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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sugar Land Health Care Center during CMS and state inspections, most recent first.
A resident with a seizure disorder was admitted with hospital orders for Divalproex Sodium ER 1000 mg twice daily, but due to a transcription error, only received 250 mg twice daily during her stay. Facility staff interviews revealed inconsistent procedures for verifying and documenting new admission medication orders, and there was no evidence that the error was identified or corrected by staff.
A nurse aide failed to use proper feeding technique by placing a resident's food dish on her lap while assisting with meals, despite the availability of an over-bed table. The resident had severe cognitive and physical impairments and required full assistance with eating. This practice was identified as an infection control issue by the DON, and other residents were observed receiving meals with trays properly placed on over-bed tables.
A resident with multiple comorbidities, including atrial fibrillation and on anticoagulant therapy, experienced an unwitnessed fall with head injury. Although the NP ordered immediate hospital transfer, there was a significant delay in dispatching and transporting the resident, as regular transport was used instead of 911. Staff interviews revealed confusion about protocols for head injuries in residents on anticoagulants. The resident was eventually transported to the hospital, where she later died from intracranial hemorrhage.
Two residents did not receive multiple prescribed medications as ordered due to pharmacy delays, miscommunication among staff, and confusion over medication procurement responsibilities. One resident missed nine critical medications on the day of admission, while another missed 41 doses of a phosphate binder over several weeks. Facility staff did not follow established procedures for handling unavailable medications, resulting in missed doses and incomplete documentation.
Two residents did not receive prescribed medications as ordered, including multiple critical medications for one resident and a phosphate binder for another, due to delays in pharmacy delivery, insurance issues, and breakdowns in staff communication and follow-up. Facility staff did not consistently follow procedures for obtaining, administering, or documenting unavailable medications, resulting in numerous missed doses.
Staff failed to follow infection prevention protocols during incontinent care for a resident with dementia, including improper glove use, lack of hand hygiene, and reusing the same washcloth surface. In a separate incident, an LVN disposed of a used lancet in a resident's trash can instead of a sharps container after checking blood glucose, contrary to infection control policy.
Failure to Accurately Transcribe and Administer Anti-Seizure Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate transcription and administration of medications for a resident admitted with a seizure disorder, cerebral infarction, and hypertension. Upon admission from the hospital, the resident's discharge orders specified Divalproex Sodium ER 1000 mg twice daily, but the facility's physician order was transcribed as 250 mg every 12 hours. The resident subsequently received only 250 mg twice daily throughout her stay, as documented in the Medication Administration Records (MARs). There was no documentation or evidence that the physician or nurse practitioner reviewed or corrected the medication order to match the hospital discharge instructions. Interviews with facility staff revealed inconsistent procedures for verifying and documenting new admission medication orders. The LVN responsible for transcription stated there was no protocol for documenting verification with the physician or nurse practitioner, and the DON confirmed there was no set process for order verification. The nurse practitioner reported she instructed the nurse to continue all hospital medications but did not review the orders herself. The discrepancy in the Divalproex Sodium ER dosage was identified by the resident's family after discharge, and there was no indication in the record that the error was recognized or addressed by facility staff during the resident's stay.
Incompetent Feeding Technique by Nurse Aide
Penalty
Summary
A nurse aide failed to demonstrate competency in feeding assistance for a resident with significant care needs. The resident, who had diagnoses including dysphagia, lack of coordination, muscle weakness, and severely impaired cognition, was dependent on staff for eating. A staff member was observed feeding the resident while holding the resident's food dish on her lap, rather than using the over-bed table that was available in the room. This technique was captured in a video provided by the resident's family member, who expressed concern about the feeding method. The Director of Nursing reviewed the video and confirmed that the feeding technique was inappropriate and constituted an infection control issue. Additional observations of other residents receiving meal assistance showed that trays were properly placed on over-bed tables. The facility did not provide a policy specific to staff assistance with meals but did provide a blank CNA skills checklist that included feeding residents. The incident involving the improper feeding technique was not consistent with observed practices for other residents and was acknowledged by facility leadership as unacceptable.
Delayed Emergency Response for Anticoagulated Resident After Fall
Penalty
Summary
A facility failed to provide treatment and care in accordance with professional standards of practice for a resident who was prescribed an anticoagulant. The resident, an elderly female with a history of metabolic encephalopathy, cerebral infarction, hypertensive heart disease, chronic kidney disease, and heart failure, experienced an unwitnessed fall in her room, striking her head. Upon assessment, she exhibited bruising and swelling to her left eye but reported no pain. The nurse on duty initiated neuro and skin assessments, found her vital signs to be normal, and notified the responsible party, DON, and nurse practitioner (NP), who ordered immediate transfer to the hospital for further evaluation. Despite the NP's order for immediate transfer, there was a significant delay in dispatching and transporting the resident to the hospital. The transport was not dispatched until over two hours after the fall, and the resident was not transported until nearly four hours after the incident. During this time, neuro checks and vital signs were monitored and remained within normal limits. The nurse chose to use regular transport rather than 911, citing the resident's stable condition, and did not recall if the NP specified the mode of transport. The resident's family member arrived at the facility during this period and accompanied her to the hospital. Upon arrival at the hospital, imaging revealed no acute intracranial hemorrhage, but the resident later passed away. The death certificate listed intracranial hemorrhage and atrial fibrillation as causes of death. Interviews with facility staff revealed uncertainty regarding the appropriate mode of transport for residents on anticoagulants with head injuries and inconsistent understanding of protocols for such incidents. The facility's failure to ensure timely and appropriate emergency response for a resident on anticoagulant therapy who sustained a head injury constituted a deficiency in providing care according to professional standards.
