Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sterling Hills Rehabilitation And Healthcare Cente during CMS and state inspections, most recent first.
A resident’s completed discharge MDS was not transmitted to CMS within the required timeframe. The resident had diagnoses including muscle weakness, subdural hemorrhage, seizures, and major depressive disorder, and staff stated the discharge assessment should have been submitted but was missed because the transmission box had been checked by mistake. The DON and ADM were not aware the discharge MDS had not been sent, and staff acknowledged the assessment should have been transmitted within 14 days of completion.
A resident with chronic pain and multiple pain-related diagnoses had an order for PRN hydrocodone for breakthrough pain, but the medication was not available when she requested it. Staff reported they could not reach the pharmacy to obtain the code for the emergency med kit, and the LVN did not notify the DON. The resident said staff repositioned her and offered acetaminophen and hospital transfer, but she remained without her PRN opioid until later the next morning.
Narcotic Dose Not Documented on MAR or Count Sheet: An ADON administered PRN hydrocodone/acetaminophen to a resident with chronic pain, but the dose was not documented on the MAR or narcotics count sheet. The resident had multiple pain-related and neurologic diagnoses, and the ADON stated she forgot to sign out the medication after being sidetracked by other duties. The DON and ADM stated staff were expected to document medications as they were given, and facility policy required documentation after administration.
Failure to Document Unavailable PRN Pain Medication: An LVN could not obtain access to a resident’s PRN hydrocodone/acetaminophen because the pharmacy provider could not be reached, but the incident was not documented in the EHR or MAR. The resident, who had chronic pain and multiple pain-related diagnoses, reported requesting the medication at night and being told staff could not get the code needed for the emergency medication kit. The LVN said she kept calling the pharmacy, informed the resident, and passed the issue in report, while the DON and ADM stated the event should have been documented.
Hand hygiene was not performed between glove changes during Foley catheter care for one cognitively intact resident with cerebral palsy, CKD, and neurogenic bladder, and during incontinence care for another cognitively intact resident with CKD, HF, muscle weakness, and gout due to renal impairment. CNA C and CNA D both removed and replaced gloves during care without using hand hygiene as required by facility policy and as described by the DON and CNA D during interview.
The facility failed to inform residents of their right to file grievances, including anonymously, and did not provide access to grievance forms or information on the grievance process. Interviews revealed residents were unaware of how to file grievances or their right to a written decision. The ADM and SW confirmed the lack of access to grievance forms and procedures for anonymous submissions.
Two residents in the facility had incomplete Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms, with missing physician information and relative signatures. The facility lacked a system to monitor the accuracy of these forms, leading to potential risks of not honoring residents' end-of-life wishes. The errors were attributed to human error, and the facility's policies did not provide specific guidance on OOH-DNR form creation.
The facility failed to ensure proper labeling and storage of medications, as evidenced by loose and unlabeled pills found in two medication carts. An LPN found a loose metoprolol pill in Medication Cart 2, and another LPN found a loose bisacodyl pill in Medication Cart 4. Despite being trained to check for such issues, the presence of these pills indicates a lapse in adherence to the facility's medication storage policy.
The facility failed to provide properly prepared puree diets, serving food with chunks that required chewing, contrary to the needs of residents with swallowing difficulties. Observations revealed that puree meals contained inappropriate textures, such as chunky chicken and okra with seeds. Staff interviews confirmed that puree foods should be smooth and pudding-like, as per facility policy, to prevent choking or aspiration.
Two CNAs failed to use enhanced barrier precautions during foley care for a resident with a urinary catheter, despite being aware of the requirement to wear gowns. The resident, who was cognitively intact and had multiple health conditions, had a physician's order for foley care every shift. The facility's policy mandates the use of PPE for residents with indwelling medical devices, but the CNAs did not adhere to this protocol due to nervousness and oversight.
