Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 1 of
1 resident (Resident #66) reviewed for baseline care plans:
The facility failed to complete Resident #66's baseline care plan in a person-centered manor that accurately
depicted resident's condition upon entrance to the facility.
This deficient practice could affect residents who receive care at the facility and could result in missed or
inadequate care.
The findings included:
Record review of Resident #66's face sheet dated 6/11/25 revealed a [AGE] year-old male admitted to the
facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following cerebral infarction
affecting right dominant side, Other Toxic Encephalopathy , Other Seizures, Acute Respiratory Failure with
Hypoxia, Extended Spectrum Beta Lactamase (ESBL) Res istance, Local infection of the skin and
subcutaneous tissue, unspecified, Quadriplegia, unspecified, Morbid Obesity with Alveolar Hypoventilation,
Neuromuscular Dysfunction of bladder, hypotension, hypo-osmolality and Hyponatremia, Pleural Effusion,
not elsewhere classified, Sepsis, Unspecified organism, Obstructive sleep Apnea, Autonomic Dysreflexia,
Hypertensive Chronic Kidney Disease with stage 1 through 4, Chronic Atrial Fibrillation, Chronic Diastolic
(Congestive) Heart Failure, Other Speech and Language Deficits Following Cerebral infarction, Other
specified soft tissue disorders, Slurred Speech, and Acute Posthemorrhagic Anemia.
Record review of Resident #66's admission MDS dated [DATE] had not been completed before exit on
6/11/25.
Record review of Resident #66's baseline care plan, with an initiation date of 6/5/2025 indicated: Focus:
The resident is at risk for alteration in skin integrity. Goal: the resident will remain free of new skin
impairment through the review date. Interventions: Apply barrier cream per facility protocol to help protect
skin from excess moisture, encourage/assist with turning and repositing every 2-3 hours, and provide
skin/wound treatments as ordered.
Record review of Resident #66's Progress note dated 6/5/2025 at 6:40 PM, titled Nursing Evaluation
revealed the following:
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
676460
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676460
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ignite Medical Resort Webster, LLC
16130 Galveston Rd
Webster, TX 77598
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
-
Level of Harm - Minimal harm
or potential for actual harm
Skin integrity: The Resident has skin integrity concerns. Right knee (front)- skin tear, Left iliac crest (front)Burn spot, Ulcer on both heels.
Residents Affected - Few
Neurological: Is alert. Is oriented to person. Is oriented to place. Is oriented to time. Is oriented to Situation.
Resident has clear speech. Hand grasps are weak on right side.
Record review of Resident # 66's Wound Rounds dated 6/6/2025 he was Moderately at Risk for skin issues.
He was admitted with an Abrasion to Abdomen and left Elbow, a Pressure ulceration of left lateral and
medial foot unstageable, Pressure Ulceration Right Heel unstageable, and Fungal infection on right side
upper back. All were identified on 6/6/2025.
Record review of Resident #66's physician's telephone orders, dated 6/5/2025 revealed the following:
- Pressure Reducing cushion for wheelchair Ordered 6/5/2025
- Pressure Reducing Mattress on bed Ordered 6/5/2025
- Prevision boots: Monitor placement every shift for Bilateral heels Ordered 6/6/2025
Record review of Resident #66's Wound TAR dated 6/1/2025-6/30/2025 revealed the following:
Right Toes: Clean with wash cloth, pat dry, paint with betadine, wrap with kerlix everyday shift for wound.
First started on 6/6/2025.
Santyl External Ointment 250 unit/GM Apply to left lateral foot topically everyday shift for wound clean with
wash cloth, pat dry, apply ointment, and cover with xeroform and wound dressing. First administer 6/7/2025
Santyl External Ointment 250 Unit/GM Apply to right heal topically every day shift for wound clean with
wash cloth, pat dry, apply ointment , cover with Santyl and wound dressing. First administered 6/6/2025.
