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 Sweetwater Healthcare Center during CMS and state inspections, most recent first.
Inaccurate PASRR Level I Screenings for Residents with Mental Illness Diagnoses: Three residents had PASRR Level I forms that did not reflect documented mental illness diagnoses, including Major Depressive Disorder and PTSD. Their charts, MDSs, care plans, physician orders, and diagnosis reports showed active psychiatric diagnoses and related psychotropic medications, but the PASRR screenings still indicated no mental illness. The DON, SW, and ADM stated staff were responsible for ensuring PASRR accuracy and updating screenings when diagnoses changed, but the incorrect PASRRs were not identified.
Improper Food Labeling and Storage in Dietary Area: Kitchen observation found opened frozen fries and tator tots unsealed, unlabeled, and undated, along with refrigerated items lacking required use-by dates, an expired sloppy joe mix, and a dented can of peaches stored with other cans. The DM and dietary staff stated food items must be labeled and dated when opened and that dented or expired items should not be used, but the same issues were still observed during follow-up review.
The facility failed to follow its smoking policy for multiple smokers by not completing required smoking assessments on admission and quarterly. A SW said she was responsible for the assessments but did not know one resident was a smoker until the week before survey, and his assessment was not completed until the day of the interview. The DON and ADM said they were unaware the assessments were not being completed, and the policy required evaluation of smoking status and safe smoking ability with quarterly re-evaluation.
A resident with severe cognitive impairment and a history of stroke had a bathroom sink observed broken and detached from the wall. The DON, ADM, and MD all acknowledged the repair was high priority and that the facility used an online maintenance system with phone notifications, but the sink was not repaired immediately after it was reported. The MD stated he attempted the repair, could not complete it, and did not arrange for the resident to be moved.
A facility failed to store discontinued controlled medications in accordance with policy and accepted professional principles. An observation of the ADON office closet found discontinued narcotics in an unsecured basket and a black box that was not secured to the floor, and the ADON stated the closet was not always double locked because her office door was not always closed and locked. The DON and ADM were unaware the discontinued narcotics were not being stored with double locks, despite policy requiring controlled substances to be separately locked in permanently affixed compartments.
The facility failed to provide accessible information on filing grievances, affecting 7 residents who were unaware of the process, including how to file anonymously. Interviews revealed that grievance forms were not available without staff assistance, and there was no visible posting of the grievance procedure. The ADM acknowledged the absence of a grievance posting and a process for anonymous grievances.
The facility failed to provide a private space for Resident Council meetings, holding them in a dining room with open doorways and frequent staff interruptions, making it difficult for residents to voice grievances privately. Interviews revealed that the dining room was consistently used despite the lack of privacy, contrary to facility policy.
The facility failed to provide palatable and properly prepared meals across three food forms, as observed during a meal service. Residents reported dissatisfaction with the taste and seasoning of the food, describing it as bland. The Dietary Manager admitted to not consistently tasting the food before serving, despite being trained to do so. The facility's grievance log showed no complaints about food palatability, and alternate food options were available for residents.
The facility failed to maintain proper kitchen sanitation and food storage standards, as observed during a survey. Freezer handles were found unclean, and several food items in the refrigerator and freezer were not properly sealed. The Dietary Manager acknowledged the oversight, and both the DM and ADM confirmed that all dietary staff were trained in these areas. Facility policies emphasized the importance of maintaining clean and sanitary conditions to prevent foodborne illness.
A facility reported a medication error rate of 7.69% due to two errors involving two residents. An LPN administered Midodrine to a resident despite blood pressure readings that required the medication to be held, and gave another resident two Tylenol tablets instead of one. The errors were identified during a medication pass observation, and the LPN acknowledged the mistakes, despite regular training and audits in place.
A resident on Enhanced Barrier Precautions due to a feeding tube did not receive proper infection control measures from two CNAs who failed to wear PPE during care activities. Despite clear signage and facility policy, the CNAs did not adhere to the required precautions, and the facility administration was unaware of this non-compliance until the survey.