Failure to Transmit Completed Discharge MDS
Penalty
Summary
The facility failed to transmit a completed discharge MDS that accurately reflected Resident #83’s status within the required timeframe. Resident #83 was admitted with diagnoses including muscle weakness, nontraumatic subacute subdural hemorrhage, seizures, and major depressive disorder, and the record showed a discharge Return Not Anticipated MDS with a completed status. The assessment history indicated the discharge MDS had not been submitted and no batch had been created, even though the RN assessment coordinator had signed the assessment as complete. During interviews, MDS Nurse A stated Resident #83 was managed care and the MDS assessments were not transmitted to CMS, while MDS Nurse B stated the discharge MDS should have been submitted and that all discharge MDSs should be transmitted to CMS within 14 days of completion. MDS Nurse A stated the box to prevent transmission had been checked by mistake, and the discharge MDS had not been transmitted. The DON stated she was not aware the discharge MDS had not been transmitted, and the ADM stated the discharge assessment should have been transmitted within 14 days and that she was not aware it had not been submitted until the day of the interview.
PRN Pain Medication Not Available for Resident With Chronic Pain
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for a resident with chronic pain and multiple pain-related diagnoses, including inflammatory polyneuropathy, right shoulder pain, low back pain, osteoarthritis, muscle spasms, a thoracic vertebral fracture, fibromyalgia, and rheumatoid arthritis. The resident’s assessment showed pain almost constantly, with pain interfering with day-to-day activities frequently. Her care plan directed staff to anticipate pain, respond immediately to complaints of pain, and provide PRN hydrocodone for breakthrough pain, along with other pain-related interventions. The resident had an active order for Hydrocodone/Acetaminophen 10-325 mg every 6 hours as needed for breakthrough pain. The MAR showed doses were given on 03/23/2026 and again on 03/24/2026, while the narcotic count sheet showed the last tablet was administered at 12:30 PM on 03/23/2026 and the count was zero after that dose. A later narcotic count sheet documented a new prescription filled with 56 pills. Progress notes documented that a nurse called the physician’s office on 03/25/2026 to request a Norco prescription be sent to the pharmacy provider. During interviews, the resident stated she requested her hydrocodone when she was in pain but was told staff could not get the code needed to access the emergency medication kit because they could not reach the pharmacy provider, and that the medication had not yet been delivered. She stated staff repositioned her, rubbed her fentanyl patch, offered acetaminophen, and offered to send her to the hospital, which she declined. The LVN stated she tried calling the pharmacy repeatedly and could not get through, and the DON and ADM stated staff should have notified them when the medication was unavailable so other options could be explored. The facility policy stated residents should receive treatment and care in accordance with professional standards of practice, the care plan, and the resident’s choices related to pain management.
Narcotic Dose Not Documented on MAR or Count Sheet
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of one resident by not accurately documenting administration of a PRN narcotic on the resident’s narcotics count sheet and MAR. Resident #43 was a cognitively intact female with diagnoses including vascular dementia, anxiety, chronic pain, rheumatoid arthritis, osteoarthritis, fibromyalgia, epilepsy, and a thoracic vertebral fracture. Her assessment indicated she reported pain almost constantly and that pain interfered with daily activities frequently. She had an active order for Hydrocodone/Acetaminophen 10-325 mg, 1 tablet by mouth every 6 hours as needed for breakthrough pain. Record review showed the narcotics count sheet documented a dose of Hydrocodone/Acetaminophen given at 4:07 PM on 03/17/2026 with 15 pills remaining, and the next entry showed a dose given at 11:00 AM on 03/18/2026 with 13 pills remaining. The MAR for the same period did not show a dose given at 12:30 AM on 03/18/2026. Progress notes also did not show documentation that the medication was administered at that time. During interview, the ADON stated she worked overnight, gave Resident #43 Hydrocodone/Acetaminophen at 12:30 AM while covering another hall, and forgot to sign it out on the narcotics count sheet and MAR because she became sidetracked by other duties. The ADON stated she was trained to pop the pill, sign it out on the narcotics count sheet, give it to the resident, and then document on the MAR, and she acknowledged she was responsible for ensuring medications were documented. The DON and ADM stated staff were expected to document medications as they were given, including on the narcotic count sheet and MAR, and both stated they were not aware the dose had not been documented until surveyor inquiry. Facility policy required documentation after administration, including date and time, dosage, route, indication if PRN, resident response when required, and signature and credentials. The controlled substances policy also required controlled substances to be counted and reconciled through records including MARs and controlled substance records.
