Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ignite Medical Resort Katy, Llc during CMS and state inspections, most recent first.
The facility failed to ensure that three dependent, incontinent residents received scheduled showers or bed baths three times weekly as required for ADLs and personal hygiene. Each resident had significant medical conditions, including respiratory failure, PEG tubes, colostomies, ESRD on hemodialysis, hip fracture, and mobility impairments, and required substantial or total assistance with bathing. Residents and families reported that baths were infrequent and often only occurred when specifically requested. EMR shower task records showed missing or “Not Applicable” entries on multiple scheduled bath days, and the shower sheet binder lacked corresponding paper documentation or refusals. Paper shower sheets produced after survey exit showed some bed baths that were not consistently documented in the EMR. Facility policies required scheduled hygiene care and emphasized dignity and respect, but observations, interviews, and record review showed that scheduled showers/bed baths were not reliably provided or documented for these residents.
A resident with cognitive impairment and multiple chronic conditions was admitted with a sacral pressure injury, but did not receive documented wound care, assessments, or treatment for this wound during their stay. Despite a care plan requiring regular evaluation and treatment, there was no evidence in the EMR of wound care being provided, and staff did not escalate the lack of orders or treatment. Interviews revealed the wound was missed and left untreated, possibly due to a change in documentation systems, and staff could not explain the failure to address the missing care.
A resident with end stage renal disease, heart failure, and severe cognitive impairment did not have their weights consistently documented as required by physician orders and the care plan. Despite the care plan identifying the need to monitor for fluid overload and the facility's policy emphasizing person-centered care, staff failed to record the resident's weight on a scheduled date, and this omission was confirmed through record review and staff interviews.
A resident with multiple complex medical conditions was not weighed as ordered by the physician, and the required weight documentation was missing from the medical record. Staff interviews confirmed that the process for obtaining and recording weights was not followed, resulting in a failure to monitor the resident's nutritional status as outlined in the care plan and facility policy.
A resident with esophageal cancer experienced severe pain due to the facility's failure to provide prescribed pain medications, Lyrica and Tramadol, after admission. The resident missed multiple doses, and staff did not follow protocols to ensure medication availability or conduct required pain assessments. Communication breakdowns among nursing staff, the DON, and the pharmacy contributed to the deficiency.
A resident with esophageal cancer did not receive prescribed pain medications, Lyrica and Tramadol, from admission until two days later due to a failure in communication and protocol adherence. Despite physician orders, the pharmacy did not have the prescriptions, and nursing staff did not effectively intervene, leading to unmanaged pain. The resident's family repeatedly requested pain relief, but the facility did not follow its pharmaceutical services and pain management policies, resulting in the resident experiencing significant pain.
A resident's dignity was compromised when their Foley catheter bag was not covered with a privacy bag, as observed by staff. Despite being aware of the issue, the staff had not addressed it due to being busy. The resident, who was cognitively intact and had multiple health conditions, was left with their Foley bag exposed, which was acknowledged as a dignity issue by the RN, CNA, and DON.
A resident with a urinary catheter was observed with foley tubing touching the floor, posing a risk of infection. Despite having a care plan to check tubing placement, staff failed to prevent the tubing from touching the floor during a transfer. Interviews revealed a lack of specific training for foley care, although infection control training was provided. The facility's policy requires the collection bag to be kept off the floor.
A resident with multiple health conditions requiring enteral nutrition did not receive appropriate care during a feeding procedure. RN A failed to verify tube placement, used cold water for flushing, and did not follow infection control protocols. The resident's care plan and facility policies were not adhered to, potentially compromising the resident's safety.
The facility failed to maintain an effective infection prevention and control program, with observed deficiencies involving staff members. A CNA left a waste bag on the floor, and an RN did not follow proper infection control procedures during a resident's G-tube feeding, including failing to don a gown and using the same gloves throughout the procedure. Additionally, a resident's Foley catheter tubing was observed touching the floor, posing an infection risk.
