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Complaint Investigation

Sterling Oaks Rehabilitation

Inspection Date: November 19, 2025
Total Violations 2
Facility ID 676417
Location KATY, TX
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Inspection Findings

F-Tag F0755

Pharmacy Service Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident could fall. She said she was aware 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.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sterling Oaks Rehabilitation

25150 Lakecrest Manor Dr Katy, TX 77493

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)

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F-Tag F0842

Resident Assessment and Care Planning Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

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📋 Inspection Summary

STERLING OAKS REHABILITATION in KATY, TX inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in KATY, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from STERLING OAKS REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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