Cycle 1
Health 2025-05-27 · Fire 2025-05-27
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Sugar Land, TX
Sugar Land Health Care Center
3-star overall rating with 3-star inspections with $38,518 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
333 Matlage Way, Sugar Land, TX
(281) 491-2226
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
91
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Health Services Management
Operator or chain grouping
Approved since
1995-09-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,522
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9926
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.9
Baseline 18.97% · Performance 18.23% · Measure score 6.9 · Achievement 6.9 · Improvement 3.30
Healthcare-associated infections
4.91
Baseline 5.77% · Performance 6.37% · Measure score 4.91 · Achievement 4.91 · Improvement 0
Total nurse turnover
1.63
Performance 57.00% · Measure score 1.63 · Achievement 1.63 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.39
Baseline 3.61 hours · Performance 3.76 hours · Measure score 2.39 · Achievement 2.39 · Improvement 0.19
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.17% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 101 · Observed rate 14.85% · Lower 95% interval 8.41% |
| Discharge to community | 50.43% |
50.57%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 98 · Observed rate 40.82% · Lower 95% interval 40.9% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 91.67% |
95.27%
3.6 pts worse
|
Numerator 110 · Denominator 120 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 119 |
| Discharge self-care score | 62.82% |
53.69%
9.1 pts better
|
Numerator 49 · Denominator 78 |
| Discharge mobility score | 46.15% |
50.94%
4.8 pts worse
|
Numerator 36 · Denominator 78 |
| Pressure ulcers or injuries, new or worsened | 4.2% |
2.29%
1.9 pts worse
|
Numerator 5 · Denominator 119 · Adjusted rate 3.19% |
| Healthcare-associated infections requiring hospitalization | 6.37% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 6.06% · Lower 95% interval 4.17% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 152 |
| Staff flu vaccination coverage | 14.56% |
42%
27.4 pts worse
|
Numerator 23 · Denominator 158 |
| Discharge function score | 61.54% |
56.45%
5.1 pts better
|
Numerator 48 · Denominator 78 |
| Transfer of health information to provider | 62.5% |
95.95%
33.5 pts worse
|
Numerator 55 · Denominator 88 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 22.78% |
25.2%
2.4 pts worse
|
Numerator 18 · Denominator 79 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
97.1%
0.6 pts worse
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 97.2% · Q3 97.3% · Q4 95.8% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
97.9%
0.8 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.3%
1.2 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.2% · Q3 5.3% · Q4 4.2% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
2.7%
2 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
3.3%
About the same
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.1% · Q3 1.6% · Q4 5.3% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.5% |
18.9%
2.4 pts better
|
19.6%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 19.7% · Q3 13.6% · Q4 14.5% · 4Q avg 16.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.0% |
10.8%
1.8 pts better
|
16.7%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 11.3% · Q3 8.0% · Q4 8.3% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.9% |
15.4%
4.5 pts better
|
16.3%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 3.2% · Q3 3.5% · Q4 22.8% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.7% |
16.1%
1.6 pts worse
|
14.9%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 6.2% · Q3 10.9% · Q4 20.0% · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
0.8%
0.1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.5% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.3% |
15.0%
7.7 pts better
|
19.8%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 7.6% · Q3 3.0% · Q4 9.3% · 4Q avg 7.3% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
4.2%
3.8 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 11.9% · Q3 5.4% · Q4 7.7% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.2% |
89.7%
25.5 pts worse
|
81.7%
17.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.9% · Q2 74.9% · Q3 62.0% · Q4 38.7% · 4Q avg 64.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.3% |
12.0%
1.3 pts worse
|
12.0%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.3% · Observed 14.8% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.7% |
88.0%
11.3 pts worse
|
79.7%
3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.3% |
25.9%
1.4 pts worse
|
23.9%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.3% · Observed 31.3% · Expected 27.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-01-26 · Fire 2023-01-26
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-05-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-05-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-03
E · Potential for more than minimal harm
2024-03-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-29
C · Minimal harm
2023-01-26
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-01-26
C · Minimal harm
2023-01-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-17
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2026-01-12
J · Immediate jeopardy
2025-05-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-05-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-05-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-05-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-03
D · Potential for more than minimal harm
2024-03-07
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-29
J · Immediate jeopardy
2023-08-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-08-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-08-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-08-17
K · Immediate jeopardy
2023-01-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-01-26
E · Potential for more than minimal harm
2023-01-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-02-17
E · Potential for more than minimal harm
2023-01-26
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-02-17
D · Potential for more than minimal harm
2023-01-26
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-02-17
D · Potential for more than minimal harm
2023-01-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-17
Penalties and ownership
What sits behind the stars
$22,925
2025-05-27
Fine
Fine · fine $22,925
Fine
$15,593
2023-08-22
Fine
Fine · fine $15,593
Fine
Ownership
Winnie-Stowell Hospital District
5% Or Greater Direct Ownership Interest · Organization
Hsmtx/Sugar Land, LLC
Operational/Managerial Control · Organization
Murrell, Edward
Corporate Director · Individual
Staples, Bernadette
Operational/Managerial Control · Individual
White, Joshua
Operational/Managerial Control · Individual
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#3
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