Failure to Document Unavailable PRN Pain Medication
Penalty
Summary
The facility failed to ensure medical records were accurately documented for Resident #43 when an LVN could not obtain access to the resident’s PRN hydrocodone/acetaminophen during the night shift because she could not reach the pharmacy provider through the electronic health record. Resident #43 was a cognitively intact female with diagnoses including vascular dementia, chronic pain, rheumatoid arthritis, osteoarthritis, fibromyalgia, epilepsy, and a thoracic vertebral fracture. Her MDS pain assessment indicated she reported pain almost constantly and that pain interfered with daily activities frequently. Record review showed Resident #43 had an active order for hydrocodone/acetaminophen 10-325 mg, 1 tablet by mouth every 6 hours as needed for breakthrough pain. The MAR did not show documentation of when the medication was requested or that it was unavailable after 10:00 PM on the night in question. Progress notes also did not contain documentation by the LVN about the inability to access the pain medication because the pharmacy provider could not be reached. During interview, Resident #43 stated she requested her pain medication at night because she was in pain and was told staff could not get the code needed to access the emergency medication kit because the pharmacy provider could not be reached. She stated she was told the hydrocodone had been ordered but had not yet been delivered, and she later received the medication early the next morning. The LVN stated she tried calling the pharmacy several times, kept getting a busy tone, told the resident about the issue, and did not document the incident in the EHR even though she was trained to do so. The DON and ADM stated staff should have notified them if the pharmacy could not be reached and that the incident should have been documented in the resident’s record.
Hand Hygiene Not Performed Between Glove Changes During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when CNA C and CNA D did not perform hand hygiene between glove changes during resident care. During observation of Foley catheter care for a cognitively intact female resident with cerebral palsy, chronic kidney disease, and neuromuscular dysfunction of the bladder, CNA C cleaned the resident’s genital area, removed dirty gloves, and put on new gloves without using hand hygiene between glove changes. CNA C also cleaned the resident’s bottom, removed dirty gloves, and applied new gloves without hand hygiene between glove changes. During observation of incontinence care for another cognitively intact female resident with chronic kidney disease with heart failure, muscle weakness, and chronic gout due to renal impairment, CNA D unfastened the brief, cleaned the front, turned the resident to her left side, and cleaned her bottom without changing gloves or using hand hygiene before moving to a different area of the resident’s body. CNA D then changed gloves after cleaning the resident’s bottom and put on new gloves without hand hygiene between glove changes. CNA D applied skin barrier cream to the resident’s bottom with a gloved hand, removed the glove from her right hand only, and put on a new glove without hand hygiene between the glove change. During interview, CNA D stated she had been trained on infection control and hand hygiene and that hand hygiene during incontinence care was to be performed before starting care, during care, anytime gloves were removed, and after care was completed. The DON stated infection control training included hand hygiene and incontinence care, that staff were taught to use hand hygiene between glove changes, and that the potential negative outcome of not doing so could be spreading infection. The facility policy stated hand hygiene is the primary means to prevent the spread of infections and that gloves do not replace hand hygiene.
Failure to Inform Residents of Grievance Procedures
Penalty
Summary
The facility failed to notify residents individually or through postings in prominent locations throughout the facility of their right to file grievances orally or in writing, including the right to file grievances anonymously. The facility also did not provide the contact information of the grievance officer, a reasonable expected time frame for completing the review of the grievance, and the contact information of independent entities with whom grievances may be filed. This deficiency was observed for 20 of 20 confidential residents reviewed for grievances. Interviews and record reviews revealed that residents did not have access to the grievance form, were unaware they could file grievances anonymously, and had not been informed of the grievance procedure during Resident Council meetings. Residents attending Resident Council did not know where to acquire a grievance form, who to submit it to, or what happened once a grievance was filed. Additionally, they were unaware of their right to receive a written decision once their grievance was resolved. The facility's grievance policy stated that the grievance/complaint procedure should be posted on the resident bulletin board, and residents should be provided with written information on how to file a grievance upon admission. However, observations revealed that grievance forms were not available to residents, and there was no access to submit a grievance anonymously. The ADM and SW confirmed that the grievance forms were kept in the Social Worker's office, and there was no procedure for residents to submit grievances anonymously. The ADM also stated that the grievance procedure was not being discussed in Resident Council, and the box that previously held grievance forms had fallen off the wall and had not been replaced.
