Sterling Oaks Rehabilitation

During an observation on 5.26.26 at 2:25 pm Resident #22's open mail (Your Medicare Part D Explanation of Benefits) was out in a common area. Resident #22's mail had information such as date of birth , account number, and address.

During an observation on 5.27.26 at 11:27 AM Resident #22's open mail was still sitting out in common area exposed to everyone.

During an interview and observation on 5.27.26 at 2:15 PM DON stated that Resident #22's mail should be in the resident's room.

She stated whether Resident #22 opened it or not, it was the responsibility of the staff to make sure no personal information of any resident was sitting out in a common room for anyone to see.

During an interview on 5.28.26 at 2:50 PM Administrator stated that Resident #22's mail sitting out in the common area was brought to his attention. He stated this needs to be taken care of, HIPAA was not protected for the residents. He stated this was important to all residents because it was the responsibly of the staff to protect all residents' personal information.

Record review of the facility's policy titled, Safeguards, Posted Protected Health Information, dated March 2013, reflected: POLICY:All employees safeguard electronic protected health information in an effort to fulfill their duty to maintain the confidentiality and integrity of patient/resident health information as required by law, professional ethics, and accreditation requirements.

Access to and the use and disclosure of electronic protected health information is limited to the minimum necessary to fulfill the employee's obligations and duties.

When accessing systems or applications that contain electronic protected health information including systems or applications administered by health plans or other providers; the following procedures must be followed.

Whenever possible, the de-identified information will be used.

676417 05/28/2026

Sterling Oaks Rehabilitation 25150 Lakecrest Manor Dr Katy, TX 77493

During an interview on 05/28/2026 at 10:58 a.m. with the DON, she stated oxygen signs were expected to be posted outside rooms where oxygen was in use.

She stated the signs identified residents receiving oxygen therapy and alerted visitors and staff to associated fire safety risks.

She stated LVNs, RNs, ADONs, and the DON were responsible for verifying the signs were in place.

Record review of the facility's policy titled Leadership Policies and Procedures, Section IX: Patient/Resident Care, Subject: oxygen supply – monitoring and re-ordering, revised on 11/1/2017, read in part: POLICY: The Facility has established a policy and procedure to ensure an adequate supply of oxygen for the prescribed care of patients and residents.

• Post oxygen safety sign on the patient/resident's room door.

F.

Oxygen safety sign placed on patient/resident's room door.

676417 05/28/2026

Sterling Oaks Rehabilitation 25150 Lakecrest Manor Dr Katy, TX 77493

services of a licensed pharmacist.

facility were properly stored and or disposed of according to professional standards in 2 of 2

expired IV mixed solution medications.

The facility failed to properly store 1 glass bottle medication in the refrigerator which led to the breaking of the bottle.

This failure caused the medication to be spilled inside of the plastic zip bag and caused breakdown of the box the mediation was stored in resulting in the medication being unsafe to administer.This failure could place residents receiving medication that is expired at risk of not receiving the intended therapeutic benefit of their medication, or other adverse side effects.The findings include:In an observation on 5/28/2026 at 11:30 AM of the Medication storage room for the 300/400 hall revealed 3 residents had IV medications that had expired. A total of 27 doses of IV mixed solution medications past the date on the labels to have been administered by. A total of 11 doses of Meropenem expired on 5/25/2026, 1 dose of Vancomycin expired on 5/26/2026, 3 doses of Cefazolin expired on 4/1/2026 and 9 doses of Cefazolin expired on 4/6/2026.

One refrigerated medication stored in a clear zipper sealed bag had a broken bottle and the medication and box were saturated in a fluid substance making the medication unsafe for administration. In an interview with RN-D on 5/28/2026 at 11:30 AM while observing the medication room, she stated the nurses or the nurse manager were responsible for ensuring out of date medications were removed from the storage room.

She stated 3 of the expired medications belonged to residents currently in the facility, and one that had been discharged from the facility.

She stated that administering medications that are out of date would not work as well, decrease the efficacy of the dose or cause infection to get worse. RN-D was unaware of the broken bottle of medication stored in the refrigerator.

She stated a negative outcome would be the medication would be contaminated and could possibly contaminate other medications in the refrigerator. In an interview with DON on 5/28/2026 at 1:40 PM she stated her expectation was for medications not being used or expired were to be disposed of in the biohazard box in the medication storage room.

She stated it was the responsibility of the Charge nurse, ADON and DON to ensure medications are checked to ensure medications are properly stored, labeled, and discarded when not being used or expired.

