Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ignite Medical Resort Sugar Land, Llc during CMS and state inspections, most recent first.
Failure to care plan midline and IV antibiotic therapy: A resident with multiple complex diagnoses and impaired cognition received IV antibiotics via a midline for an infected sacral wound, but the care plan did not include the midline or IV therapy. The MAR showed ongoing IV meds and line care, and the line later had leakage and a hub break requiring replacement. The MDS Coordinator and DON both acknowledged the missing care plan area.
Two residents who required assistance with ADLs and were identified as fall risks did not have accessible call lights as required by their care plans and facility policy. One resident with respiratory failure, mobility impairments, and muscle weakness was repeatedly observed in bed without a call light in the room, later using manual bells that could not be heard beyond a few feet, and then with a call light clipped to a walker out of reach. Another resident with hemiplegia, contractures, and aphasia was observed attempting to manage her breakfast while her call light was placed in a basket on the nightstand, not within her reach. Staff interviews confirmed that call lights were supposed to be kept within residents’ reach and that nonfunctioning call lights should be reported, but there was no repair log and the existing system did not allow review of call light response times.
The facility's kitchen operations were found deficient in maintaining sanitary conditions. Observations revealed unlabeled and undated food items in the freezer, and the standing oven was dirty with food particles and grime. Interviews with the DM and Administrator highlighted a lack of cleaning logs and proper food labeling practices, potentially risking cross-contamination and food-borne illnesses.
A resident with complex medical conditions, including a stage 4 sacral pressure ulcer, did not receive proper wound care in an LTC facility. The nurse performed wound care incorrectly, using inappropriate techniques and materials, and lacked training. The treatment physician highlighted the need for nursing education, and the DON acknowledged the importance of following physician orders, but no relevant policy was provided.
A resident with an indwelling catheter did not receive proper catheter care from a CNA, who failed to separate the labia and clean the catheter insertion site during incontinence care. The CNA admitted to not following the facility's perineal care policy, which could increase the risk of infections. The resident had a complex medical history and required extensive assistance with daily activities.
A facility failed to ensure sterile technique during tracheotomy care for a resident with acute respiratory failure. An RN did not change gloves or perform hand hygiene during the procedure, contrary to facility policy. The resident, who was severely cognitively impaired, was at risk due to these actions. The DON confirmed the RN's failure to use sterile technique, acknowledging the potential risk of infection.
A resident with complex medical conditions did not receive medications as ordered due to errors by an LVN. The LVN failed to administer Lacosamide and Hydralazine on time and did not provide full doses of several other medications, leaving significant amounts in the administration cups. The resident required medications via a G-tube due to severe cognitive impairment and other health issues.
A resident in an LTC facility experienced medication administration errors, resulting in a 26% error rate. LVN A administered medications at incorrect times and dosages, leaving significant amounts of medication in the cups. The resident, with complex medical needs, did not receive medications as prescribed, potentially affecting therapeutic outcomes. The DON confirmed the importance of timely and accurate medication administration.
The facility failed to properly dispose of garbage and refuse around the dumpster area, leading to debris accumulation including paper, diapers, and a broken dresser. The Director of Housekeeping was unaware of the issue, and the Administrator expected the area to be clean, indicating a lack of monitoring. The facility's policy requires garbage to be stored in a manner inaccessible to pests and storage areas to be kept clean.
A facility failed to maintain proper infection control practices, as observed in the actions of a CNA and an RN. The CNA did not change gloves or wash hands after providing incontinent care to a resident with cognitive impairment and a history of UTIs. The RN failed to use sterile technique and perform hand hygiene during tracheostomy care for another resident, increasing the risk of infection. These deficiencies were confirmed through staff interviews.
A resident with chronic respiratory failure and designated as full code was found unresponsive, but staff failed to initiate CPR immediately. RT A and LVN A delayed life-saving measures, leading to a 12-minute delay before EMS was called. The resident was pronounced deceased after EMS took over CPR efforts.