Incomplete OOH-DNR Forms for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had their Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms completed with all required information. Resident #4, a female with multiple diagnoses including Chronic Obstructive Pulmonary Disease and Major Depressive Disorder, had an OOH-DNR form that lacked the printed name of the physician associated with the signature. This oversight was identified during a record review, which showed inconsistencies between the resident's care plan and the incomplete OOH-DNR form. Similarly, Resident #63, a male with Alzheimer's Disease and heart disease, had an OOH-DNR form that was missing the relation of the qualified relative who signed it, as well as the signature and date from the relative. This deficiency was noted during a review of the resident's records, which included a care plan indicating a DNR status. The absence of complete information on the OOH-DNR form was attributed to human error, as stated by the facility's Social Worker and Administrator during interviews. The facility lacked a system for monitoring the accuracy of OOH-DNR forms, which contributed to the incomplete documentation for both residents. The Social Worker and Administrator acknowledged the errors and the absence of a monitoring system, which could potentially lead to residents' end-of-life wishes not being honored. The facility's policies and procedures on advance directives did not include specific guidance on creating OOH-DNR forms, further contributing to the oversight.
Medication Storage Deficiency Due to Loose and Unlabeled Pills
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, as evidenced by the presence of loose and unlabeled pills in two medication carts. During an observation, a loose oval white pill identified as metoprolol was found in the bottom drawer of Medication Cart 2. Similarly, a loose round orange pill identified as bisacodyl was found in the bottom drawer of Medication Cart 4. Both LPNs responsible for these carts confirmed the presence of the loose pills and acknowledged that they were trained to check for cleanliness, expired medications, and loose pills during their shifts. Interviews with the LPNs and the DON revealed that the facility's policy required daily checks of medication carts for expiration dates, loose pills, and restocking needs. The DON and ADON were also responsible for weekly checks of the carts and medication room. Despite these protocols, the presence of loose pills in the carts was verified, indicating a lapse in adherence to the facility's medication storage policy. The ADM confirmed that compliance was monitored by nursing administration, but the deficiency suggests that the checks were not effectively preventing medication errors or ensuring proper labeling and storage of medications.
Failure to Provide Properly Prepared Puree Diets
Penalty
Summary
The facility failed to ensure that residents received food that was palatable, attractive, and at a safe and appetizing temperature, specifically for the puree food form. During observations, it was noted that puree plates served to residents contained chunky baked chicken and okra with large seeds, which required chewing. A test tray also revealed rotisserie chicken with large chunks and okra/tomato with whole seeds, both of which were not suitable for residents on a puree diet. Additionally, a puree hamburger meal and Mexican cream corn were found to have chunks and corn skin that required chewing, contrary to the requirements for a puree diet. Interviews with staff, including a dietary manager (DM) and an administrator (ADM), confirmed that puree foods should be smooth, like baby food, and of a pudding-like consistency to accommodate residents with swallowing difficulties. The facility's policy on texture modifications, dated 2013, specifies that pureed foods should be smooth and free of lumps, husk, or seeds. The failure to adhere to these guidelines could potentially lead to residents choking or aspirating on food chunks, as acknowledged by the staff during interviews.
Failure to Utilize Enhanced Barrier Precautions During Foley Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs who did not utilize enhanced barrier precautions during foley care for a resident. The resident, a cognitively intact female with a history of COPD, a femur fracture, atrial fibrillation, and end-stage chronic kidney disease, had a physician's order for foley catheter care every shift. Despite the presence of an enhanced barrier precaution sign on the resident's door, the CNAs entered the room and performed foley care without wearing gowns, which is a requirement for such procedures. Interviews with the CNAs revealed that both were aware of the need for enhanced barrier precautions, including the use of gowns, but failed to adhere to these protocols due to nervousness and oversight. The Director of Nursing, who also serves as the infection preventionist, confirmed that staff are trained monthly on infection control and that compliance is monitored through rounds and education. The facility's policy on enhanced barrier precautions, revised earlier in the year, clearly states the necessity of PPE, including gowns and gloves, for residents with indwelling medical devices, such as urinary catheters.
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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 Sweetwater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sweetwater Healthcare Center | 1.7 mi | ★★★★★ | 7 | 0 |
| Merkel Nursing Center | 21.6 mi | ★★★★★ | 34 | 5 |
| Mitchell County Nursing And Rehabilitation Center | 29.4 mi | ★★★★★ | 9 | 0 |
| Homeplace Manor Healthcare Center | 33 mi | ★★★★★ | 25 | 0 |
| Avir At Snyder | 33.8 mi | ★★★★★ | 12 | 0 |
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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 July 2026) and official state health department websites.