She stated that medication, routine or as needed, was no longer being administered would be kept for the resident until expired in case it was needed again. A negative outcome of administering medications that were not stored properly or were expired could result in the residents not getting medications that are effective for their prescribed treatment. In an interview with ADMN on 5/28/2026 at 1:55 PM, he stated when a medication was out of date or was no longer ordered for a resident, the medication should be removed from circulation and destroyed or sent back to pharmacy for credit. He was unable to state a negative outcome for having expired medication or for contaminated medications. He stated it was the responsibility of the nurse, ADON or DON to check the medication rooms for expired or unused medications.

The administrator stated facility did not have a policy related to removal or disposal of expired, broken, or unused non-narcotic medications.

676417 05/28/2026

Sterling Oaks Rehabilitation 25150 Lakecrest Manor Dr Katy, TX 77493

Observation of the following stored in the refrigerator:Bag of hamburger patties in open box and open bag exposed to the open air.Bag of corn dogs in open box and open bag exposed to the open air.Bag of cheesy garlic breadsticks in open box and open bag exposed to the open air.

During an interview and observation on 5.28.26 at 2:59 PM with DM of freezer revealed an open box of hamburger patties, corn dogs, and cheesy garlic bread was still open with bag open to environment.

He stated that that should be covered and not exposed to the open air. He stated that it would cause freezer burn or could cause exposure to the elements which could cause the residents to get sick. He stated he would get that fixed immediately.

During an interview on 5.28.26 at 10:56 AM with ADMN, he stated DM and staff were responsible for items in fridge and dry storage room and making sure all items are sealed.

All staff have been trained on food storage in the refrigerator and dry storage.

The facility policy was to have all items sealed. He stated the possible negative outcome could be serving exposed food to residents.

Record review of the facility's policy, titled Food Receiving and Storage, revised date 2014, reflected the following:Policy Statement- Foods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation .7.

All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) .

Record review of the FDA Food Code 2022 reflected the federally established standards. derlying surface.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

676417 05/28/2026

Sterling Oaks Rehabilitation 25150 Lakecrest Manor Dr Katy, TX 77493

regarding incontinent care on a mannequin.

The DON said that the CNAs received training or skill

back when they performed peri-care and not a side to side motion as that could possibly cause the spread of germs.

The SDC said the CNAs were trained on an annual basis and at random times.

The SDC said it was expected for the CNAs to change their gloves once they became contaminated to prevent cross contamination.

The SDC said if the CNAs did not change their gloves, then that could possibly lead to the spread of infections.

Interview on 05/28/2026 at 1:45 PM the ADMN said the CNA's were expected to wipe the resident's peri-area from front to back.

The ADMN said the CNA should have changed their gloves after they became contaminated to prevent the spread of infections.

Record review of the facility document titled Infection prevention and control policies and procedures and dated 05/15/2023 revealed in part: Purpose: To establish a facility wide program that incorporates a system for preventing, identifying reporting, investigating, and controlling infections and communicable disease.

The program covers all residents, staff, consultants, students in the facility's nurse aide training program or from affiliated academic institutions, volunteers, visitors, and other individuals providing services under a contractual agreement and is a based on the individual facility assessment following accepted national standards.

Infection prevention and control program consists of currently acceptable infection control standards, practices, and activities.

Examples of these are: Surveillance for healthcare acquired infection (HAI) identification; data analysis, and evaluation.

Infection prevention and control program plan (continued) 6.

Staff Development: 10) Cleaning, disinfecting and sanitation procedures.

Compliance with applicable federal, state, and local regulations concerned with patients/residents and employees.

Staff are provided with information and training on: Infection prevention and control information and plans.

Hand hygiene, including hand washing and alcohol-based hand rub (ABHR).

Universal/standard and transmission-based precautions.

Record review of the facility document titled Staff education/orientation policies and procedures dated 01/12/2024 indicated in part: Competency: Peri-care.

Performance criteria.

Provides privacy, performs hand hygiene, applies disposable gloves and other PPE as indicated.

Male: Gently raises penis and places towel underneath if uncircumcised retracts foreskin.

Disposes of soiled gloves, performs hand hygiene, and puts on clean gloves.

Washes tip of penis and urethral meatus first using circular motion from meatus outward.

Rinses and dries completely unless using no rinse preparation, returns foreskin to normal position.

Cleanses shaft to penis with gentle but firm downward strokes, notes abnormalities in underlying surface.