A resident with a tracheostomy and ventilator dependency experienced a dislodged tracheotomy circuit, leading to agonal breathing, cardiac arrest, and death. The facility failed to provide adequate respiratory care, as emergency equipment was not available at the bedside, and staff did not respond promptly to the ventilator alarm. The resident had a complex medical history and was fully dependent on staff for care. Interviews revealed inadequate training and confusion about emergency roles, contributing to the incident.
A non-diabetic resident in a LTC facility was incorrectly administered insulin, leading to hypoglycemia and emergency hospitalization. The error stemmed from RN A adding an insulin order without proper verification, resulting in the resident receiving 48 units of insulin over two days. Facility records did not support the need for insulin, and staff interviews revealed confusion and miscommunication regarding the order.
Failure to Care Plan Midline and IV Antibiotic Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was receiving IV antibiotics through a midline catheter. The resident was admitted with multiple diagnoses including type II diabetes, tracheostomy status, osteomyelitis, chronic respiratory failure, and infection related to an indwelling urethral catheter. The admission MDS indicated short-term and long-term memory problems and severely impaired cognitive skills for daily decision making. The resident’s care plan, initiated on 5/20/2026, did not include any care plan area for the midline catheter or for IV antibiotic administration. On 6/12/2026, the physician ordered a midline for IV antibiotics for a bacterial infection in the sacral wound, and the resident was started on Imipenem-Cilastatin-Relebactam, Daptomycin, and Fosfomycin. The midline was inserted into the left upper arm later that day, and consent for PICC/midline insertion was signed for placement in the left basilic vein. The June 2026 MAR showed ongoing IV antibiotic administration and routine line care tasks such as checking the IV dressing each shift, monitoring the site and dressing for signs and symptoms of infection, and flushing the line for patency. During the course of treatment, the resident’s midline required replacement after leakage was noted on 6/22/2026, and the line was later noted to have a break at the catheter hub on 6/25/2026, requiring reinsertion. The MDS Coordinator stated the resident did have a midline used to administer IV antibiotics for a wound infection and acknowledged there was no care plan area included for the midline and IV antibiotics. The DON also stated this should have been included in the resident’s care plan and that the MDS Coordinator was typically responsible for updating and completing care plans.
Failure to Ensure Accessible Call Lights for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring proper availability and accessibility of call lights for two residents. For one resident, a female with respiratory failure with hypoxia, gait and mobility abnormalities, muscle weakness, and Restless Leg Syndrome, record review showed she required assistance with eating setup and cleanup, oral hygiene, toileting hygiene, dressing, rolling in bed, and was wheelchair dependent. During observation, she was found in bed without a call light present in the room, and she reported being a fall risk, needing help to go to the restroom, and not knowing where her call light was. A Wound Care LVN also could not locate the call light, stated she did not know how long it had been missing, and believed it might be elsewhere in the facility. On a subsequent observation, the same resident was again in bed with oxygen in use and had two manual bells placed on her bedside table instead of a functioning call light. She stated she did not know what happened to her call light and that staff had given her the bells to ring when she needed help, but that staff took a long time to respond. When she rang the bells, they could not be heard beyond 2–3 feet from her door, and an RN walking past did not hear them. Later, the resident was observed lying in bed while a call light was clipped to her walker, which was not within her reach. For the second resident, a female with hemiplegia and hemiparesis affecting the right dominant side, contractures of the right upper extremity, and aphasia, the care plan identified her as a fall risk and specified that the call light should be within reach at all times. She required assistance with toileting, bathing, eating, dressing, transfers, and bed mobility. During observation, she was seated in a wheelchair with breakfast in front of her and was attempting to insert a straw into a sealed juice cup, while her call light was observed in a basket on her nightstand and not within her reach. Staff interviews confirmed that facility policy required call lights to be within residents’ reach and that staff were expected to respond to call lights and report nonfunctioning equipment, but there was no log for call light repairs and the facility did not have the capacity to review call light response times with the current system.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. Specifically, the facility did not ensure that stored food was properly labeled, dated, and contained. During an inspection of the freezer, several food items, including hash browns, mixed vegetables, vegetable egg rolls, and Beyond chicken tenders, were found unlabeled and undated. Additionally, the standing oven by the grill was found to have dry food particles, sticky residue, and grime, indicating a lack of cleanliness. Interviews with the Dietary Manager (DM) and the Administrator revealed further issues. The DM admitted to not having a cleaning log and was unsure of the last cleaning date for the oven, estimating it was cleaned a week prior. The Administrator acknowledged the lack of labeling and dating of food items and expressed expectations for staff to date and label food, including discard dates. She also noted that the oven should be cleaned after every use to prevent leftover particles. These deficiencies could potentially place residents at risk of cross-contamination and food-borne illnesses.
