Inspection visit
Inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0645
PASARR screening for Mental disorders or Intellectual Disabilities
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure individuals with mental health disorders were
provided an accurate PASARR for 1 of 4 residents (Residents # 44) reviewed for PASARR Level 1
screenings.
Residents Affected - Few
The facility failed to correctly code Resident #44's PASARR Level I assessment for mental illness, which
resulted in the resident not receiving a PASARR Level II evaluation.
This failure could affect residents with mental illness placing them at risk for a diminished quality of life and
not receiving necessary care and services in accordance with individually assessed needs.
Findings include:
Record review of Resident #44's admission record revealed the resident was a [AGE] year-old male
admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: schizoaffective
disorder, bipolar type (feelings of euphoria, racing thoughts), Major depressive disorder, recurrent, severe
with psychotic symptoms (mental health condition of persistently depressed moods), delusional disorder (a
belief of altered reality), paraplegia, unspecified (inability to move lower body) and PTSD (anxiety and
flashbacks).
Record review of Resident #44's PASARR level 1 screening dated 06/02/21 revealed Resident #44 was
negative for mental illness, intellectual disability, and developmental disability.
Record review of Resident #44's admission MDS dated [DATE] revealed he had a BIMS score of 12 out of
15 which indicated his cognition was moderately impaired. Resident #44 required extensive assistance of
one to two staff assist with bed mobility and required extensive assistance of one to two staff assist for
transfers, dressing and toilet use. Resident # 44 was incontinent of bladder and bowel. His active diagnoses
included psychotic disorder, schizoaffective disorder, depressive type, and schizophrenia.
Record review of Resident #44's physician order dated 09/13/2022-10/13/2022 revealed an order for
Seroquel dated 09/01/20-open ended, tablet: 25 mg: amt 25mg: oral [DX: Delusional disorders] at bedtime:
08:00 PM and Zoloft (sertraline) dated 04/29/22-open ended, tablet: 50 mg: amt: 1 tab: oral [DX Major
depressive disorder, recurrent, severe with psychotic symptoms] Once a day: 08:00 AM.
Observation and interview with Resident #44 on 10/11/22 at 9:37 AM, revealed he was in bed with the head
of his bed partially raised and starring at the wall. Resident # 44 stated with a blank expression on his face
I'm okay.
(continued on next page)
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
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 14
Event ID:
676417
Printed: 05/15/2026
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
676417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/13/2022
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)
F 0645
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 10/13/22 at 02:16 PM the DON confirmed psychotic disorder, schizophrenia, anxiety
disorder, depression, bipolar disorder, and PTSD qualified as mental illness diagnosis for PASARR and
there should have been a PASARR Level II conducted. The DON stated the MDS nurse should have
followed through with the PASARR screening because the risk of not doing so would be the resident would
not get the needed services they qualified for.
Residents Affected - Few
Interview on 10/13/22 at 02:32 PM, MDS LVN A stated Resident #44's PASARR was not correct because of
his schizoaffective disorder, Major depressive disorder with psychotic symptoms, and PTSD diagnosis. She
stated the MDS nurse was responsible for following up on PASARR triggers. The MDS LVN A stated the
risk of not following up on PASARR triggers is the residents would not get the services they need.
Record review of the NF policy on PASARR Documentation Policy revised November 01, 2017, read in
part: This policy is intended as a general guide for the PASARR process. 1. PASARR requires that: A. All
applicants to a Medicaid -certified nursing facility are evaluated for mental illness and or intellectual
disability, prior to admission and; B. Offered the most appropriate setting for their needs which may be in
the community, a nursing facility, or an acute care setting, and: C. Receive necessary services in those
settings to address any specific need related to the diagnosis of mental illness or intellectual disability.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 2 of 14
Printed: 05/15/2026
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
676417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/13/2022
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review, the facility failed to develop and implement a comprehensive person-centered
care plan for each resident which included measurable objectives and timeframes to meet a resident's
medical, nursing, and mental and psychosocial needs that were identified in the comprehensive
assessment for 2 of 7 residents (Residents #105 and #77) reviewed for comprehensive assessments.
-The facility failed to ensure Resident #105's comprehensive care plan reflected the use of antidepressant
and anticoagulant medications.
-The facility failed to ensure Resident #77's comprehensive care plan reflected the resident was receiving
physical therapy services.
