Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to provide a safe, functional, sanitary, comfortable, and
homelike environment for five of five residents (five residents interviewed during a confidential group
interview) who utilized laundry services at the facility.
-The facility failed to ensure residents who utilized laundry services clothing was returned to them in a
timely manner.
These failures could place the residents at risk of decreased quality of like due to the lack clothing.
Findings include:
A confidential group interview was conducted with five residents on [DATE] at 1:57 PM. There were five
residents present during the interview. All five residents reported lost items from the laundry services. The
residents said laundry would go missing for an extended period of time and then would be found and
returned, or the facility would replace it. One resident said she was missing all but two pairs of her pants.
The same resident said the previous year she had to wear a nightgown and had spoken to the facility's
administrator while wearing the nightgown because she had no other clothing. The resident said that day
three loads of her clothing were returned to her. The residents all said the laundry services take a long time
to return their clothing. They stated the clothing goes missing, was misplaced in other resident's rooms, or
was delayed in return.
Interview on [DATE] at 1:05 PM with The HKM, she said she had been employed for three days. The HKM
said all laundry was to be labeled completely with the resident's name and room number. The HKM said in
other facilities when there was unclaimed or unlabeled laundry, the CNA's will review it see if they can
identify which residents clothing it was. The HKM said as she just started, the facility had not begun that
process yet. The HKM said personal clothing was washed separate and there was no bleach put in the
resident's clothing. The HKM said she had not seen a green laundry bag with a drawstring
Interview on [DATE] at 9:58 AM with the HKM, she said she had been employed for four days. The HKM
said her duties included scheduling, ordering supplies, ensuring staff coverage on all halls, ensuring
housekeeping duties were completed timely, ensuring the cleaning chemicals were at appropriate levels,
overseeing all housekeeping services including all laundry services, and reviewing grievances. The HKM
said she had been made aware of resident complaints of missing laundry items. The HKM said she had
begun to hang-up all the laundry which did not have a name on it. The HKM said she would set
(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 5
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
01/05/2024
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
a date with the activities director to bring all of that laundry to a centralized location for the residents and
staff to claim. The HKM said she would be present and would ensure each unlabeled piece of clothing was
then labeled and returned to the resident. The HKM said in order to prevent that from occurring in the future
she had spoken to the intake director and asked that she be informed when a new resident admitted , and
she would personally label all clothing for that resident. The HKM also asked that staff inform her if
residents received new clothing and she would label that personally as well.
Interview on [DATE] at 10:58 AM with The Administrator, he said he had been employed by the facility for
two years, and with the company for almost three. The Administrator said his primary duties included
protection of all the residents, financial oversight of the facility, customer service, and any other duties
needed. The Administrator said his expectations for the third-party laundry services provider were that the
laundry would be completed and completed properly. The Administrator said he expected the onsite
third-party laundry personnel to fix mistakes and elevate issues which needed further review from the
facility. The Administrator said he expected unclaimed laundry to be brought to a central location for
claiming once monthly. The Administrator said the amount of unclaimed laundry in the laundry facility could
have occurred in one month, but he was unsure if it had. The Administrator said some of the unclaimed
laundry may have been from residents who had expired. The Administrator said he was aware that the
facility had received nine separate grievances related to laundry in the previous six months. The
Administrator said the facility's resident's complaints related to missing laundry were an ongoing concern.
The Administrator said he had spoken to the third-party vendor's management about his concerns with the
laundry services provided, and he had also spoken to his corporate leadership about the missing and late
laundry concerns. The Administrator said the laundry's timeliness and missing laundry continued to be a
concern for the facility. The Administrator said the third-party laundry services provided to the residents was
not meeting his expectations.
Record review of the facility's grievance log from [DATE] through [DATE] revealed nine resolved concerns
related to laundry and no unresolved concerns.
Record review of the facility's contract with the third-party vendor revealed the contract was initiated on
[DATE]. The contract documented the third-party vendor would provide management, consulting services,
and perform housekeeping services on the facility premises.
Record review of the facility's Maintenance/Housekeeping Policies and Procedures: Laundry policy dated
3/2006 revealed a policy statement which read Laundry services will comply with appropriate guidelines to
assure that measures are implemented to provide pro effective laundry service. The policy documents the
personnel would be trained appropriately in healthcare laundry, participate in education, and were properly
dressed for the services at all times. Per the policy, the facility was required to have sufficient clean linens to
meet the demands of the facility and access to clean linens was maintained during all shifts.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 2 of 5
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
01/05/2024
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 - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the
facility were stored and labeled in accordance with currently accepted professional principles for 1 of 5
Residents (Resident #38) and 1 of 8 medication carts (100 Hall Medication Aide Cart) reviewed for
medication storage.
The facility failed to ensure LVN B secured insulin from Resident #38's bedside when left unattended.
The facility failed to ensure MA A locked 100 Hall Medication Cart before leaving it unattended.
These failures could place residents at risk for possible drug diversions or accidental ingestion.
Findings included:
Resident #38
Record review of Resident #38's face sheet dated 01/04/2024 revealed the resident was admitted on
[DATE]. Resident #38 was a [AGE] year-old male. The resident's admitting diagnosis included Type 2
diabetes mellitus (elevated blood sugar).
Record review of Resident #38's care plan problem onset dated 06/08/2023 revealed:
Problem: Resident #38 was a diabetic attempted to control by insulin;
Goal: Diabetic status would remain stable as evidenced by Resident #38's blood sugar would remain within
the resident's normal range;
Approach: Administer medications as ordered.