Deficient Pressure Ulcer Care for Resident
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with existing sacral pressure ulcers, leading to a deficiency in care. The resident, who had multiple complex medical conditions including encephalopathy, tracheostomy, respiratory failure, and a stage 4 sacral pressure ulcer, did not receive the necessary treatment and services to promote healing and prevent infection. The resident's wound care orders included specific instructions for cleansing and dressing the wound, which were not followed by the nursing staff. During an observation, a registered nurse was seen performing wound care incorrectly by cleaning the wound from the outside in, not changing gloves, and using inappropriate dressing materials. Interviews with the registered nurse and the Director of Nursing (DON) revealed that the nurse had not received proper training on wound care and that the facility lacked the necessary supplies for the resident's treatment. The treatment physician confirmed that the wound care was not performed according to the prescribed orders and emphasized the need for nursing education on wound dressing. The DON acknowledged the importance of following physician orders and stated that not doing so could potentially affect the resident's health. However, no policy or procedure regarding adherence to physician orders was provided by the DON at the time of the survey exit.
Inadequate Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident, identified as Resident #18, who was incontinent of bladder and had an indwelling catheter. During an observation, CNA A did not separate the resident's labia or clean the foley catheter insertion site properly while providing incontinence care. Additionally, CNA A did not perform proper hand hygiene during the procedure. This lack of proper care was acknowledged by CNA A, who admitted to being nervous and aware of the importance of proper cleaning to prevent infections. Resident #18 had a complex medical history, including encephalopathy, tracheostomy, respiratory failure, osteomyelitis, and a stage 4 pressure ulcer, among other conditions. The resident required extensive assistance with activities of daily living and was frequently incontinent of bowel. The facility's policy on perineal care, revised in March 2017, outlined the correct procedure for cleaning, which was not followed by CNA A during the observed incident. The Director of Nursing confirmed that the failure to follow proper peri-care procedures placed residents at risk of urinary tract infections.
Failure to Use Sterile Technique in Tracheotomy Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident requiring tracheotomy care and suctioning. Specifically, a registered nurse (RN) did not adhere to sterile technique during the tracheotomy care and suctioning process for a resident diagnosed with acute respiratory failure with hypoxia. The RN used the same gloves throughout the procedure without performing hand hygiene, failed to change gloves when necessary, and did not use sterile gloves appropriately. These actions were observed during a tracheotomy care session where the resident was noted to have audible moist breath sounds. The resident involved was an elderly male with severe cognitive impairment, as indicated by the absence of a BIMS assessment and staff observations of memory and recall problems. The facility's policy on tracheostomy care, which requires aseptic technique and the use of sterile gloves, was not followed. Interviews with the RN and the Director of Nursing (DON) confirmed that the RN did not use sterile technique and acknowledged the risk of infection posed by the improper procedure. The DON noted that while the respiratory therapy department primarily oversees tracheostomy care, nursing staff are trained to perform the care when respiratory therapists are unavailable.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, specifically in the administration of medications. LVN A did not administer Lacosamide and Hydralazine at the scheduled time of 7:00 am as ordered by the physician. Additionally, LVN A failed to administer the full doses of Hydralazine, Carvedilol, Baclofen, Glycopyrrolate, Doxycycline, and Isosorbide to the resident, leaving significant amounts of medication in the cups used for administration. The resident involved, a male with multiple complex medical conditions including Parkinson's Disease, Epilepsy, and Essential Hypertension, required medications to be administered via a gastrostomy tube. The resident's medical history also included severe cognitive impairment, necessitating total care assistance