snf, NOT APPLICABLE, since 04/01/2022
• WHITE, JIM — operational/managerial control, 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 FORT WORTH JV LLC — direct ownership interest, NOT APPLICABLE, since 04/01/2022
• IGNITE POST ACUTE SOLUTIONS LLC — indirect 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 FORT WORTH, LLC — direct 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