Sugar Land Health Care Center

In the surveyor’s words

From the most serious findings on record at Sugar Land Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF692Jan 26, 2023

  Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible or resident preferences indicated otherwise for 10 of 86 residents (Resident #56, #7, #44, #59, #18, #23, #72, #5, #14, and #45) reviewed for weight loss. 1. The facility failed to obtain accurate monthly weights for Resident #56. 2. The facility failed to ensure Resident #56 had appropriate interventions in place to prevent a severe weight loss of 39.3 % from 10/10/22 to 1/17/23. 3. The facility failed to obtain accurate monthly weights for residents from October 2022 to January 2023. […]

• Immediate jeopardy, isolatedF684May 27, 2025

  Based on interviews and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (CR #1) of 5 residents reviewed for quality of care. -The facility failed to ensure treatment and care was provided to CR #1 consistent with professional standards of practice. CR #1, who was prescribed an anticoagulant, had a fall hitting her head on [DATE] at approximately 9:00 p.m. NP A recommended CR #1 be sent to the hospital immediately. Transport was not dispatched until 11:27 p.m. and CR #1 was not transported to the hospital until 12:48 a.m. on [DATE] where she later passed away. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 10:27 a.m. […]

• Immediate jeopardy, isolatedF689Aug 22, 2023

  Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #2) of 4 residents reviewed for accidents in that: -Physical Therapy Assistant performed a two person transfer alone on 08/18/23. Resident #2 suffered right femur fracture that was identified via X-ray on 08/19/23. The noncompliance was identified as PNC. The IJ began on 8/18/23 and ended on 8/21/23.The facility had corrected the noncompliance before the survey began. This failure can place residents at risk of injury, pain, hospitalization and a diminished quality of life. […]

• Actual harm, isolatedF660Nov 16, 2021

  Based on interview and record review the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 of 3 residents (CR #1) reviewed for safe discharge . The facility failed to provide sufficient preparation to ensure safe and orderly discharge of CR#1. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge. Findings include: Record review of the admission sheet for CR #1 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. […]

• Actual harm, isolatedF689Oct 15, 2021

  Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 did not sustain a major injury ( [CONDITION(S)]) during transfer with one staff in which a fall occurred. This failure placed facility resident at risk of harm to include neglect, diminished quality of life, and psychosocial harm. Findings Included: Record review of Resident #1's, undated, face sheet revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. […]