Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sterling Oaks Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that an unattended laptop on a crash cart was left open in a common area with the electronic health record system displaying multiple residents’ information. The AD acknowledged the laptop was hers and that she left it open when responding to a resident calling for help, despite knowing it should have been closed or locked. An LPN, CNA, RN, DON, and the Administrator all confirmed that staff are expected to secure laptops with PHI and that leaving resident information visible is a HIPAA violation. Review of facility policy showed that PHI must not be displayed in public locations and that staff must safeguard electronic PHI and limit access to the minimum necessary.
Two residents experienced incomplete and inaccurate documentation on their MARs and nurse's notes, including missing vital sign entries and lack of explanation for medication administration decisions. Staff admitted to failing to document when medications were held or given, and acknowledged that there should be no blanks on the MARs, making it difficult to verify if physician orders were followed.
A resident with hypertension received Metoprolol despite physician orders to hold the medication if systolic blood pressure was below 120. The medication was administered on two occasions when the resident's blood pressure was below the specified threshold, and there was no documentation indicating the medication was held or the reason for not holding it, contrary to facility policy and physician instructions.
Two residents with cardiac and hypertensive conditions had incomplete and inaccurate documentation on their MARs and nurse's notes, including missing blood pressure and heart rate entries, unexplained administration of medications outside of physician parameters, and blank sections on records. Staff interviews confirmed that these documentation lapses made it unclear whether medications were given or held, contrary to facility policy.
A resident with hypertension was given Metoprolol despite physician orders to hold the medication for low systolic blood pressure. The medication was administered on two occasions when the resident's blood pressure was below the ordered threshold, and there was no documentation to indicate the medication was held or the reason for not holding it. Staff interviews confirmed the error and lack of proper documentation, in violation of facility policy.
The facility failed to label and date medications on the 100 and 200 hall medication carts, including eyedrops and nasal sprays, which were found open and undated. Staff interviews revealed awareness of the requirement to date medications, but the practice was not consistently followed, as confirmed by the DON and ADM.
The facility failed to implement comprehensive care plans for two residents, neglecting to address their specific medical diagnoses and medication needs. One resident's care plan lacked focus on anxiety, depression, and dementia, while another's did not address anxiety or medication orders. The oversight was acknowledged by the responsible LVN, and the DON confirmed the need for care plans to address all resident needs.
A resident requiring respiratory care did not have their oxygen tubing and humidifier bottle changed weekly as per facility protocol, leading to a deficiency. The resident, with a history of obstructive sleep apnea and shortness of breath, was receiving oxygen therapy and BIPAP. Staff interviews revealed that the equipment was not changed due to oversight, despite the facility's policy requiring weekly changes to prevent infections.
The facility failed to maintain proper infection control practices in utility rooms on two halls. On Hall 200, soiled linen was improperly placed on top of a waste barrel and a towel was on the floor. On Hall 300, a trash bag was found on the floor with no barrels available. Staff interviews confirmed that these practices did not align with the facility's infection control policy, which requires proper disposal to prevent contamination.
The facility failed to administer medications on time for three residents, with delays ranging from over three to nearly five hours. One resident did not receive the correct dosage of cranberry AZO due to a supply issue. Staff interviews revealed that the medication aide was running behind schedule and did not communicate effectively about medication availability and timing.