D/C 6/9/2025
Mupirocin External Ointment 2% Apply to abdomen topically every day shift every other day for wound
clean with wash cloth, pat dry, apply ointment, cover with wound dressing. First administered on 6/7/2025.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676460
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676460
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ignite Medical Resort Webster, LLC
16130 Galveston Rd
Webster, TX 77598
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In an interview with Resident #66 on 6/9/2025 at 3:40 PM, resident said the facility staff treat him well.
Resident was observed having a hard time talking due to having a hard time breathing. At the time he did
not have his oxygen on his face. He put his oxygen on his face. Resident stated his oxygen was only as
needed.
During an interview with MDS Nurse A on 6/11/2025 at 01:04 PM she stated baseline care plans usually
include enhanced barriers, fall risk, medications, indwelling catheter, diet, code status, return to community
or discharge plan and cognitive state, using oxygen, peg tube, basic skin evaluation will be on there and if
there are any interventions. Since it is the baseline, and they are still in the comprehensive window they can
still add things. She said if resident comes in with wounds, they should be documented on the 48 Hour care
plan. She said she felt the statement on Resident # 66's care plan provide skin/wound care as ordered
covered everything.
In a follow up interview with MDS Nurse A on 6/11/2025 at 1:11 PM, she stated she had a resident
assessment certification from a MDS certification course. It is renewed every 2 years, and she had to take
continuing education classes to maintain the certificate. She stated that not completing a care plan
accurately could have a potential of negative care and delay in treatment or care of the resident.
In an interview with the DON on 6/11/2025 at 3:08 PM, he stated that baseline care plans are started by
the nurse who does the assessment for the resident. He stated that they make sure care plans are accurate
by documentation during morning meetings and it's an ongoing process. When asked how it can affect the
residents care if care plan is not correct, he stated that a baseline care plan gives a picture of the patient it
is more minimal for baseline with minimal information as they do not know the resident yet. A detailed
report would go on their comprehensive care plan.
Record review of the facility document titled, Care Plan Revision date of November 2018 and last reviewed
11/2024 revealed in part: General: Each resident will have a care plan that is current, individualized, and
consistent with their medical regimen. Responsible Party: Care Plan/ MDS coordinator, Social Services,
Activities, Rehab, Dietary, Nursing, and other members of the interdisciplinary team. A baseline care plan is
developed for each resident upon admission, but no later than 48 hours of admission, to the facility, this
care plan includes minimum health care information necessarily to properly care for the resident. The care
plans are developed by the members of the interdisciplinary team based on their assessments and
interaction with the resident and/or resident's significant others. The care plan consists of the following
Problems as identified by reviewing the medical record and discussion with the resident/and or significant
others.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676460
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676460
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ignite Medical Resort Webster, LLC
16130 Galveston Rd
Webster, TX 77598
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to develop and implement a comprehensive
person-centered care plan for each resident, that includes measurable objective and time frames to meet a
resident's medical, nursing, mental and psychosocial needs for 1 (Resident #3) of 6 residents reviewed for
care plans.
The facility failed to ensure that Resident #3's care plan was person-centered as it did not include
information specifying what Resident #3 was resistive of care to and did not specify specific medications for
interventions.
This failure could place residents at risk of not receiving appropriate care and interventions to meet their
needs or staff having complete knowledge regarding a resident's care.
Findings included:
Record review of Resident #3's face sheet dated 6/11/2025, revealed the resident was an [AGE] year-old
female admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection and Need for
Assistance with Personal Care.
Record review of Resident #3's admission MDS dated [DATE] revealed a BIMS score of 15 that indicated
cognition was intact . MDS also revealed Resident #3's rejection of evaluation or care (e.g. bloodwork,
taking medications, ADL assistance) that behavior occurred 1 to 3 days. MDS also revealed Resident #3
required varying degrees of assistance from independent to substantial/maximal assistance for functional
abilities.
Record review of Resident #3's care plan printed 6/11/25 at 11:53 a.m., revealed focus Resident #3 is
resistive to care (SPECIFY) r/t with date initiated of 5/22/25 but no information regarding what resident was
resistive to. Care plan also had focuses related to diuretic (medication that increases production of urine)
use, receiving opioid (medication used to treat pain) medications, and anticoagulant (blood thinner) therapy
but specific medications were not listed.
