Sugar Land Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 (CR #1) of 4 residents reviewed for pharmacy services.-CR #1's hospital discharge orders were not transcribed properly to the resident's facility admission orders. CR #1 did not receive the correct dose of Divalproex Sodium.This failure could result in CR #1 not receiving the correct dose of anti-seizure medication.Findings include: Review of the admission Record for CR #1 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures (seizure disorder), cerebral infarction (condition where blood flow to a part of the brain is disrupted, resulting in brain-tissue death), and hypertension (high blood pressure). She was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a nurse aide was able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one (CR #2) of five residents reviewed for assistance with meals. -An unidentified staff supported CR #2's food dish on the staff's lap as she fed the resident. The failure placed the resident at risk for acquiring food-borne illness.Findings include: Record review of the admission Record for CR #2 revealed he was [AGE] years old, admitted to the facility on [DATE]. Diagnoses included dysphagia (difficulty swallowing), lack of coordination, and muscle weakness. He was discharged from the facility on 08/08/2025. Record review of CR #2's 5-day admission MDS assessment dated [DATE] revealed, he exhibited severely impaired cognition. He had impaired range-of-motion to both upper and lower extremities. He was dependent on staff for eating assistance.In an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide services that met professional standards of quality for 2 of 15 residents (Residents #55 and #24) reviewed for services. 1. Resident #55 failed to receive nine medications he was ordered to receive on 2/2/2025. 2. Resident #24 did not receive one medication 41 times from 04/20/2025 to 05/07/2025. These failures could place residents at risk of worsening of illnesses and not receiving the therapeutic dosage. Findings included: Resident #55 Record review of Resident #55's face sheet, he was an [AGE] year-old male originally admitted on [DATE] at 4:45 p.m. and discharged [DATE] to home. His medical diagnoses included metabolic encephalopathy (brain disorder caused by the body's metabolic processes and lead to impaired brain function), hyperlipidemia (high levels of fat in the blood), chronic inflammatory demyelinating polyneuritis (a rare neurological disorder affecting the nerves and nerve roots and leading to weakness and paired motor function),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents and pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 15 (Residents #55 and #24) reviewed for medication administration. 1. Resident #55 did not receive nine medications as ordered by the Physician on 2/2/2025. 2. Resident #24 did not receive one medication 41 times from 04/20/2025 to 05/07/2025. This failure could lead to a decline in residents' physical, mental and emotional health due to not receiving the medications and the therapeutic effects to treat their conditions as ordered by their physician. Findings included: Resident #55 Record review of Resident #55's face sheet, he was an [AGE] year-old male originally admitted on [DATE] at 4:45 p.m. and discharged [DATE] to home. His medical diagnoses included metabolic encephalopathy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 19 residents (Residents #61 and #99) reviewed for infection control practices. -The facility failed to ensure CNA A followed proper infection control, cleaning and hand hygiene for Resident #61 during incontinent care. CNA A double gloved, CNA A failed to use a clean washcloth surface area and perform hand hygiene between glove changes during incontinent care. -LVN G checked Resident #99's blood glucose level with a lancet, then discarded the used lancet into the trash can in the resident's room. These failures could place residents at risk of infection or a decline in health. The findings included: Resident #61 Record review of Resident #61's admission face sheet undated revealed an [AGE] year-old female…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 1 resident (Resident #12) reviewed for resident call system. The facility failed to ensure a call cord was in reach for Resident #12 on 03-05-24. This failure placed residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Findings included: Record Review of Resident #12's face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record Review of Resident #12's diagnoses revealed he had cerebral palsy (congenital disorder of movement, muscle tone, or posture), pressure ulcer of sacral region, stage 4, seizures, embolism, and thrombosis of unspecified deep veins of unspecified lower extremity (blood blots…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #147) of five residents reviewed for oxygen therapy was provided care that was consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. -Resident #147 had an oxygen humidifier that was dated 02/19/2024, 10 days prior to his admission on [DATE], and possibly previously used by a different resident. Resident #147 had been recently admitted to the facility with respiratory compromise. The failure placed Residents at increased risk of infection. Findings included: Record review of the admission Record (printed 03/05/2024) revealed Resident #147 was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, encephalopathy (a group of disorders that affect the brain and cause confusion, memory loss, and other mental changes), pleural effusion (buildup of fluids around the lungs), and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with established food preparation practices and safety techniques in that; 1. Frozen food were thawed in a sink with no running and/or standing water. 