Inspection·December 17, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **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 discharged from the facility on 07/04/2025.Review of CR #1's 5-day Entry MDS assessment dated [DATE] revealed the resident scored 11/15 on the BIMS, indicative of moderate cognitive impairment. The resident exhibited little or no interest or pleasure doing things, had difficulty falling or staying asleep (or sleeping too much), and felt tired or had no energy.Review of CR #1's hospital Discharge Orders dated 06/14/2025 revealed she was receiving Divalproex Sodium ER (medication to treat Epilepsy/seizures) 1000 mg, twice daily.Review of CR #1's Physician's Order dated 06/14/2025 revealed Divalproex Sodium ER oral tablet Extended Release 24 hour 250 MG. to be administered every 12 hours for seizures. The order was transcribed by LVN B.Review of CR #1's Physician's PN dated 06/17/2025 at 08:18 a.m., revealed Physician A documented he saw the resident at the facility on that date. The PN reflected the resident was receiving 50 mg of Depakote ER (generic form of Divalproex Sodium ER) twice daily, instead of 1000 mg twice daily as reflected in the hospital discharge summary or 250 mg every 12 hours, as reflected in the facility Physician Order dated 06/14/2025. The PN reflected no correction of the Physician Order dated 06/14/2025. Review of CR #1's June 2025 MAR revealed she received one 250 mg tablet of Divalproex Sodium ER every 12 hours from 06/14/2025 at 9:00 p.m. to 06/30/2025 at 9:00 p.m.Review of CR #1's July MAR revealed she received one 250 mg tablet of Divalproex Sodium ER every 12 hours from 07/01/2025 to 07/04/2025 at 9:00 a.m. (date of discharge).In an interview on 12/17/2025 at 2:44 p.m., LVN B said the procedure for new admissions was to call or text the physician or NP that the resident had arrived and ask them to review medications. If there was a change, the physician or NP was to notify the nurse via phone, text, or in person. She said the medication orders were not to be entered into the system without approval. When asked if the verification was to be documented, she responded there was no protocol, so she did not document in every case. She said she would have verified the orders with NP C. She said she could not remember if NP C changed any of the orders. In an interview via telephone on 12/17/2025 at 3:12 p.m., CR #1's family member said when the resident was discharged , he noticed the facility had been administering one 250 mg tablet of Divalproex Sodium ER twice daily, instead of 1000 mg twice daily, as reflected in the hospital discharge orders. He said after the resident was discharged from the facility she would scream ‘Help me!' all day. She was admitted to a different facility and passed away on 11/22/2025.In an interview on 12/17/2025 at 3:30 p.m., the DON said there was no set way for the nurses to verify new admission orders, but the nurse could call, text, or use an app. The nurse was to contact the NP or doctor, give report, and have them reconcile the medications. He said the nurse should chart that they contacted the physician. The DON said if the medications were not verified, it could result in a medication error. He said he did not know if NP C changed CR #1's Divalproex Sodium ER (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete order upon admission.In an interview via telephone on 12/17/2025 at 4:42 p.m., NP C said she looked through her texts and said she received CR #1's medication list from the hospital. She said she told the nurse to continue with all of the medications. She said she does not review medications but tells the nurse to continue the hospital medications. When asked what complications could arise from the resident receiving 250 mg of Divalproex Sodium ER twice daily versus 1000 mg Divalproex Sodium twice daily, she said she did not want to answer that.In an interview via telephone on 12/17/2025 at 5:15 p.m., Physician A was asked what complications could arise from the resident receiving 250 mg of Divalproex Sodium ER twice daily versus 1000 mg Divalproex Sodium twice daily. He said it would depend on what other medications the resident was on. He said the resident also had low sodium levels, which could have caused altered mental status. The facility policy admission Orders (Revised 02/01/2023) read, in part, .A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the residents' immediate care and needs.1. The written and/or verbal orders should include at the minimum:.b. Medication orders if indicated. Review of the package insert for Divalproex Sodium (Section 8.5) revealed discontinuation of Valproate was occasionally associated with somnolence (excessive sleeping) and tremors. Event ID: Facility ID: 675538 If continuation sheet Page 3 of 3