These failures could place residents at risk of not receiving the care and treatment listed in the care plan
and could lead to a diminished quality of care.
Findings include:
Record review of the admission sheet for Resident #105 revealed a [AGE] year-old female admitted to the
facility on [DATE] with diagnoses which included shortness of breath, depression, and peripheral vascular
disease.
Record review of Resident #105's comprehensive MDS assessment, dated 09/23/2022, revealed the BIMS
score was 14 out of 15, which indicated intact cognitive mental status. Further view of section N0410
revealed Resident #105 was coded for receiving antidepressant and anticoagulant medications.
Record review of Resident #105's physician orders, dated 09/21/22, revealed an order for duloxetine
capsule, delayed release(DR/EC); 30 mg; amt: 1 tab; oral Twice A Day 09:00 AM, 05:00 PM.
Record review of Resident #105's physician orders, dated 09/21/22, revealed an order for Xarelto
(rivaroxaban) tablet; 20 mg; amt: 1 tab; oral Once A Day 07:00 AM - 12:00 PM. Further review, revealed an
order, dated 09/21/22, for clopidogrel tablet; 75 mg; amt: 1 tab; oral Once A Day 07:00 AM - 12:00 PM
Record review of Resident # 105's care plan, initiated 09/22/22, revealed the resident was not care planned
for receiving antidepressant or anticoagulant medications.
Record review of Resident # 105's care plan, after surveyor's intervention revealed a care plan initiated
9/22/22 and revised on 10/12/22 read in part: .Problem: High risk for increase bleeding R/T BLOOD
THINNING AGENT Resident currently takes: [ ] Coumadin [ ] Lovenox [ ] Heparin [ x] ASA [x] Other Xarelto,
plavix, alteplase
Goal: [Resident #105] will have no side effects from medication.Approach: Monitor for side effects. Notify
MD if bleeding is not stopped with pressure. Soft bristle tooth brush for brushing teeth
Problem: Resident #105 is at risk for adverse consequences R/T receiving antidepressant medication
(Duloxetine) for treatment of Depression.Goal: Resident #105 will not exhibit signs of drug related
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 3 of 14
Printed: 05/15/2026
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
676417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/13/2022
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
side effects or adverse drug reaction. Approach: Assess/record effectiveness of drug treatment. Monitor
and report signs of sedation, hypotension, or anticholinergic symptoms. Monitor Resident #105's mood and
response to medication .
Resident #77
Residents Affected - Some
Record review of the admission sheet for Resident #77 revealed a [AGE] year-old female admitted to the
facility on [DATE] with diagnoses which included diffuse traumatic injury without loss of consciousness,
unspecified intracranial injury with loss of consciousness of unspecified duration, and cognitive
communication deficit.
Record review of Resident #77's comprehensive MDS assessment, dated 09/13/22, revealed the BIMS
score was 12 out of 15, which indicated moderately impaired cognitive mental status.
Record review of Resident #77's Comprehensive Care Plan, dated 9/13/22, revealed therapy was not care
planned.
In an interviewed with Physical Therapist on 10/13/22 at 1:13p.m., she said Resident #77 started receiving
PT, OT and speech therapy on 7/12/22 and was D/C on 8/12/22 due to change of payor source. Resident
#77 resumed therapy on 09/09/22 to end on 11/07/2022.
In an interview on 10/12/22 at 2:13p.m., with MDS Nurse A and MDS Nurse B, MDS Nurse A said foley,
g-tube, falls, dialysis, meds, PT services had to be care planned. She said, pretty much it's a group effort.
Initial baseline care plan was initiated by the floor nurse, since they were the first contact with the resident.
The MDS nurses updated the care plan quarterly and on change of condition to add behaviors and follow
up on falls. She said ADONs were responsible for care plan on antidepressants, foley and [NAME]. MDS
Nurse B said she was responsible/assigned for completing Resident#105's MDS and update the
comprehensive care plan quarterly.
In an interview on 10/12/22 at 2:21p.m., with ADON A, she said the floor nurses completed the baseline
care plan and ADON looked over it. She said, all the department heads could add on the comprehensive
care plan.