Record review of Resident #38's quarterly Minimum Data Set (MDS) dated [DATE] revealed Cognitive
Patterns Brief Interview for Mental Status (BIMS) Summary Score of 15 out of 15 indicating resident's
cognition was intact.
Record review of Resident #38's Physician Order report dated 12/04/2023-01/04/2024 revealed Lantus
U100 Insulin. Administer 23 units once a day in the morning.
Record review of Resident #38's Diabetic Administration History dated 01/01/2024-1/04/2024 revealed LVN
B administered insulin to Resident #38 on 01/04/2024.
During an observation on 01/04/2024 at 8:08 AM revealed LVN B removed Resident #38's Lantus insulin
Flex Pen (disposable insulin pen with dial up dosage and push button extension to dispense insulin) from
the medication cart. During this observation LVN B dialed the flex pen to administer 23 units of insulin. LVN
B placed the inulin flex pen on a small tray. As the observation continued at 8:12 AM LVN B carried the tray
with insulin to Resident #38's bedside. Resident #38 was sitting up in bed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 3 of 5
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
01/05/2024
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 - Few
with his tray table across in front of him. Resident #38 was observed eating breakfast independently using
his right hand. LVN B placed the tray with insulin on the tray table next to Resident #38's breakfast tray. The
tray with the insulin flex pen was within reach of Resident #38's right hand. LVN B pulled the resident's
privacy curtain around the resident. The resident's bedside was not in view from the doorway. LVN B walked
away from Resident #38's bedside to go to the medication cart parked in the hall at the doorway of the
room. The resident's insulin was left unattended at the resident's bedside. LVN B returned to Resident #38's
bedside at 8:13AM.
During an interview on 01/04/2024 at 10:30 AM Resident #38 stated he saw the insulin left on his tray table.
Resident #38 stated he had not seen anyone leave it there in the past.
During an interview on 01/04/2024 at 1:25 PM LVN B stated medications should never be left at the
bedside. LVN B stated she should have taken the medication with her. LVN B stated she thought she did
take it with her. LVN B stated the risk was the resident could have taken it. LVN B stated it could cause
harm to the resident. LVN B stated it was unlawful to leave medications unattended in the resident's reach.
100 Hall Medication Aide Medication Cart
During an observation on 01/04/2024 at 8:25 AM revealed MA A was at Hall 100 Medication Aide
Medication Cart in front of room [ROOM NUMBER]. MA A dispensed medications for the resident in room
[ROOM NUMBER]. During the observation MA A left the medication cart unlocked parked in the hall in front
of room [ROOM NUMBER]. MA A carried the medications into room [ROOM NUMBER]and closed the
resident's privacy curtain. At 8:27 AM MA A returned to the medication cart.
During an observation on 01/04/2024 at 10:18 AM an inventory of 100 Hall Medication Aid Medication cart
accompanied with MA A revealed the following:
Right Side:
Drawer #1:
Vitamins C, B, D, A;
stool softeners;
Calcium;
Melatonin;
Sodium tablets;
Fiber tablets;
Acidophilus (good probiotic for normal bacterial found in the intestine).
Drawers #2, # 3, #4: Resident individual medication containers for 41 residents
LEFT SIDE:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 4 of 5
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
01/05/2024
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
Drawer #1: Artificial tear eye drops, nasal spray;
Level of Harm - Minimal harm
or potential for actual harm
Drawer #2: locked narcotic box for 11 residents;
Drawer #3: liquid medications, antacid, laxatives, lactulose;
Residents Affected - Few
Drawer #4: Medication supplies
During an interview on 01/04/2024 at 3:26 PM MA A stated all medication carts were to be locked when left
unattended. MA A stated the risk of the medication cart not being locked was that someone could get into it
and take something they should not have. MA A stated she believed she left the cart unlocked because was
nervous and forgot to lock it. MA A stated she normally locked the cart when she left it. MA A state next
time she would think about what she was doing to make sure it was locked before she left it.
In an interview on 01/04/2024 at 3:35 PM the DON stated Resident #38 could have done something with
the insulin syringe, while it was left with him. She stated her expectations are that medication carts were
locked when not attended. The DON stated it was important to ensure no one had access to any
medications they should not have. The DON stated other resident could have taken something out of the
unlocked medication cart. The DON stated the staff were trained quarterly and annually on medication
storage. The DON stated the staff working on the medication cart was responsible for locking the cart
before leaving it. The DON stated nurses, charge nurses, administration all were responsible to monitoring
daily as they round the halls. The DON stated they would make more frequent rounds to do spot checks of
medication carts and reeducate the staff.
In an interview on 01/04/2024 at 3:46 PM the administrator stated leaving insulin at the bedside and
medication carts unlocked when out of site was not best practice. The administrator stated medication carts
should be locked when not in sight.
Record review of the facility policy titled Pharmacy Services Policies and Procedures revision dated
04/01/2022 read in part . SECTION 8-MEDICATION STORAGE SUBJECT: 8.2 GENERAL GUIDELINES
FOR STORAGE OF MEDICATION AND BIOLOGICALS POLICY: 1. Medications and biologicals are stored
safely, securely and properly following manufacture's recommendations or those of the supplier. In
accordance with State and Federal laws, the facility will store all drugs and biologicals in locked
compartment under proper temperatures and other appropriate environmental controls to preserve integrity
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676417
If continuation sheet
Page 5 of 5
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Back to topCitations
2 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.
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.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
FAQ · About this visit
Common questions about this visit
What happened during the January 5, 2024 survey of STERLING OAKS REHABILITATION?
This was a inspection survey of STERLING OAKS REHABILITATION on January 5, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at STERLING OAKS REHABILITATION on January 5, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional princip..."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.