Failure to Administer Medications as Ordered and Maintain Professional Standards
Penalty
Summary
Two residents did not receive medications as ordered, resulting in a failure to provide services that met professional standards of quality. One resident, a male with multiple complex diagnoses including metabolic encephalopathy, hyperlipidemia, chronic inflammatory demyelinating polyneuritis, lumbar fracture, and muscle weakness, was admitted and subsequently discharged on the same day. He was dependent on assistance for activities and had physician orders for several critical medications, including anticoagulants and anticonvulsants. On the day of admission, he did not receive nine scheduled medications because the facility did not have them available. The nurse documented that the medications had not arrived from the pharmacy and that the earliest delivery would be after the resident's planned discharge. Communication between medication aides, nurses, and facility leadership revealed confusion and miscommunication regarding the process for obtaining medications from the emergency kit and timely notification of missing medications. The nurse practitioner was not informed of the missed doses at the time, and the resident and his family chose to leave the facility due to the lack of medication availability. Another resident with end-stage kidney disease, anemia, history of kidney cancer, and dependence on hemodialysis did not receive a prescribed phosphate binder medication, Sevelamer Carbonate, for a total of 41 missed doses over several weeks. The medication was ordered to be given three times daily with meals, but was not administered on multiple occasions due to unavailability. Nursing staff reported calling the pharmacy and dialysis center, but there was confusion regarding responsibility for ordering the medication, especially after a change in CMS rules that shifted responsibility to the dialysis center. The assistant director of nursing was unaware of the missed doses until reviewing the medication administration record, and the director of nursing later approved a supply to be delivered at the facility's expense. Documentation errors were also noted, with some doses marked as given in error. The resident's physician was aware of the medication's unavailability within a few days but did not consider the missed doses a risk to the resident's health. Facility policy required timely administration of medications and specific procedures for handling unavailable medications, including physician and family notification, completion of medication error reports, and monitoring for adverse reactions. In both cases, the facility did not follow these procedures, resulting in residents not receiving medications as ordered and a lack of timely communication and documentation regarding the missed doses.
Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide routine and emergency medications as ordered for two residents, resulting in missed doses of critical medications. One resident, a male with multiple complex diagnoses including metabolic encephalopathy, chronic inflammatory demyelinating polyneuritis, and a recent lumbar fracture, was admitted and did not receive nine prescribed medications on the day of admission. These included anticoagulants, antiarrhythmics, antihypertensives, and other essential medications. Documentation showed that the medications were not received from the pharmacy in time, and there was a lack of clear communication among staff regarding the availability and administration of these medications. The resident's care plan required administration and monitoring of these medications, but the medications were not administered as ordered, and the reasons for the missed doses were not clearly documented in the progress notes. Another resident with end-stage kidney disease and dependence on hemodialysis did not receive a prescribed phosphate binder, Sevelamer Carbonate, for a total of 41 missed doses over several weeks. The medication was not available due to insurance coverage issues and a change in responsibility for ordering the medication, which led to a gap in supply. Nursing staff identified the issue but did not consistently follow up or communicate effectively with the pharmacy, dialysis center, or physician. The resident's care plan required administration of medications as ordered and monitoring for side effects, but the medication was placed on hold without clear documentation of who authorized this action. Laboratory results showed elevated phosphate levels during the period when the medication was not administered. Interviews with facility staff revealed inconsistent practices regarding the process for obtaining and administering medications, as well as unclear lines of communication and responsibility. Staff were not always aware of missed doses or the procedures to follow when medications were unavailable. Facility policies required timely administration of medications and specific actions when medications were missed, but these procedures were not consistently followed for the residents involved.
Infection Control Lapses During Resident Care and Sharps Disposal
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during care for two residents. For one resident with dementia and frequent incontinence, a CNA performed incontinent care without following established infection control protocols. The CNA donned two pairs of gloves, changed gloves multiple times without performing hand hygiene between changes, and used the same surface area of a washcloth for multiple wipes without refolding or changing to a clean area. The CNA acknowledged being aware of the correct procedures but did not follow them during the observed care. Interviews with facility staff, including the infection control nurse and the DON, confirmed that double gloving is not recommended, and hand hygiene is required between glove changes. The facility's policy also specifies that a new section of a washcloth or a new disposable wipe should be used for each wipe during perineal care. The observed actions did not align with these policies, and staff recognized the risk of contamination and infection resulting from these lapses. In a separate incident, an LVN checked a diabetic resident's blood glucose using a lancet and then improperly disposed of the used lancet in the resident's room trash can instead of a designated sharps container. The LVN admitted this was not the correct procedure and acknowledged the potential infection control concern. The DON also confirmed that used lancets should be disposed of in sharps containers, as improper disposal poses a significant infection control risk.
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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 | 0.3 mi | ★★★★★ | 11 | 1 |
| Ignite Medical Resort Sugar Land, Llc | 2 mi | ★★★★★ | 7 | 0 |
| Paradigm At First Colony | 3.6 mi | ★★★★★ | 8 | 0 |
| West Houston Rehabilitation And Healthcare Center | 4.6 mi | ★★★★★ | 6 | 0 |
| Park Manor Of Quail Valley | 4.9 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.