Failure to Provide and Document Scheduled Showers/Bed Baths for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure dependent residents received scheduled showers or bed baths three times weekly to maintain grooming and personal hygiene. For one female resident with acute respiratory failure, mouth cancer, pulmonary fibrosis, tracheostomy, PEG tube, and total dependence for bathing, the admission MDS documented that she was always incontinent of bowel and bladder and required full assistance with showers/baths. Her care plan addressed ADL self-care deficits and incontinence care but did not include specific shower/bath interventions. During observation and interview, the resident communicated via a board that she only received a bed bath once a week and wanted at least two baths weekly; her family member reported having already spoken with the administrator about the issue. EMR shower task records for the prior 30 days showed only two entries, both marked “Not Applicable,” with no documentation of completed showers/baths or refusals on the dates she was scheduled to receive them. After survey exit, paper shower sheets provided by the facility showed bed baths on four dates, but these were not reflected in the EMR shower task documentation. A second female resident with diverticulitis with perforation and abscess, type 2 diabetes, heart failure, splenic abscess, acute respiratory failure, ESRD on hemodialysis, PEG tube, colostomy, and dependence for showers/baths was also involved. Her admission MDS showed normal cognition, lower extremity impairment, wheelchair use, and dependence for showers/baths, with incontinence of bladder and shortness of breath with exertion, at rest, and when lying flat. Her care plan included a focus on ADL self-care deficits and incontinence, with an intervention specifying substantial/max assist with baths/showers. During observation and interview, the resident’s family member stated she had only received one bath so far and only after they requested it, and the resident stated she wanted at least two baths weekly to help prevent infections. Review of the shower sheet binder showed no paper shower sheets or refusals for this resident, and EMR shower tasks for the prior 30 days showed “No Data Found” despite her being scheduled for showers/baths three times weekly. After exit, paper shower sheets produced by the facility showed three bed baths, which again were not documented in the EMR shower task system. A third male resident with a right hip fracture, atrial fibrillation, pacemaker, muscle weakness, gait and mobility abnormalities, and incontinence of bowel and bladder was also affected. His admission MDS documented normal cognition, lower extremity impairment, wheelchair use, and a need for substantial/max assistance with showers/baths. His care plan addressed ADL self-care deficits and incontinence, with an intervention specifying substantial/max assist with baths/showers. During observation and interview, he reported that his only complaint was not receiving baths three times a week, that he required bed baths because he could not walk, and that he did not remember the last time he had received one. EMR shower task records for the prior 30 days showed only four completed baths, with missing entries for other scheduled dates. The shower sheet binder contained only one paper shower sheet for the month documenting a bath on one date, with no other sheets or refusals. After exit, the facility provided additional paper shower sheets showing bed baths on two later dates, which were not consistently reflected in the EMR. Interviews with the DON and a CNA confirmed that showers/baths were expected three times weekly and that documentation should occur in the EMR, with paper sheets used primarily to note skin issues, but the records reviewed did not substantiate that scheduled showers/baths were consistently provided or documented for these residents. Facility policies on Activities of Daily Living and Resident Rights stated that hygiene is to be maintained, showers and baths are to be scheduled with assistance provided, and residents are to be treated with dignity and respect in a manner that maintains or enhances quality of life, self-esteem, and self-worth. Despite these policies, the survey findings showed missing or incomplete documentation of scheduled showers/baths in both the EMR and paper shower sheets for three residents who were dependent or required substantial/max assistance for bathing and were incontinent. Progress notes for the review periods contained no documentation of refusals of showers/baths for these residents. The combination of resident and family reports, observation, and record review demonstrated that the facility failed to ensure that these residents received the necessary services to maintain personal hygiene and grooming as scheduled and as required by their conditions and care plans.
Failure to Provide and Document Wound Care for Pressure Injury
Penalty
Summary
A resident with cognitive impairment and multiple chronic medical conditions, including sepsis and type 2 diabetes, was admitted to the facility with a documented sacral pressure injury and other skin conditions. The resident's care plan specified that the sacral wound should be evaluated and treated per physician's orders, with regular assessments, documentation, and monitoring. Despite these requirements, there was no documentation of wound care treatment, dressing changes, wound staging, wound assessments, or measurements for the sacral pressure injury from admission through discharge. Nursing staff submitted a wound care consultation at admission, and the Wound Care Nurse identified the sacral wound. However, the Wound Care NP did not assess or treat the sacral pressure injury during the resident's stay, and no wound care orders were provided or implemented for this wound. The facility's electronic medical record (EMR) contained no evidence of treatment or monitoring for the sacral wound, and staff interviews confirmed that if care was not documented in the EMR, it was not performed. There was also no evidence that nursing staff followed up with the provider regarding missing orders, notified the DON or Administrator, or escalated concerns about the lack of treatment. Interviews with the DON, Wound Care NP, Wound Care Nurse, and other staff revealed a lack of clarity and follow-through regarding responsibility for ensuring wound care was provided and documented. The Wound Care NP and Wound Care Nurse both acknowledged that the sacral wound was missed and left untreated, possibly due to a transition in the wound care documentation system. Staff could not explain why the absence of treatment orders was not escalated, and there was no documentation of staff training related to wound care order, prevention, and management during the relevant period.