Unsecured Laptop Screen Exposed Residents’ Electronic Health Information
Penalty
Summary
The deficiency involves a failure to maintain the privacy and confidentiality of residents’ personal and medical records when an open laptop displaying electronic health records was left unattended in a common area. During initial rounds, a surveyor observed a laptop on a crash cart with the Matrix electronic health record platform open and showing several residents’ information on the screen. The Assistant Director (AD) acknowledged that the laptop was hers and explained that she had left it open when she responded to a resident yelling for help, stating she did not think to shut the laptop at that time. In interviews, multiple staff members confirmed that the facility’s expectation and practice are that laptop screens displaying resident information must be closed or locked whenever staff step away. An LPN with five years of experience stated that she always locks the screen when leaving the laptop and recognized that leaving resident information visible is a HIPAA violation. A CNA and an RN both reported that laptop screens should never be left open with resident information visible, that anyone walking by could see the information, and that if they observed such a situation, they would close the laptop and remind the staff member. Both indicated they had received in‑service training on HIPAA, resident rights, and confidentiality within the past one to three months. The DON and Administrator also confirmed that staff are responsible for securing laptops with resident information and that leaving screens open with PHI visible is considered a HIPAA violation. The DON stated that her expectation is that staff shut or lock screens when walking away and that she had not personally witnessed staff leaving laptops open. The Administrator reported being told that the AD left the laptop open when responding to a resident calling for help and acknowledged that an open laptop could allow others, including a state worker, to access residents’ information. Review of the facility’s Health Information Management Policies and Procedures, revised on 4‑29‑2022, showed that PHI must not be used or disclosed in a manner that violates HIPAA, must not be posted or displayed in public locations, and that all employees must safeguard electronic PHI, limiting access and disclosure to the minimum necessary.
Incomplete and Inaccurate Medication Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in documentation deficiencies on the Medication Administration Records (MARs) and nurse's notes. For one resident with diagnoses of atrial flutter and hypertension, the MARs for September did not include required documentation of heart rate and blood pressure when medications were held, leaving blank spaces where this information should have been recorded. The staff member responsible for administering the medication acknowledged that she held the medication but failed to document the action or the vital signs, and both she and another medication aide confirmed that there should be no blanks on the MARs. For another resident with hypertension, the MARs indicated that blood pressure medication was administered on two occasions when the resident's systolic blood pressure was below the physician-ordered threshold for holding the medication. There was no documentation in the nurse's progress notes explaining why the medication was given despite the low blood pressure, and the staff member later stated that the documentation was an error and that the medication was likely held but not properly recorded. The resident confirmed that her blood pressure medication was sometimes withheld due to low readings, and the staff member admitted to forgetting to document the reasons for holding or administering the medication. Interviews with staff, including the Assistant Director of Nursing, confirmed that the facility's expectation is for all medication administration and related vital signs to be documented accurately and without blanks, in accordance with facility policy. The lack of documentation made it difficult to determine whether medications were given or held as ordered, and whether physician instructions were followed.
Failure to Hold Antihypertensive Medication per Physician Order
Penalty
Summary
The facility failed to ensure that pharmaceutical services met the needs of a resident by not holding a prescribed antihypertensive medication, Metoprolol, as ordered by the physician. The physician's order specified that the medication should be held if the resident's systolic blood pressure (SBP) was less than 120. Despite this, the medication was administered on two occasions when the resident's SBP was 118/62 and 110/64, respectively. There was no documentation in the medication administration records (MARs) or nurses' notes indicating that the medication was held or providing a reason for not holding it, as required by the physician's order and facility policy. The resident involved was an older adult with a diagnosis of hypertension and demonstrated intact cognitive skills, as indicated by a BIMS score of 15. Interviews with staff revealed that the medication should have been held according to the parameters, and the lack of documentation made it unclear whether the medication was administered or appropriately withheld. Staff acknowledged the error in documentation and the need to accurately record when medications are held or given, especially when specific parameters are outlined in the physician's orders.
