Ignite Medical Resort Fort Worth, LLC
6301 Oakmont Blvd, Fort Worth, TX 76132 · Tarrant County · 70 certified beds · avg 48 residents/day · certified since Jun 21, 2018
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: 2/5
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, one-off · May 31, 2025 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jun 1, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Jun 28, 2024 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Aug 2, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Nov 2, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 20, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Nov 2, 2023 · F-0607 · triggered by a complaint
The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Why it matters: Without working prevention policies, mistreatment is more likely to happen and less likely to be caught.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 20, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 7, 2026 · F-0698 · triggered by a complaint
The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Why it matters: Mistakes in dialysis care can quickly become life-threatening for residents with kidney failure.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 10, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 4, 2024 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 30, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 18, 2023 · 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 15, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 18, 2023 · 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 15, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 18, 2023 · F-0777 · triggered by a complaint
The facility did not provide or obtain x-rays and other imaging tests when ordered, or did not promptly tell the ordering doctor the results.
Why it matters: A missed or delayed x-ray can leave a fracture or illness untreated while a resident is in pain.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 15, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (43)
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 |
|---|---|---|
| Feb 12, 2026 | 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. |
| Feb 12, 2026 | F · Potential for harm, facility-wide | The facility did not dispose of garbage and refuse properly. |
| Feb 12, 2026 | 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. |
| Feb 12, 2026 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Feb 12, 2026 | 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. |
| Feb 12, 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. |
| Feb 7, 2026 | ▲ G · Actual harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint |
| Dec 8, 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 8, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Dec 8, 2025 | 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. · from a complaint |
| Jul 10, 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 |
| May 31, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| May 31, 2025 | E · Potential for harm, repeated | 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 |
| May 31, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| May 31, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Feb 5, 2025 | E · Potential for harm, 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 |
| Feb 5, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Feb 5, 2025 | 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. · from a complaint |
| Nov 7, 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. |
| Nov 7, 2024 | 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. |
| Nov 7, 2024 | D · Potential for harm, one-off | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. · from a complaint |
| Sep 4, 2024 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Sep 4, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy. · from a complaint |
| Sep 4, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Sep 4, 2024 | 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. · from a complaint |
| Sep 4, 2024 | 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 |
| Sep 4, 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 28, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Mar 14, 2024 | 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 |
| Nov 2, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 2, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Nov 2, 2023 | 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 |
| Nov 2, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy. · from a complaint |
| Oct 24, 2023 | 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 |
| Sep 18, 2023 | ▲ G · Actual harm, one-off | 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 |
| Sep 18, 2023 | ▲ G · Actual 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 |
| Sep 18, 2023 | ▲ G · Actual harm, one-off | The facility did not provide or obtain x-rays and other imaging tests when ordered, or did not promptly tell the ordering doctor the results. · from a complaint |
| Sep 18, 2023 | 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. |
| Sep 18, 2023 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 18, 2023 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Sep 18, 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. |
| Sep 18, 2023 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 13 | 5 | J ▲ |
| 2024 | 11 | 2 | K ▲ |
| 2025 | 11 | 1 | J ▲ |
| 2026 | 8 | 1 | G ▲ |
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)
6 fines totaling $141,703.
| Date | Type | Amount / length |
|---|---|---|
| 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 |
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) | 3.61 | 3.46 | 3.95 | top 30% in Texas; bottom 42% in the U.S. |
| Registered Nurse hours | 0.77 | 0.44 | 0.69 | top 7% in Texas; top 30% in the U.S. |
| Weekend total nurse staffing | 3.22 | 3.04 | 3.50 | top 28% in Texas; bottom 43% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.60 | 0.34 | 0.48 | top 8% in Texas; top 23% in the U.S. |
| Total nursing staff turnover (%) | 54.5 | 55.3 | 45.8 | bottom 44% in Texas; bottom 26% in the U.S. |
| RN turnover (%) | 62.5 | 54.6 | 42.9 | bottom 38% in Texas; bottom 19% in the U.S. |
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 4.36, RN 0.93, weekend 3.90. Staffing rating: 2/5.
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: 5/5 · long-stay residents: —/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Berger Fam Tr Ua 06252014 | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Blue Pearl Financial LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Carr, Jared | Individual | Indirect Ownership Interest | NOT APPLICABLE | 01/01/2025 |
| Gillis, Karen | Individual | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Gobst, Ryan | Individual | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Gold Pearl, LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Ignite Fort Worth JV LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Ignite Post Acute Solutions LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Ignite-Villa Holdco LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Israel Family Investment Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Israel Investment Tr | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Jablonski, Nicole | Individual | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| McFarlane, John | Individual | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Prestige Worldwide Fort Worth, LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Rose, Marc | Individual | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Shearer, Rachel | Individual | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Stern Family Investment Tr | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Thengil, Mathew | Individual | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| White, Jim | Individual | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Berger, Aviva | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/17/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "How do you coordinate and monitor care for residents who receive dialysis?"
- "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?"
- "If a doctor orders an x-ray, how soon does it happen and when does the doctor see the results?"
- "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 |
|---|---|---|---|---|---|
| Wedgewood Nursing Home | 0.8 mi | Fort Worth, TX | ★★★☆☆ | 2/5 | |
| Cityview Nursing and Rehabilitation Center | 0.9 mi | Fort Worth, TX | ★★☆☆☆ | 1/5 | |
| Garden Terrace Healthcare Center of Fort Worth | 1.1 mi | Fort Worth, TX | ★★★★☆ | 3/5 | |
| Ft. Worth Southwest Nursing Center | 1.3 mi | Fort Worth, TX | ★★★☆☆ | 2/5 | |
| Avir at Fort Worth | 1.5 mi | Fort Worth, TX | ★★☆☆☆ | 1/5 | abuse |
| Mira Vista Court | 1.6 mi | Fort Worth, TX | ★★☆☆☆ | 2/5 | |
| Renaissance Park Multi Care Center | 2.1 mi | Fort Worth, TX | ★★☆☆☆ | 2/5 | |
| Benbrook Nursing & Rehabilitation Center | 3.6 mi | Benbrook, TX | ★☆☆☆☆ | 1/5 | abuse |
| Stonegate Nursing and Rehabilitation | 3.6 mi | Fort Worth, TX | ★★★★★ | 4/5 | |
| Arlington Heights Health and Rehabilitation Center | 4.4 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
| Estates Healthcare and Rehabilitation Center | 5.0 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | abuse |
| Ridgmar Medical Lodge | 5.4 mi | Fort Worth, TX | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 676449.