Failure to Implement Comprehensive Care Plan and Document Weights for Dialysis Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including end stage renal disease, heart failure, and dependence on dialysis. The resident required total assistance with activities of daily living and had severe cognitive impairment. Although the care plan identified the need to monitor for fluid overload and included interventions such as monitoring and documenting weights, the facility did not ensure that weights were consistently documented as ordered by the physician. Specifically, there was no documentation of the resident's weight on a scheduled date, and this omission was confirmed through review of the medical administration record, treatment administration record, and progress notes. Interviews with staff revealed that weights were typically obtained by aides and then reported to the nurse for documentation, but in this instance, the required documentation was missing. The DON and Administrator acknowledged that weights were important for tracking the resident's progress and care, and that failure to document weights could result in a lack of awareness of the resident's condition. The facility's policy emphasized person-centered care and monitoring of key indicators such as unintended weight loss, but the failure to document weights as required represented a lapse in following both physician orders and facility policy.
Failure to Document Required Resident Weights per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status by not following physician orders for regular weight monitoring. Specifically, the resident, who had multiple complex medical diagnoses including second-degree burns, COPD, type 2 diabetes, anemia, dependence on renal dialysis, major depressive disorder, and heart failure, was not weighed on a scheduled date as ordered by the physician. The resident's care plan included monitoring for alterations in nutrition and hydration, with specific interventions to track and report significant weight loss. However, review of the medical administration records and weight logs showed that the required weight measurement was not documented on the specified date. Interviews with staff revealed that weights were typically obtained by aides and then reported to a nurse for documentation, but in this instance, the process was not completed as required. The DON acknowledged that weights should have been documented to monitor the resident's progress, and the absence of this documentation meant that staff would not be aware of changes in the resident's condition. The facility's policy emphasized person-centered care and monitoring of unintended weight loss, but the failure to document the resident's weight as ordered constituted a deficiency in care.
Failure in Pain Management for Resident with Esophageal Cancer
Penalty
Summary
The facility failed to provide adequate pain management for a resident with esophageal cancer, resulting in the resident missing multiple doses of prescribed pain medications, Lyrica and Tramadol, after being admitted from a cancer treatment hospital. The resident missed six doses of Lyrica over a period of two days and reported experiencing severe pain at a level of 10 on a scale of 0 to 10. The facility did not ensure that the pain medications were available and administered as per the physician's orders, nor did they conduct pain assessments every shift as required. The nursing staff, including RN A and RN B, did not follow proper protocols when the pain medications were not delivered. RN A failed to notify the Director of Nursing (DON) about the missing medications and did not verify the availability of the medications in the building. RN B did not document calls made to the pharmacy or notify the physician or DON about the issue. The facility's system for ensuring the availability of medications broke down, as the nurses did not communicate effectively with the physician or pharmacy to resolve the issue. Interviews with the DON, VPCO, and NP B revealed that there was a lack of communication and adherence to protocols, which contributed to the resident's pain not being managed effectively. The facility's policies on pharmacy services and pain management were not followed, leading to the resident experiencing unnecessary pain. The failure to provide timely and appropriate pain management could cause serious harm to residents who rely on these medications for relief.
Failure to Provide Pain Medication to Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with cancer of the esophagus, resulting in the resident not receiving prescribed pain medications, Lyrica and Tramadol, from the time of admission on 09/04/2024 until 09/06/2024. Despite the physician orders for these medications being created on 09/04/2024, the pharmacy did not have the prescriptions, and the nursing staff did not intervene effectively to ensure the medications were available. This led to the resident experiencing unmanaged pain, as indicated by a pain level of 10 reported by the resident on 09/06/2024. The resident's care plan highlighted the potential for pain and required immediate response to any pain complaints, yet the facility did not conduct pain evaluations consistently, and there was no documentation of pain medication administration until 09/06/2024. Interviews with the resident's family member and nursing staff revealed that the family repeatedly requested pain medication, but the nurses failed to take appropriate action to resolve the issue. The nursing staff did not follow the facility's protocol for obtaining medications from the emergency kit or notifying the physician and DON about the missing medications. The breakdown in communication and protocol adherence was evident in the interviews with the nursing staff and the DON. The nurses did not document their attempts to resolve the issue or notify the appropriate personnel, leading to a delay in addressing the resident's pain management needs. The facility's policies on pharmaceutical services and pain management were not followed, resulting in the resident being in pain until the situation was addressed on 09/06/2024.