Incomplete and Inaccurate Medication Documentation on MARs and Nurse's Notes
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in documentation errors on Medication Administration Records (MARs) and nurse's notes. For one resident with atrial flutter and hypertension, physician orders required that Metoprolol and Digoxin be held if certain blood pressure or heart rate parameters were not met. However, on specific dates, the MARs showed that these medications were not given, but there was no documentation of the resident's blood pressure or heart rate, and the relevant sections on the MARs were left blank. Staff interviews confirmed that there should be no blanks on the MARs, as this makes it unclear whether medications were administered or withheld. For another resident with hypertension, physician orders specified that Metoprolol should be held if systolic blood pressure was below a certain threshold. The MARs indicated that the medication was administered on days when the resident's blood pressure was below the hold parameter, but there was no documentation in the nurse's notes explaining why the medication was given despite the low blood pressure. The staff member responsible for administering the medication stated that the documentation was an error and that the medication was likely held, but she had forgotten to document it correctly. Facility policy required that all entries in medical records be complete, legible, and made in chronological order without leaving blank spaces. Interviews with staff and the Assistant Director of Nursing confirmed that the expectation was for all medication administration and reasons for holding or giving medications to be clearly documented in the clinical records, and that blanks on the MARs were not acceptable.
Failure to Hold and Document Blood Pressure Medication per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of hypertension received Metoprolol, a blood pressure medication, despite physician orders to hold the medication if the systolic blood pressure (SBP) was less than 120. On two occasions, the medication was administered when the resident's SBP was 118/62 and 110/64, respectively. There was no documentation indicating that the medication was held as ordered, nor was there any explanation in the nursing notes for not holding the medication. The medication administration record (MAR) did not reflect that the medication was withheld, and the nurse responsible later stated that she documented in error and could not confirm whether the medication was actually held or given. Interviews with staff confirmed that the medication should have been held according to the physician's parameters and that proper documentation was required when medications were not administered. The resident was alert, oriented, and able to communicate her needs at the time of observation. Facility policy required that medications be administered only as ordered by a physician, including adherence to parameters for holding medications. The failure to follow these orders and document actions appropriately constituted a medication error for this resident.
Failure to Properly Label and Date Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals used in the facility were labeled according to currently accepted professional principles. Specifically, the medication carts in Hall 100 and Hall 200 contained multiple medications, including eyedrops, ointments, creams, and nasal sprays, that were opened but not labeled with the resident's name and the date of opening. This oversight was observed during a survey, where it was noted that medications such as Latanoprost Ophthalmic solution, Timolol Maleate ophthalmic solution, and various artificial tears lubricant eye drops, among others, were open and undated. The lack of proper labeling could potentially place residents at risk of adverse medication reactions and infections. Interviews with staff members, including a Medication Aide (MA A) and a Licensed Vocational Nurse (LVN K), revealed that they were aware of the requirement to date medications upon opening, as they had been in-serviced on this procedure. However, the medications were still found to be undated. The Director of Nursing (DON) confirmed that staff had been in-serviced about four weeks prior on the importance of dating medications when opened and acknowledged the need for further in-servicing. The Administrator (ADM) also expressed that it was his expectation for nurses to date drugs when opened, indicating a lapse in adherence to established protocols by the nursing staff.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which did not address their specific medical diagnoses and medication needs. Resident #6, a female with multiple diagnoses including dementia, generalized anxiety disorder, depression, Parkinson's disease, and type 2 diabetes mellitus, had a care plan that lacked focus areas for her anxiety, depression, and dementia. Additionally, her care plan did not reflect her active orders for anti-anxiety, anti-depressant, and anti-Parkinson's medications. Similarly, Resident #30, a female with a diagnosis of generalized anxiety disorder, had a care plan that did not address her anxiety diagnosis or her active order for anti-anxiety medication. The MDS assessment for Resident #30 indicated severely impaired cognition, yet her care plan failed to incorporate these critical aspects of her care needs. The oversight in both cases was acknowledged by LVN-MDS A, who was responsible for completing the care plans and assessments. The Director of Nursing (DON) confirmed that comprehensive care plans should address all nursing, mental, and psychosocial needs of the residents, including necessary interventions and services. The facility's policy on comprehensive care planning mandates that each resident should have a person-centered care plan that meets their medical, physical, mental, and psychosocial needs. The failure to include these elements in the care plans could place residents at risk of not receiving appropriate care.