In an interview on 10/12/22 at 2:36p.m., with the DON, she said the care areas that were triggered on
CAAs were care planned. She said antidepressant meds were care planned as it gave the indication of
having depression or risk of depression, anticoagulants for bleeding and services required. She said
nursing was responsible for updating and completing the comprehensive care plan. She said it was
important to update the care plan because nurses followed the care plan.
No policy on care plan was provided on exit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 4 of 14
Printed: 05/15/2026
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
676417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/13/2022
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)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure residents who needed respiratory care
were provided such care, consistent with professional standards of practice for 2 of 4 residents (Resident
#34 and #105) reviewed for respiratory care in that:
Residents Affected - Some
-The facility failed to ensure Residents #34's and #105's physician orders for oxygen use were followed.
This deficient practice could affect residents, who received oxygen therapy, and could result in residents
receiving incorrect or inadequate oxygen support and could result in a decline in health.
Finding included:
Record review of the admission sheet for Resident #34 revealed a [AGE] year-old male admitted to the
facility on [DATE] and re-admitted on [DATE] with diagnoses which included depression, congestive heart
failure and hypertension.
Record review of Resident #34's Comprehensive MDS, dated [DATE], revealed the BIMS score was 99 out
of 15, revealed her staff assessment for mental status was conducted due to the resident was unable to
complete the brief interview for mental status questions. She was assessed as having short term memory
problems, long term memory problems, and cognitive skills for daily decision making was severely impaired
never/rarely made decision. Further review of Section O0100: Resident was not coded for receiving oxygen
therapy.
Record review of Resident # 34's Care plan initiated 12/8/21 and revised on 2/5/22 revealed resident was
not care planned for receiving oxygen therapy.
Record review of Resident #34's physician order dated 6/5/22 revealed an order for albuterol sulfate
solution for nebulization; 0.63 mg/3 mL; amt: 3ml; inhalation twice a day 09:00 AM, 05:00 PM. Further
review 22 revealed an order, dated 09/16/22, for O2 at 2 liters per minute via nasal cannula Every Shift PRN
An interview and observation on 10/11/22 at 9:16 a.m. of Resident #34 revealed he was lying in his bed. He
had a nasal cannula in place and an oxygen concentrator at his bedside. The concentrator was on and set
to deliver 10 LPM (liters per minute). The oxygen tubing and the nebulizer mask were not dated.
During an observation and interview on 10/11/22 at 9:28 a.m., ADON A confirmed Resident #34's
concentrator was on and set to deliver between 10 LPM (liters per minute). The oxygen tubing was not
dated. Further observation revealed a nebulizer mask was sitting on top of the side drawer in a clear bag,
not dated. ADON A said she did not know Resident's oxygen administration orders. She said the tubing was
changed weekly by the floor nurse. She said there should have been a date written to show when the
tubing/neb mask was last changed. She said the ADONs were responsible to ensure the tubing was
changed. She said that the importance of changing the tubing it was best infection control practice.
In an interview and observation on 10/12/22 at 10:10 a.m., of Resident #34 revealed he was lying in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 5 of 14
Printed: 05/15/2026
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
676417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/13/2022
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)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
his bed. He had a nasal cannula in place and an oxygen concentrator at his bedside. The concentrator was
on and set to deliver 10 LPM (liters per minute). The oxygen tubing was not dated.
Observation and interview on 10/12/22 at 10:12a.m., this Surveyor reviewed Resident #48's physician
orders with RN AA. RN AA said the order was for resident to receive 2 LPM every shift. She said, he was
decompensating last week so we turned it up a little. I noticed he was on 10 L this morning at 10:00 am. His
02 stats were 99% so I texted and notified the physician. She said the physician told her to decrease O2
according to the order. She said if the resident had COPD, it could make it worst. She said, more is not
always better it was important to follow physician's order.
Resident#105
Record review of the admission sheet for Resident #105 revealed a [AGE] year-old female admitted to the
facility on [DATE] with diagnoses which included shortness of breath, depression, and peripheral vascular
disease.
Record review of Resident #105's Comprehensive MDS, dated [DATE], revealed the BIMS score was 14
out of 15, which indicated intact cognitive mental status. Further view of section O0100: Resident was not
coded for receiving oxygen therapy.
Record review of Resident # 105's Care plan initiated 9/22/22 and revised on 10/12/22 revealed resident
was not care planned for receiving oxygen therapy.