with activities of daily living. During an observation, it was noted that LVN A did not administer the complete doses of the medications, which were crucial for managing the resident's conditions. Interviews with LVN A and the DON revealed that the medications were administered late and not in full doses, which could potentially affect the resident's therapeutic outcomes. The DON acknowledged the importance of administering medications at the correct time and dosage, emphasizing that errors could lead to serious effects on residents. Despite being trained on G-tube medication administration, LVN A did not provide a reason for the failure to administer the medications correctly during the observed medication pass.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 26% due to 8 errors out of 30 opportunities. This involved a resident who was administered medications incorrectly by LVN A. The medications Lacosamide and Hydralazine were given at 9:08 am instead of the prescribed time of 7:00 am. Additionally, LVN A administered incorrect doses of Hydralazine, Carvedilol, Baclofen, Glycopyrrolate, Doxycycline, and Isosorbide, leaving significant amounts of medication in the cups after administration. The resident involved had a complex medical history, including Parkinson's Disease, Epilepsy, and other conditions requiring precise medication management. The resident was dependent on a gastrostomy tube for feeding and had severely impaired cognition, necessitating total care assistance. The errors in medication administration could potentially impact the resident's therapeutic outcomes and overall health. During the survey, LVN A acknowledged the errors and attempted to correct them by adding more water to the medication cups to ensure the resident received the full doses. The DON, who was new to the facility, confirmed that medication administration should adhere to the prescribed times and dosages, with a permissible window of one hour before or after the scheduled time. The facility's policy on medication administration did not adequately address the timeliness and accuracy of medication delivery.
Improper Garbage Disposal Around Dumpster
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, specifically around the dumpster area. During an observation and interview with a housekeeper, it was noted that there was a significant amount of debris, including paper, diapers, leaves, wood, and a broken dresser, surrounding the dumpster. The housekeeper was unsure whether the responsibility for cleaning the area around the dumpster fell on the facility or the company that picks up the dumpster. This uncertainty was highlighted during the surveyor's visit. Further interviews revealed that the Director of Housekeeping, who had been working at the facility since March 2024, was unaware of the debris around the dumpster. He admitted that he had not checked the area and was surprised by the amount of trash present, as it could attract pests. The Administrator also expressed an expectation that the dumpster should be closed and the surrounding area kept clean, indicating a lack of monitoring prior to the surveyor's findings. The facility's policy, revised in October 2017, states that garbage and refuse should be stored in a manner inaccessible to pests and that storage areas should be kept clean at all times.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and glove use by staff members during resident care. Specifically, a CNA did not change gloves or wash hands after providing incontinent care to a resident, and an RN failed to perform hand hygiene during pressure ulcer treatment and tracheostomy care for two residents. These actions were observed during a survey, highlighting lapses in infection control practices. One resident, who was cognitively impaired and required extensive assistance with activities of daily living, was at risk due to these lapses. The resident had a history of urinary tract infections and pressure ulcers, necessitating careful infection control measures. During the survey, it was noted that the CNA did not change gloves or wash hands after providing incontinent care, potentially leading to cross-contamination. Another resident, who was severely cognitively impaired and had a tracheostomy, was also at risk due to improper care practices. The RN did not use sterile technique or perform hand hygiene during tracheostomy care and suctioning, which could increase the risk of respiratory infections. These deficiencies were confirmed through interviews with the staff involved and the Director of Nursing, who acknowledged the risks associated with these practices.
