The facility made errors in documenting whether residents used oxygen therapy, according to a September inspection report.
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The incident occurred after the coordinator drove Resident #1 to an orthopedic appointment that ended around 2:30 or 3:00 in the afternoon.
In every case observed, residents couldn't access the call buttons that serve as their lifeline to nursing staff.
The resident had no current doctor's order for the narcotic pain medication.
The resident required substantial assistance for bathing due to muscle weakness, seizures, lack of coordination, and muscle wasting.
The documentation gaps at Sterling Oaks Rehabilitation made it impossible to verify if Resident #2 received prescribed heart medications during her stay.
The medication error at The Brazos of Waco occurred on September 20, 2025, when an agency nurse administered an incorrect dose of Valacyclovir to Resident #1.
The September 10th incident at North Pointe Care Center left Resident 1 with facial lacerations and swelling on the right side of his face.
The resident had severe cognitive impairment and was dependent on staff for all daily activities, inspection records show.
Inspectors observed the violation during wound care on September 26.
None of this happened for Resident 1.
Federal inspectors discovered the violation during a September inspection of the 32-bed facility.