Record review of Resident #105's physician orders, dated 9/21/22, revealed an order for O2 at 2 liters per
minute via nasal cannula
Every Shift - PRN
Record review of Resident #105's physician orders, dated 9/22/22 revealed an order for EQUIPMENT
Oxygen: Change O2 tubing/nasal cannula/mask/humidification system weekly Once A Day on Sun 06:00
PM - 06:00 AM.
An interview and observation on 10/11/22 at 9:43 a.m. of Resident #105 revealed she was lying in her bed.
She had a nasal cannula in place and an oxygen concentrator at her bedside. The concentrator was on and
set to deliver 2 LPM (liters per minute). The oxygen tubing was not dated.
During an observation and interview on 10/11/22 at 9:46a.m., ADON A confirmed Resident #105's
concentrator was on and set to deliver between 2 LPM (liters per minute). The oxygen tubing was not
dated.
In an interview on 10/12/22 at 2:36p.m., with the DON, she said the oxygen tubing was changed weekly on
Sundays by the night shift nurses and the ADON checked weekly to ensure, as it placed risk for infections.
She said it was important to adhere to the physician's order for respiratory and COPD. She said
Resident#34 changed the setting and it was later adjusted as ordered. She said the nurses should be
checking the oxygen setting daily to follow physician order. At the time policy on following physician order
was requested.
Record review of facility's Respiratory Policies and Procedures, revised 04/01/22, read in part: .Subject:
Equipment Change schedule. Policy: The facility shall have a schedule for changing
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 6 of 14
Printed: 05/15/2026
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
676417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/13/2022
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)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
disposable equipment at regular intervals as determined by manufacturer recommendations and local
community policies. Procedures: Equipment will be changed as follows: Equipment: Nasal Cannula-change
on and as needed basis or per state regulations .
No policy on following physician's orders was provided on exit.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 7 of 14
Printed: 05/15/2026
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
676417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/13/2022
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)
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure each resident's drug regimen was free from
unnecessary drugs, to include adequate monitoring for 2 of 5 residents (Resident #34 and #105) reviewed
for unnecessary medications.
Residents Affected - Some
-The facility failed to monitor the side effects for Resident #34 and #105's antidepressant and anticoagulant
medications.
This deficient practice could place residents at risk of increased behaviors, negative outcomes, and a
decline in health.
Findings include:
Resident#34
Record review of the admission sheet for Resident #34 revealed a [AGE] year-old male admitted to the
facility on [DATE] and re-admitted on [DATE] with diagnoses which included depression, congestive heart
failure, and hypertension.
Record review of Resident #34's comprehensive MDS assessment, dated 09/14/22, revealed the BIMS
score was 99 out of 15, revealed her staff assessment for mental status was not conducted due to the
resident being unable to complete the brief interview for mental status questions. She was assessed as
having short term memory problems, long term memory problems, and cognitive skills for daily decision
making was severely impaired, and the resident never or rarely made decisions. Further review of Section
N0410 revealed Resident #34 was coded for receiving antidepressant and anticoagulant medications.
Record review of Resident # 34's care plan, initiated 12/8/21 and revised on 2/5/22, revealed the following:
Problem: Resident # 34 has a DX of Depression and receives Anti-Depressants daily.
Goal: Resident # 34 will have no unaddressed complications through the next review date.
Approach: Monitor for side effects of antidepressant: dry mouth, blurred vision, constipation, urinary
retention, appetite changes, headache, insomnia, dyspepsia, weigh changes; notify MD if side effects are
observed
Record review of Resident #34's physician orders, dated 10/8/22 revealed an order for duloxetine capsule,
delayed release(DR/EC); 60 mg; amt: 1 cap; oral
Special Instructions: Give after breakfast Once A Day 07:00 AM - 12:00 PM. Further review revealed an
order, dated 06/02/22, for Eliquis (apixaban) tablet; 2.5 mg; amt: 1 tab; oral Twice A Day 09:00 AM, 05:00
PM
.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 8 of 14
Printed: 05/15/2026
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
676417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/13/2022
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)
F 0757
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Record review of Resident #34's MAR and TAR, for October 2022, revealed no documentation of nursing
staff monitoring Resident #34 for possible side effects of antidepressant and anticoagulant medications.
