Sterling Oaks Rehabilitation
STERLING OAKS REHABILITATION in KATY, TX — inspection on September 29, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Resident #2's blood pressure was always low, and she had to hold the medication on several occasions.
She said she must pay more attention and always document when medications were given or not given. In an interview on 09/29/2025 at 11:37am, the ADON said blood pressure medication should not be given when the blood pressure was within the parameter the doctor said should be held.
She said if medications were held it should be documented and the reason why it was held.
She said if the medication was given, when it was supposed to be held the blood pressure could drop lower, and the residents could get dizzy and fall.
She said her expectations of the staff were to ensure the physician's orders were followed and documented in the clinical records.
She said the plan going forward was to in-service the staff, ensuring blood pressures were checked and supervise the blood pressure medication administration.
She said the staff will be in-serviced on documentation in resident's clinical records.
Record review of the facility policy titled Physician's Order dated May 5, 2023, Read in Part .
Policy: The qualified licensed nurse will obtain and transcribe orders according to the facility's practice guidelines.ProceduresAdmissionThe qualified licensed nurse completes an admission medication regimen review from the transfer record from an acute care hospital, home or other entity.a. A call is placed to the physician to confirm the orders and request any additional orders as needed.
Medication/Treatment1.
The facility should not administer medications or biologicals except upon the order of a physician/prescriber lawfully authorized to prescribe them.2.
Elements of medication include:- Parameters for holding medication if indicated.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Sterling Oaks Rehabilitation
25150 Lakecrest Manor Dr Katy, TX 77493
SUMMARY STATEMENT OF DEFICIENCIES
blood pressure medication because her blood pressure was low.
She said she was not getting the medication for blood pressure; she was getting it to treat her heart. In an interview on 09/29/2025 at 11:20am with MA A she said she was the one who gave medications to Resident#2.
She said if the blood pressure was low, she would have held the medication.
She said the documentation was an error.
She said she was sure the medication was held and had forgotten to document it correctly.
She said she was aware Resident #2's blood pressure was always low, and she had to hold it on several occasions.
She said she must pay more attention and always document when medications were given and if not given to document it, and the reason it was given or not given.
She said there should be no blanks on the MARS.
Blanks on the MARs could indicate that the medication was not given.
She said she must pay more attention and always document after completing a task. In an interview on 09/29/2025 at 11:37 AM, ADON said there should be no blanks on the MARs.
She said if medications were given or not given it should be documented on the MARs.
She said if there were no documentations it's hard to determine it the medications were given or not given.
She said the expectations of the staff were to ensure the physician's orders were followed and documented in the resident's clinical records.
She said the plan going forward was to in-service the staff, ensuring blood pressures were checked and documented.
She said the staff will be in-serviced on documentation in resident's clinical records.
Record review of the facility's policy and procedures on Documentation dated May 5th 2023 read in part .Subject: Documentation GuidelinesPolicy:Documentation guidelines pertinent to good clinical record practice will be followed by all individuals who document the medical record.
Guidelines:1.
Print or write neatly and legibly5.
Make all entries in chronological order and do not leave blank spaces between entries.6.
Date and sign all entries, including the first initial last name and title of the writer.7.
All entries should be based on the writer's first hand knowledge
Facility ID: