Sugar Land Health Care Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.