Resident #105
Record review of the admission sheet for Resident #105 revealed a [AGE] year-old female admitted to the
facility on [DATE] with diagnoses which included shortness of breath, depression and peripheral vascular
disease.
Record review of Resident #105's comprehensive MDS assessment, dated 9/23/22, revealed the BIMS
score was 14 out of 15, which indicated intact cognitive mental status. Further view of section N0410
revealed Resident #105 was coded for receiving antidepressant and anticoagulant medications.
Record review of Resident # 105's care plan, initiated 9/22/22 and revised on 10/12/22 read in part: .
Problem: High risk for increase bleeding R/T BLOOD THINNING AGENT Resident currently takes: [ ]
Coumadin [ ] Lovenox [ ] Heparin [ x] ASA [x] Other Xarelto, plavix, alteplase
Goal: [Resident #105] will have no side effects from medication.
Approach: Monitor for side effects. Notify MD if bleeding is not stopped with pressure. Soft bristle tooth
brush for brushing teeth
Problem: Resident #105 is at risk for adverse consequences R/T receiving antidepressant medication
(Duloxetine) for treatment of Depression.
Goal: Resident #105 will not exhibit signs of drug related side effects or adverse drug reaction.
Approach: Assess/record effectiveness of drug treatment. Monitor and report signs of sedation,
hypotension, or anticholinergic symptoms. Monitor Ms. Narinesingh's mood and response to medication .
Record review of Resident #105's physician orders, dated 9/21/22, revealed an order for duloxetine
capsule, delayed release(DR/EC); 30 mg; amt: 1 tab; oral Twice A Day 09:00 AM, 05:00 PM
Record review of Resident #105's physician orders, dated 9/21/22, revealed an order for Xarelto
(rivaroxaban) tablet; 20 mg; amt: 1 tab; oral Once A Day 07:00 AM - 12:00 PM. Further review revealed an
order, dated 09/21/22, for clopidogrel tablet; 75 mg; amt: 1 tab; oral Once A Day 07:00 AM - 12:00 PM
Record review of Resident #105's MAR and TAR, for October 2022, revealed no documentation of nursing
staff monitoring Resident #105 for possible side effects of antidepressant and anticoagulant medications.
In an interview on 10/12/22 at 10:12a.m., RN AA said nurses monitored for possible side effects of
antidepressant and anticoagulant medications. She said nurses documented presence or absence of side
effects on the TAR every shift for complications and monitoring. She said the nurse who entered the order
into the system, should have added the order to monitor for the drug side effects. She said
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 9 of 14
Printed: 05/15/2026
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
676417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/13/2022
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)
F 0757
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
the ADON went through the new orders the following day. She said it was important to monitor s/sx for
anticoagulant for excessive bruising, bloody stool. Antidepressants were monitored for behaviors to be put
on or taken off. If it's the right dose, effective, or appropriate treatment for the resident.
Record review and interview on 10/12/22 at 11:02a.m. with ADON A revealed the Surveyor reviewed
Resident # 34 and #105's physician orders. The ADON A said the admission nurse entered the orders upon
admission, including the antidepressant/anticoagulant monitoring. The next day, ADON A followed up that
the orders were entered. She said Resident #34 was moved from long term hall 200 to skilled hall 400.
Therefore, she did not reconcile/check his orders. She said she overlooked Resident #105's orders. She
said, it was missed.
In an interview on 10/12/22 at 2:36p.m., with the DON, she said any nurse could enter the order to monitor
for the drug side effects and the ADON checked. She said the ADON was responsible for ensuring orders
were transcribed, reconciled and entered. She said the facility monitored for side effects and behaviors with
any antidepressant medications and excessive bleeding for anticoagulant medications. She said nursing
staff documented antidepressant/anticoagulant side effect monitoring in the TAR for complications and
monitoring.
Record review of facility's Anticoagulation Monitoring Program (revision 12/10/2018) read in part: .Policy:
Administration of anticoagulants to patients/residents is based on a defined management program to
individualize the care provided to each patient/residents. The management of the program with
individualized care will reduce the likelihood of harm to patient/residents associated with the use of
anticoagulation therapy. Procedures: 17. Adverse effects of medication must be reported to the nursing
supervisor and should be documented in the patient's/resident's chart per facility policy. A. Adverse effects
may include, but are not limited to: 1) red or tarry stools, spitting or coughing up blood, heavy bleeding
during menstruation, pin red, or dark brown urine, coughing or vomiting coffee ground substance, any
unusual bleeding or bruising .