Record review of Resident #3's Order Summary Report dated 6/11/25 revealed active orders for
Acetaminophen-Codeine (opioid/medication used to treat pain) Tablet 300-30 mg with instructions to give 1
tablet by mouth every four hours as needed for pain, Apixaban (anticoagulant/blood thinner) oral tablet 5
mg with instructions to give 1 tablet by mouth two times a day, Furosemide (diuretic/medication that
increases production of urine) oral tablet 20 mg with instructions to give 1 tablet by mouth one time a day
for edema (swelling).
Record review of Resident #3's May 2025 and June 2025 MAR revealed Resident #3's refusal of
medications.
Record review of Resident #3's May 2025 and June 2025 TAR revealed Resident #3's refusal of being
weighed.
During an interview on 6/11/25 at 12:59 p.m., MDS Coordinator A said items on the care plan like when
resident was receiving opioid (medication used to treat pain) therapy was not written with the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676460
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676460
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ignite Medical Resort Webster, LLC
16130 Galveston Rd
Webster, TX 77598
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
specific medication as sometimes they change pain medications.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 6/11/25 at 12:59 p.m., MDS Coordinator B said she worked at the facility since May
2021 and worked on the hallway with Resident #3. MDS Coordinator B said regarding items on the care
plan like if a resident was receiving opioid, antibiotic, diuretic therapy etc., medications were not specific as
medications change frequently and it was hard to keep up with medication changes and residents were
here short term. MDS Coordinator B said that residents' medications change quickly. MDS Coordinator B
said that regarding Resident #3's care plan focus of Resident #3 is resistive to care that the care plan
should be specific regarding what resident was resistant to but was probably medication refusal. MDS
Coordinator B said she completed the care plan from the MDS and what trigged from the cause. MDS
Coordinator B said the nurses did the baseline care plan, so things were pulled from the baseline care plan
into the care plan, and she built from that. MDS Coordinator B said it depended on who care plans what.
MDS Coordinator B said it was probably them that was responsible for the resistive focus on Resident #3's
care plan because it triggered on the cause. MDS Coordinator B said if the care plan did not have all the
information needed it would affect the staff's knowledge of how to care for the resident as they used the
care plan to care for residents. MDS Coordinator B said if a resident was resistant to care then staff needed
to know and what they liked to refuse. MDS Coordinator B said they had a consultant to refer to regarding
care plans. MDS Coordinator B said they got any updates that affect care plans regarding MDS through
MDS certification and consultant. MDS Coordinator B said the DON will give in-services if there were
changes regarding care plans. MDS Coordinator B said that during the morning meeting if the nurse
reported changes for residents that was when they care planned changes. MDS Coordinator B said We
look to see if things have been care planned from the morning meetings and if changes.
Residents Affected - Few
During interview on 6/11/25 at 1:23 p.m. MDS Coordinator B said she updated Resident #3's care plan to
reflect her resistance of mediations.
Record review of Resident #3's care plan printed 6/11/25 at 1:27 p.m. revealed focus Resident #3 is
resistive to care (refusal of medications).
During interview on 6/11/25 at 3:06 p.m., the DON said the MDS Coordinators was responsible for entering
information on the comprehensive care plans. The DON said there was two MDS Coordinators one for the
north hall and one for the south hall. The DON said they was to ensure accuracy of the comprehensive care
plans through documentation of every department, morning meetings that occurred Monday through Friday
and was an ongoing process. The DON said that they received updates from each department and from
weekend staff. The DON said if the comprehensive care plan was not accurate then the care plan would not
show the picture of the resident.
Record review of facility's policy Care Plan with last revision 11/2024 revealed Problems as identified by
reviewing the medical record and discussion with the resident and /or significant others.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676460
If continuation sheet
Page 5 of 5
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
FAQ · About this visit
Common questions about this visit
What happened during the June 11, 2025 survey of IGNITE MEDICAL RESORT WEBSTER, LLC?
This was a inspection survey of IGNITE MEDICAL RESORT WEBSTER, LLC on June 11, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at IGNITE MEDICAL RESORT WEBSTER, LLC on June 11, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted"
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.