Failure to Provide Timely CPR to Full Code Resident
Penalty
Summary
The facility failed to provide basic life support, including CPR, to a resident who was designated as full code and required emergency care. The resident, who had a history of chronic respiratory failure, Type 2 Diabetes Mellitus, anoxic brain damage, pulmonary hypertension, and was dependent on a ventilator and tracheostomy, was found unresponsive at approximately 5:25 a.m. Despite being a full code, CPR was not initiated immediately by the staff, leading to a delay of 12 minutes before emergency medical services (EMS) were called at 5:37 a.m. The resident was pronounced deceased at 6:14 a.m. The incident involved RT A and LVN A, who failed to initiate life-saving measures when the resident was found unresponsive. RT A discovered the resident in respiratory distress with the ventilator circuit dislodged and attempted to reinsert the tracheostomy tube but was unsuccessful. LVN A, upon being called to the room, noted agonal breathing and a palpable pulse but did not start CPR immediately. Instead, LVN A called 911 and attempted to use an AED, but CPR was not effectively performed until EMS arrived. Interviews with staff revealed that there was confusion and a lack of immediate action in responding to the resident's condition. The DON confirmed that both RT A and LVN A were aware of the resident's full code status and should have initiated CPR immediately. The facility's failure to provide timely CPR in accordance with professional standards of practice placed the resident at risk and resulted in the identification of an Immediate Jeopardy situation.
Failure in Respiratory Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide adequate respiratory care to a resident who required tracheostomy care, leading to a critical incident. The resident, who was dependent on a ventilator and had a tracheostomy, experienced a dislodged tracheotomy circuit, resulting in agonal breathing, cardiac arrest, and ultimately death. The incident occurred when the respiratory therapist discovered the circuit on the floor and the tracheostomy dislodged, but was unable to reinsert it successfully. The resident was in respiratory distress, and despite attempts to provide emergency care, including CPR and the use of an AED, the resident was pronounced deceased. The resident had a complex medical history, including chronic respiratory failure with hypoxia, Type 2 Diabetes Mellitus, anoxic brain damage, pulmonary hypertension, and was designated as full code. The facility's records indicated that the resident was comatose and fully dependent on staff for care. On the night of the incident, the resident's ventilator alarm was reportedly not heard by the staff, and the emergency tracheostomy equipment was not readily available at the bedside, which delayed the response to the resident's respiratory distress. Interviews with staff revealed a lack of immediate response to the ventilator alarm and inadequate training in handling such emergencies. The respiratory therapist on duty at the time of the incident had previously been verbally reprimanded for loose trach ties, but there was no documentation of these incidents. The facility's Director of Nursing and other staff members were not able to provide a clear explanation of the events leading to the resident's death, and there was confusion about the roles and responsibilities during the emergency. The facility's failure to ensure proper tracheostomy care and timely emergency response contributed to the resident's death.
Insulin Administration Error in Non-Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services, resulting in a non-diabetic resident receiving insulin, which led to a medical emergency. The incident involved a resident who was incorrectly administered 12 units of Lispro insulin every 8 hours, despite not having a diagnosis of diabetes. This error caused the resident to experience hypoglycemia, leading to symptoms such as sweating and lethargy, and ultimately required emergency medical intervention. The error occurred when RN A incorrectly added an insulin order to the resident's chart, which was then administered by LVN A and RN A over two days. The resident received a total of 48 units of insulin within 24 hours, which was not supported by any sliding scale order or medical necessity. The facility's records, including the resident's care plan and MDS, did not indicate a need for insulin or a diagnosis of diabetes, highlighting a significant oversight in the facility's pharmaceutical procedures. Interviews with facility staff revealed confusion and miscommunication regarding the insulin order. RN A and LVN E both denied administering the insulin, despite documentation indicating otherwise. The facility's DON and other staff were unable to provide a clear explanation for the insulin administration, and the physician confirmed that no such order was given. This lack of clarity and adherence to proper procedures placed the resident at risk and demonstrated a failure in the facility's medication management system.
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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 Sugar Land
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Crescent | 1.9 mi | ★★★★★ | 11 | 1 |
| Sugar Land Health Care Center | 2 mi | ★★★★★ | 2 | 0 |
| Paradigm At First Colony | 3.9 mi | ★★★★★ | 8 | 0 |
| Chelsea Gardens | 4.6 mi | ★★★★★ | 10 | 2 |
| Park Manor Of Quail Valley | 4.8 mi | ★★★★★ | 0 | 0 |
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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 August 2026) and official state health department websites.