Record review of facility's Psychotropic Drugs policy (revision 7/1/2016) read in part: .Procedures: A.
Antidepressants: Residents/patients should be monitored closely for worsening of depression and/or
suicidal behavior or thinking, especially during initiation of therapy and during any change in dosage.
Targeted behaviors, number of behavior episodes, intervention, outcome and side effects will be monitored
by qualified staff each shift and total number of behaviors will be totaled for each shift at the end of the
month .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 10 of 14
Printed: 05/15/2026
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
676417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/13/2022
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals
used in the facility were stored properly in accordance with professional standards of practice in one of two
facility units (Unit #100), reviewed for labeling and storage of drugs and biologicals, in that:
The facility failed to ensure there were no expired medications in the medication room on Unit #100.
These failures placed residents, in Unit #100, at risk of receiving expired medications or having adverse
reactions.
Findings Include:
An observation on 10/12/22 at 8:25 a.m. on Unit #100, inside of the medication room, revealed the following
expired medications: Fluticasone Propionate Nasal Spray, USP, 50 mcg per Spray with an expiration date of
08/2021, Geri-Lanta Regular strength antacid and antigas with an expiration date of 06/22, Acetaminophen
SUP 650 MG with an expiration date of 08/18/21, Lidocaine HCL 1% injection, USP 200/20ml (10mg/ml)
with an expiration date of 09/01/21, UltraTuss Guaifenesin expectorant, with an expiration date of 07/22,
Lactulose Soln 10GM/15ML with an expiration date of 02/08/21, and Budesonide Inhalation Suspension,
0.5mg/2 ml with an expiration date of 07/18/20.
During an interview on 10/12/22 at 8:35 a.m., the DON stated she was not aware of the expired
medications in the medication room. She stated the nurses on each unit were responsible for ensuring
there were no expired medications in the medication rooms. The DON stated the risk of having expired
medications in the medication storage room is that it could have been given to a resident and could cause
unwanted side effects.
During an interview on 10/12/22 at 01:32 p.m., LPN C stated all the nurses was responsible for checking to
ensure there were no expired medications in the medication storage rooms. LPN C stated expired
medications given to the residents will not have the correct potency and could cause unwanted side effects.
Record review of the NF policy on Medication Storage revised April 01, 2022, read in part:
.Medications and biologicals are stored safely, securely and properly following manufactures' s
recommendations or those of the supplier. 12.Outdated, contaminated, or deteriorated medications and
those in containers that are cracked, soiled, or without secure closures are immediately removed from stock
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 11 of 14
Printed: 05/15/2026
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
676417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/13/2022
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)
F 0814
Dispose of garbage and refuse properly.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse
properly for 1 of 1 dumpster reviewed for dietary services.
Residents Affected - Few
-The facility failed to ensure the dumpster doors were secured.
This failure could place residents at risk of the infestation of vermin and pests as a result of the unsecured
dumpster door.
Findings include:
An observation on 10-11-22 at 8:45 am revealed the facility's dumpster area, which was in the lot behind
the dietary department, had a commercial-size dumpster 1/2 full of garbage, and the door was open.
During an interview on 10-11-22 at 9:00 am with the Dietary Food Service Manager, she stated that the
dumpster lids always must be closed to keep vermin, pests and insects out of the dumpster and from
entering the facility.
Record review of facility's Nutrition Services policies and procedure - Subject Waste Disposal dated August
2020 revealed: Waste will be disposed of in a manner to prevent transmission of disease, nuisance or
breeding place for insects and feeding places for rodents and other animals. Procedures: . 5. Cover waste
containers and close dumpster always.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 12 of 14
Printed: 05/15/2026
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
676417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/13/2022
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to maintain an infection prevention and control
program designed to provide a safe, sanitary and comfortable environment and to help prevent the
development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #71)
reviewed for infection control, in that:
Residents Affected - Few
The facility failed to ensure the Wound Care Nurse performed hand hygiene when moving from a dirty to
clean site, while performing Resident #52's wound care.
This failure could place residents at risk for or infections.