2. Frozen food were thawed in a sink used for hand washing. This failure could cause food-borne illnesses as a result and could affect the residents who consumed food from the facility's only kitchen. Findings included: Observation of the kitchen on 03-05-24 at 08:47 a.m., revealed 2 of 2 sinks used for hand washing. Observation of the kitchen on 03-05-24 at 11:52 a.m. 3-10 pound loafs of sealed frozen ground beef in 1 of 2 sinks used for hand washing without being submerged in standing water or under running cold water. Observation of the lunch meal tray on 03-06-24 at 12:55 p.m., revealed a regular textured meal consisting of meat loaf, green beans, dinner roll, mashed potatoes and gravy, and pudding. The meal was visually presentable and was tasted and found palatable. Interview on 03-05-24 at 08:47…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure a resident received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #1) of 5 residents reviewed for showers/baths. -Resident #1 did not receive showers as scheduled. This failure affected one resident and placed 88 residents requiring assistance with baths and showers at risk of not having the assistance with personal care which could cause skin breakdown and low self-esteem. Findings include: Record review of the admission Record (printed 08/16/2023) for Resident #1 revealed she was [AGE] years old, andold and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, encephalopathy (disease that alters brain function), muscle weakness, and dementia. Record review of the quarterly MDS assessment dated [DATE] revealed no entry for Resident #1's cognitive status. The MDS reflected the resident required extensive assist of two persons for bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the clinical record were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 1 (Resident #1) of 5 residents records reviewed for medication and treatment documentation. -The nurse documented Resident #1 had pain patches applied, but they were not available. -The nurse documented Resident #1 had on compression hose on both legs, but the resident did not. The failure could place residents at risk for unaddressed pain, increased swelling, and risk of blood clots. Findings include: Record review of the admission Record (printed 08/16/2023) for Resident #1 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, encephalopathy (disease that alters brain function), muscle weakness, and dementia. The most recent diagnoses (06/13/2023) were acute embolism and thrombosis (blood clots) of unspecified deep…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 3 of 6 residents (Residents #31, #29 and #67) reviewed for pharmacy services. The facility failed to ensure LVN E administered Lorazepam (an antianxiety medication) to Resident #31 every 12 hours (twice per day) per physician's order and instead administered the medication three times per day. The facility failed to ensure LVN E administered Hydrocodone-Acetaminophen (a controlled medication used to treat moderate to severe pain) to Resident #29 every 4 hours, as ordered by the physician, and instead administered the medication every 2 hours. The facility failed to ensure LVN E signed Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for two (Nurse Medication Cart D Hall and Nurse Medication Cart A Hall) of five medication carts (Nurse Medication Cart D Hall and Nurse Medication Cart A Hall) reviewed for storage of medications. 1. -The facility failed to ensure the Nurse Medication Cart D Hall was locked when unattended. 2. -The facility failed to ensure LVN B secured medications prior to leaving the medication cart unattended. These deficient practices could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: 1. Observation on 01/23/2023 at 6:37 AM revealed Nurse Medication Cart D hall parked near room D6 and was unlocked and unattended by staff. LVN A was in room D6a behind the curtain with a resident. No staff, visitors or residents were in the hall.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a PASRR screening was completed for residents with a mental disorder or an intellectual disability for 1 of 6 residents (Resident #54) reviewed for PASRR Level I screenings. The facility did not ensure an accurate PASRR level 1 screening (a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) was completed for Resident #54. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of Resident #54's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #54 had diagnoses which included unspecified psychosis not due to a substance or known physiological condition (a severe mental disorder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 1 of 18 residents (Resident's #15) reviewed for care plan timing and revision. The facility failed to ensure Resident #15's care plan included her visual function, communication and dental care triggered on her admission MDS assessment dated [DATE]. This failure could place residents at risk for not receiving needed care. Findings include: Record review of Resident #15's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included, unspecified dementia (a group of symptoms affecting memory, thinking and social abilities) without behavioral, anxiety, Aphasia (a disorder that results from damage to portions of the brain that are responsible for language) hypertension (High…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.