Failure to Maintain Resident Dignity with Foley Bag Privacy
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident by not ensuring that the resident's Foley catheter bag was covered with a privacy bag. On the specified date, observations revealed that the resident's Foley bag was hung under the wheelchair without a privacy cover, which was acknowledged by the staff as a dignity issue. The resident, an elderly male with multiple diagnoses including esophageal cancer, diabetes, hypertension, heart disease, and dysphagia, was cognitively intact as indicated by a BIMS score of 13. Interviews with the staff, including a registered nurse (RN), a certified nursing assistant (CNA), and the director of nursing (DON), confirmed that the lack of a privacy bag was a dignity issue. The RN admitted to being aware of the need for a privacy bag but had not yet changed the Foley bag due to being busy. The CNA and DON also acknowledged the importance of using a privacy bag to prevent others from seeing the contents of the Foley bag, emphasizing that it was a matter of dignity and privacy for the resident.
Inadequate Catheter Care Leads to Potential Infection Risk
Penalty
Summary
The facility failed to ensure that a resident with a urinary catheter received appropriate care to prevent urinary tract infections. During observations, it was noted that the resident's foley tubing was touching the floor while the resident was seated in a wheelchair. This was observed by a registered nurse (RN) and confirmed during interviews with the RN, a certified nursing assistant (CNA), and the Director of Nursing (DON). The staff acknowledged that the tubing should not touch the floor due to the risk of contamination and infection. The resident involved was an elderly male with multiple diagnoses, including esophageal cancer, Type 2 Diabetes Mellitus, hypertension, atherosclerotic heart disease, and dysphagia. The resident's care plan included checking the placement of the foley tubing each shift. However, during a transfer to a wheelchair, the tubing was not properly managed, leading to it touching the floor. Staff interviews revealed a lack of specific training or skills check-off for foley care, although infection control training was provided. The facility's policy on catheterization emphasized keeping the collection bag off the floor, which was not adhered to in this instance.
Failure to Ensure Proper Enteral Feeding Procedures
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition through a feeding tube was provided with appropriate treatment and services to prevent complications. Specifically, RN A did not verify the placement of the feeding tube by listening to bowel sounds, checking for residuals, or flushing the tube with room temperature water before administering a bolus enteral feeding. Instead, RN A used cold water for flushing, which could cause discomfort such as cramping and bloating for the resident. Additionally, RN A did not follow proper infection control procedures, such as disinfecting the bedside table or using a barrier, and failed to change gloves after potential contamination. The resident involved was an elderly male with multiple diagnoses, including esophageal cancer, Type 2 Diabetes Mellitus, Hypertension, Atherosclerotic Heart Disease, and Dysphagia, requiring enteral nutrition. The resident's care plan indicated the need for enteral nutrition, and the medication administration record specified procedures for checking tube placement and residuals. However, during the observed feeding, RN A did not adhere to these protocols, potentially compromising the resident's safety and care quality. Interviews with RN A and the Director of Nursing (DON) revealed that RN A was not adequately trained in g-tube bolus feeding and did not follow the facility's policy on feeding tube management. The DON acknowledged the lapses in procedure, including the use of cold water, lack of proper equipment preparation, and failure to wear a disposable gown for enhanced barrier precautions. The facility's policy emphasized the importance of checking residuals and using room temperature water to prevent complications, which were not followed in this instance.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies involving staff members CNA A and RN A. CNA A was observed leaving a waste bag on the floor outside a resident's room, which was not disposed of in a hygienic manner. This action was acknowledged by CNA A, who admitted the bag should not have been left on the floor due to infection control concerns. The Director of Nursing (DON) confirmed that leaving trash on the floor poses an infection control risk to residents. RN A was involved in multiple infection control breaches during the care of a resident requiring G-tube bolus feeding. RN A failed to don a disposable gown, did not disinfect the stethoscope before use, and used the same gloves throughout the procedure, including when handling the resident's feeding equipment and touching various surfaces. RN A admitted to these lapses and acknowledged the need for proper hand hygiene and the use of a disposable gown due to the resident being on enhanced barrier precautions. The DON confirmed these expectations and highlighted the risk of contamination and infection due to these practices. Additionally, the facility failed to ensure that the resident's Foley catheter tubing was not touching the floor, as observed during RN A's care. Both RN A and CNA M acknowledged that the tubing should not touch the floor to prevent potential infections. The DON reiterated that the tubing should be kept off the floor to avoid contamination and infection risks. The facility's policy on catheterization and infection control was not adhered to, as evidenced by these observations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Katy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Falcon Point Post Acute | 0.9 mi | ★★★★★ | 9 | 0 |
| Sterling Oaks Rehabilitation | 1 mi | ★★★★★ | 13 | 0 |
| Heritage Park Of Katy Nursing And Rehabilitation | 2.1 mi | ★★★★★ | 0 | 0 |
| Mason Creek Transitional Care Of Katy | 2.9 mi | ★★★★★ | 1 | 0 |
| Oakmont Healthcare And Rehabilitation Center Of Ka | 3.1 mi | ★★★★★ | 2 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.