Findings included:
Record review of the admission sheet for Resident #52 revealed she was [AGE] year-old female admitted
on [DATE] and re-admitted on [DATE]. Her diagnoses included pressure ulcer of sacral region, bacterial
intestinal infection, and acute kidney failure.
Record review of Resident#52's quarterly MDS assessment, dated 8/15/2022, revealed a BIMS score of 15
out of 15 indicating intact cognition. Further review revealed Resident #52 was at risk of developing
pressure ulcer or injuries.
Record review of Resident#52's care plan, initiated 4/28/22 and revised on 10/12/22, revealed the following
read in part: .
Problem: Actual Pressure Ulcer(s) _Stage IV pressure ulcer to sacrum. Cleanse with normal saline ,pat dry
and apply calcium alginate daily until resolved. Air mattress offloading.
Goal: The resident's wound(s) will decrease in size to_____ (specify), there will be no new pressure ulcer
development, and comfort will be maintained.
Approach: Wound team to evaluate wound(s), treatments and healing weekly. Wound care as ordered. See
treatment record .
Record review of Resident#52's physician order, dated 4/28/22, revealed an order to Cleanse wound to
sacrum with normal saline, apply Aliginate , cover wound with dry dressing daily.
Every Shift
Observation on 10/12/22 at 9:55 a.m., revealed the Wound Care Nurse performing wound care on Resident
#52. Observation of the wound care revealed a dressing, dated 10/11/22, on a wound to sacral area
approximately 1 cm in diameter. The Wound Care Nurse did not clean the sacral wound from the inside to
out. The Wound Care nurse then removed her soiled gloves, without sanitizing/washing her hands, donned
new gloves and continued the wound care treatment. The Wound Care Nurse applied calcium alginate and
covered with a dry dressing.
In an interview on 10/12/22 at 9:57 a.m. with the Wound Care Nurse, she said she was not a certified
wound care nurse. She said she had her competency check sometime in June 2022 with the previous
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 13 of 14
Printed: 05/15/2026
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
676417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/13/2022
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)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
DON. She said she did not perform hand hygiene between the gloves change because there was no
drainage. She said, if there was drainage, I would have sanitized my hands between gloves change as it
placed risk for infections. She said the facility provided in-servicing on infection control or hand hygiene
every month or every other month; she could not recall the exact date.
In an interview on 10/12/22 at 2:36p.m., with the DON, she said she expected staff to follow standard
infection control techniques; to perform handwashing before the treatment, between gloves change and
after as it placed risk for infections. She said staff were provided training on infection control and hand
hygiene monthly and competency check off were done quarterly to include hand hygiene, pericare and
wound care. She said she spot checked staff once a month. She said the potential risk to the resident, due
to this failure, was cross contamination. The DON said the facility did not have a policy on hand washing.
The facility used competency check offs for hand washing as their policy.
Record review of facility's competency: Hand Washing included procedure and steps on how to perform
hand washing. The competency did not state washing or sanitizing hands between glove changes.
Record review of the in-service, conducted on 10/12/22 by the DON to the Wound Care Nurse read in part:
.Title hand hygiene in wound management. Objectives of the in-services: wash hands before & after
removing gloves. Hand hygiene is considered a primary measure for reducing the risk of transmitting
infections among patients & health care personnel. Hand Hygiene procedures include: hand washing
w/soap & water. Alcohol-based hand rubs (containing 60%-95%) alcohol .
Record review of Wound Care Nurse Competency titled: Dressing, simple: Application Of dated 10/12/22
read in part: .10. Removes old dressing. 11. Inspects wound, notes any odors, 12. Discards of dressing and
gloves appropriately. 13. Washes hands .
Record review of Wound Care Nurse Competency tilted: Dressing-Dry: Application Of dated 10/12/22 read
in part: .8. Removes old dressing. 9. Inspects wound, notes any odors, measures as needed.10. Discards of
dressing and gloves appropriately. 11. Washes hands .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 14 of 14
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Back to topCitations
9 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F761 - Labeling of Drugs and Biologicals
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.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the October 13, 2022 survey of STERLING OAKS REHABILITATION?
This was a inspection survey of STERLING OAKS REHABILITATION on October 13, 2022. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at STERLING OAKS REHABILITATION on October 13, 2022?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe and appropriate respiratory care for a resident when needed."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.