Failure to Change Respiratory Equipment Weekly
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically in changing the oxygen tubing and humidifier bottle every seven days as per the facility's protocol. This deficiency was identified for a resident who required respiratory care, including tracheostomy care and tracheal suctioning. The resident, a female with a history of cerebral infarction, spinal stenosis, obstructive sleep apnea, and shortness of breath, was receiving oxygen therapy and BIPAP. The facility's records indicated that the oxygen equipment was last changed on 02/23/25, but observations on subsequent days showed that the humidifier bottle had not been updated since 02/16/25. Interviews with staff revealed that the Assistant Director of Nursing (ADON) was responsible for ensuring the respiratory equipment was changed weekly on Sundays by the night shift nurse. However, the equipment for the resident was not changed as scheduled, which was confirmed by the ADON and the Director of Nursing (DON). The DON noted that the Maintenance Director, who was responsible for checking the equipment, was on leave during the relevant period, and the nurse assigned to change the equipment, LVN K, admitted to being distracted and not completing the task. The facility's policy on respiratory equipment change schedule required weekly changes to prevent infections. The Infection Control Nurse highlighted the risk of bacteria forming in the tubing if not changed as per protocol, which could lead to upper respiratory infections. Despite the facility's procedures and staff assignments to ensure compliance, the failure to adhere to the equipment change schedule resulted in a deficiency in providing safe respiratory care for the resident.
Inadequate Infection Control Practices in Utility Rooms
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper handling of soiled linen and trash in the utility rooms on two different halls. On Hall 200, a large plastic bag with soiled linen was observed sitting on top of a waste barrel, and a large towel was found on the floor. On Hall 300, a tied-up trash bag was found laying on the floor of the utility room, with no barrels present for proper disposal. These observations indicate a failure to adhere to the facility's infection control policy, which requires soiled materials to be stored inside designated barrels to prevent contamination. Interviews with staff members, including a Laundry Aide and the Manager of Housekeeping, confirmed that the proper procedure was not followed. The Manager of Housekeeping explained that it was the responsibility of the nursing staff to ensure that full barrel receptacles were brought to the main soiled utility room and replaced with empty ones. However, the observed practices did not align with these procedures, as confirmed by the staff interviews. The facility's policy on Infection Control, revised in May 2023, outlines the importance of proper handling of linen and waste to prevent cross-contamination, which was not adhered to in these instances.
Medication Administration Delays and Dosage Errors
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three residents by not administering medications according to physician orders at the prescribed times. Resident #1, a female with multiple diagnoses including trigeminal neuralgia, was administered her medication, carbamazepine, over three hours past the prescribed time. Similarly, Resident #2, who has a cognitive communication deficit and other conditions, received her acetaminophen dose nearly five hours late. Resident #3, diagnosed with hypertension and other conditions, was also affected by the facility's failure to administer medications on time. She received her diltiazem hcl dose almost four hours late and was not given the correct dosage of cranberry AZO due to a discrepancy in the available medication strength. Interviews with the resident and staff revealed that the medication aide was running behind schedule and did not have the correct dosage of cranberry AZO available. The facility's staff, including medication aides and the Director of Nursing (DON), acknowledged the delays and the lack of proper communication regarding medication availability and timing. The medication aide cited being busy with other duties as a reason for the delay, and the central supply staff was unaware of the cranberry AZO medication issue. The facility's policy allows for medications to be administered within an hour of the prescribed time, but this was not adhered to, leading to the deficiencies noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Katy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ignite Medical Resort Katy, Llc | 1 mi | — | 4 | 0 |
| Heritage Park Of Katy Nursing And Rehabilitation | 1.6 mi | — | 0 | 0 |
| Falcon Point Post Acute | 1.8 mi | — | 9 | 0 |
| Paradigm At Katy | 3.4 mi | — | 4 | 0 |
| Oakmont Healthcare And Rehabilitation Center Of Ka | 3.6 mi | — | 2 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.