Health inspection·May 31, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #2's face sheet revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cognitive communication deficit, unsteadiness of feet, hemorrhoids, dysphagia, muscle weakness, insomnia, major depressive disorder, constipation, and aphasia. Record review of Resident #2's Quarterly MDS dated [DATE] revealed she had a BIMS score of 99 due to the resident being unable to complete the interview. Record review of Resident #2's physician orders dated 05/2024 revealed .acetaminophen [OTC] tablet; 500 mg; amt: 2; oral Special Instructions: Give two 500mg to equal 1000mg Every 8 Hours; 06:00 AM, 02:00 PM, 10:00 PM Observation on 05/30/24 at 10:39 AM during medication pass revealed Resident #2 was administered two acetaminophen 500 mg, 4 hours, and 39 minutes past the prescribed time. Record review of Resident #3's face sheet revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of pain in the right hip, atherosclerotic heart disease, urinary tract infection, pain in shoulder, dysphagia, lack of coordination, muscle wasting atrophy, diarrhea, hypothyroidism, anxiety, mood disturbance, hypertension (high blood pressure), and dementia. Record review of Resident #2's Quarterly MDS dated [DATE] revealed she a BIMS score of 15 which meant she had limited cognitive impairment. Resident #3 was diagnosed with hypertension (high blood pressure). Record review of Resident #3's physician orders dated 05/2024 revealed AZO Cranberry (otc) tablet; 500mg; amt: 2; oral Special Instructions: Take 2 (two) soft gels daily with water. [DX: Urinary tract infection, site not specified] Once A Day; AM Cartia XT (diltiazem hcl ) capsule, extended release 24hr; 120 mg; amt: 120mg; oral [DX: Essential (primary) hypertension] Every 12 Hours; 07:00 AM, 07:00 PM Observation on 05/30/24 at 10:48 AM during medication pass revealed Resident #3 was administered one tablet of diltiazem hcl 120 mg, 3 hours, and 48 minutes past the prescribed time. Resident #3 was not administered cranberry AZO 500 mg, the bottle on the medication cart was cranberry AZO 450 mg. In an interview on 05/30/24 at 10:50 AM Resident #3 stated she usually received her medications but sometimes they came late . In an interview on 05/30/24 at 10:52 AM Med Aide A stated the facility did not have the 500 mg of Cranberry Azo. She stated she had the 450 mg tablets on her medication cart. She will speak with the nurse to have the order changed to 450 mg or the nurse will order 500 mg Cranberry. In an interview on 05/30/24 at 1:51 PM Med Aide A stated she was running behind, the facility had a lot of patients. She had to assist the nurse aides with some duties, so she was running behind on the medication pass. She stated staff can give medications 1 hour before or 1 hour after prescribed times. She should have let nurse know she was running late. Depending on the drug the physician wants to make sure the medications were on time and the resident doesn't have any reactions. In an interview on 05/30/24 at 2:06 PM the DON stated when the med aide was running behind or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676417 If continuation sheet Page 2 of 3 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 05/31/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some helping staff the ADON or Nurse would help with med pass. The medication aide was not usually running late, and this does not happen often. The DON said she will call the physician to follow up on the residents. The staff can give the medications an hour before or an hour after the prescribed time . In an interview on 5/31/24 at 2:17 PM the Central Supply staff said she was responsible for reordering the OTC meds. If the brand or strength was not correct, she should let the nurse know, should have tried to get a medication from somewhere else, or have the order changed. She was not aware of the cranberry Azo medication. If she was made aware she could have had it taken care of . In an interview on 05/31/24 at 3:04 PM Med Aide B stated when or if she was running late, the staff report that to the nurse, and the nurse will help with the medication pass. The med aide should report to the nurse if a medication was out. She lets the nurse or the staff that orders the medications know . In an interview on 05/31/24 at 3:12 PM Med Aide C stated if the medication was running low staff were supposed to inform the nurse to let them know. If the Med Aide was running late, they let the nurse know, so the, the nurse would step in, and help. In an interview on 05/31/24 at 3:50 PM LVN D stated if the Med Aides were running late, the nurse would assist with the meds. OTC go through Central Supply, the staff were supposed to notify her. The medication would be ordered, the physician notified, and family notified. Labs could be run to determine if the resident still required the medication. In an interview on 05/31/24 at 3:37 PM the DON said when Med Aides were running late, they would let the nurse know and the nurse would assist. The staff would let the physician or NP know the meds were late and see trends to determine if meds can be moved. Med Aide A said she was assisting with cleaning up a resident which caused her to run behind. She explained to the Med Aide A to communicate the situation. The nurse would have made sure the 7AM meds were given. The Med Aides were good and will assist with care. Typically, they don't give out meds in that area, they know to provide privacy, it cuts down on errors. It was important to give the residents meds on time so it will not contradict any other medications and the residents get the full effect of the medication. Record review of the facility policy Medication Management Program dated 5/5/23 revealed .Policy: The Facility implements a Medication Management Program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements .Administering the Medication Pass 2. Licensed or certified/permitted medication aide follows the MAR by identifying the eight rights . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676417 If continuation sheet Page 3 of 3