Ignite Medical Resort el Paso, LLC
3421 Joe Battle Boulevard, El Paso, TX 79936 · El Paso County · 60 certified beds · avg 51 residents/day · certified since Oct 19, 2017
SFF Candidate
Part of chain: IGNITE MEDICAL RESORTS (22 facilities, chain avg rating 2.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Mar 13, 2026 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Apr 6, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Mar 13, 2026 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Apr 6, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Mar 13, 2026 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Apr 6, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (40)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 13, 2026 | ▲ K · Immediate jeopardy, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Mar 13, 2026 | ▲ K · Immediate jeopardy, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 13, 2026 | ▲ K · Immediate jeopardy, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Mar 13, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Mar 13, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Dec 17, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Dec 17, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Dec 17, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Dec 4, 2025 | F · Potential for harm, facility-wide | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Dec 4, 2025 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Dec 4, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Dec 4, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Dec 4, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Dec 4, 2025 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint |
| Dec 3, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Jul 31, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jul 31, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 31, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Jul 31, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 31, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 27, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Mar 27, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jul 19, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| Sep 13, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 14, 2023 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Apr 14, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 14, 2023 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Apr 14, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Apr 14, 2023 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Apr 14, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Apr 14, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 14, 2023 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (8 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 9 | 0 | E |
| 2024 | 9 | 0 | E |
| 2025 | 17 | 0 | F |
| 2026 | 5 | 3 | K ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $67,425.
| Date | Type | Amount / length |
|---|---|---|
| Mar 13, 2026 | Fine | $67,425 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.81 | 3.46 | 3.95 | bottom 12% in Texas; bottom 8% in the U.S. |
| Registered Nurse hours | 0.65 | 0.44 | 0.69 | top 12% in Texas; top 42% in the U.S. |
| Weekend total nurse staffing | 2.47 | 3.04 | 3.50 | bottom 13% in Texas; bottom 8% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.33 | 0.34 | 0.48 | top 39% in Texas; bottom 38% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 55.3 | 45.8 | — |
| RN turnover (%) | 0.0 | 54.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.24, RN 0.75, weekend 2.84. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 4/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ab Investment Trust U/A/D 1/3/23 | Organization | 5% or Greater Indirect Ownership Interest | — | 12/01/2024 |
| Ignite el Paso JV, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 12/01/2024 |
| Ignite Medical Resort el Paso, LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 12/01/2024 |
| Prestige Worldwide el Paso, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 12/01/2024 |
| Ab Investment Trust U/A/D 1/3/23 | Organization | ADP of the SNF | NOT APPLICABLE | 01/16/2025 |
| Berger Fam Tr Ua 06252014 | Organization | ADP of the SNF | NOT APPLICABLE | 01/16/2025 |
| Blue Pearl Financial LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/16/2025 |
| Carr, Barry | Individual | ADP of the SNF | NOT APPLICABLE | 01/16/2025 |
| Fields, Timothy | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Fields, Timothy | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Flores, Claudia | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Gold Pearl, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/16/2025 |
| Ignite el Paso JV, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/16/2025 |
| Ignite el Paso Property, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/16/2025 |
| Ignite Medical Resort el Paso, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 11/14/2024 |
| Ignite Medical Resort el Paso, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/16/2025 |
| Ignite Post Acute Solutions LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/16/2025 |
| Ignite Team Partners LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 11/14/2024 |
| Ignite Team Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/16/2025 |
| Ignite-Villa Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/16/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can you show me the call buttons in the bathrooms and bathing areas, and tell me your average response time when one is pressed?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Center at Zaragoza, LLC | 1.1 mi | El Paso, TX | ★★★★☆ | 3/5 | |
| Avir at Tierra Este | 2.5 mi | El Paso, TX | ★☆☆☆☆ | 1/5 | |
| Edgemere Estates | 2.9 mi | El Paso, TX | ★☆☆☆☆ | 2/5 | |
| El Paso Health & Rehabilitation Center | 3.4 mi | El Paso, TX | ★☆☆☆☆ | 2/5 | |
| Pebble Creek Nursing Center | 3.7 mi | El Paso, TX | ★☆☆☆☆ | 1/5 | abuseSFF |
| St. Teresa Nursing & Rehab Center | 4.1 mi | El Paso, TX | ★☆☆☆☆ | 2/5 | |
| Vista Hills Health Care Center | 4.3 mi | El Paso, TX | ★☆☆☆☆ | 2/5 | |
| Oasis Nursing & Rehabilitation Center | 6.8 mi | El Paso, TX | ★★★★☆ | 4/5 | |
| St. Giles Nursing and Rehabilitation Center | 7.5 mi | El Paso, TX | ★★☆☆☆ | 3/5 | |
| Las Ventanas de Socorro | 9.3 mi | Socorro, TX | ★★☆☆☆ | 2/5 | |
| Nazareth Living Care Center | 9.4 mi | El Paso, TX | ★★☆☆☆ | 2/5 | |
| Mountain Villa Nursing Home | 11.2 mi | El Paso, TX | ★★★★☆ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 676428.