Inaccurate PASRR Level I Screenings for Residents with Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure that PASRR Level I screenings were accurate and updated for three residents with mental illness diagnoses. Resident #9 had diagnoses including Major Depressive Disorder, recurrent, severe with psychotic features, and Post Traumatic Stress Disorder, yet the PASRR Level I screening dated 10/08/2024 indicated no mental illness. Resident #17 had a diagnosis of Major Depressive Disorder, recurrent, severe without psychotic features, but the PASRR Level I screening dated 10/08/2024 also indicated no mental illness. Resident #18 had a diagnosis of Major Depressive Disorder, recurrent, severe without psychotic features, but the PASRR Level I screening dated 07/02/2019 indicated no mental illness. Record review showed that each resident’s clinical documentation reflected mental health diagnoses that were not reflected on the PASRR Level I forms. Resident #9’s face sheet, MDS, care plan, physician order summary, and diagnosis report documented Major Depressive Disorder and PTSD, and the resident was prescribed Seroquel related to Major Depressive Disorder with psychotic symptoms. Resident #17’s face sheet, MDS, care plan, physician order summary, and diagnosis report documented Major Depressive Disorder, and the resident was prescribed Zoloft related to Major Depressive Disorder without psychotic symptoms. Resident #18’s face sheet, MDS, care plan, physician order summary, and diagnosis report documented Major Depressive Disorder, and the resident was prescribed Cymbalta related to Major Depressive Disorder without psychotic symptoms. During interviews, the DON stated the MDS nurse was usually responsible for PASRR screenings and that she and the ADON were currently screening PASRR assessments when residents were admitted. The DON stated she was not aware that Major Depressive Disorder would classify as a mental illness and should be reflected on the PASRR Level I, and she was not aware that Residents #9, #17, and #18 had mental illness diagnoses that were not reflected on the screenings. The SW stated she assisted with PASRR Level I screenings but was not aware of the incorrect screenings for these residents. The ADM stated the DON, ADON, SW, and MDS nurse were responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting an updated screening when a resident received a new mental illness diagnosis, and he was not aware that these residents did not have accurate PASRR Level I screenings.
Improper Food Labeling and Storage in Dietary Area
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During the initial kitchen observation, opened packages of french fries and tator tots were found in the freezer unsealed, unlabeled, and undated. In the refrigerator, a container of grated parmesan cheese had an opened date of 10/21/2025 but no expiration or use-by date, and a container of processed sliced strawberries had an opened date of 03/04/2026 but no expiration or use-by date. A container of prepared sloppy joe mix was also observed with a prepared date of 03/04/2026 and a use-by date of 03/07/2026, and a can of peaches with a dent extending from the bottom into the side of the can was found on the shelf with other cans. During interviews, the dietary manager stated prepared foods and processed foods were good for 3 days in the refrigerator and were discarded after 3 days. She stated all food items had to be labeled and dated once opened with an opened date and expiration date, and that dented cans should not be used because they could cause residents to get sick. She also stated the facility did not have a separate area to store dented cans of food items. Another dietary staff member gave the same statements regarding labeling, dating, discarding expired foods, and not using dented cans. On a later kitchen observation, the processed sliced strawberries were still present without an expiration or use-by date, and the dented can of peaches remained on the shelf with other cans. The dietary manager stated she had become aware of the unlabeled freezer items after the initial tour, that the parmesan cheese and sloppy joe mix had been overlooked, and that the strawberries should have had a use-by date. She stated the dented can of peaches would be discarded right away. The administrator stated all food items were supposed to be dated when received and when opened, expired food should be discarded, and dented cans should be stored separately and not used.
Failure to Complete Required Smoking Assessments
Penalty
Summary
The facility failed to follow its smoking policy for 5 of 6 residents reviewed for smoking by not completing smoking assessments quarterly and, for one resident, not completing the assessment until after surveyor intervention. Residents #11, #21, #29, #35, and #38 were identified as smokers in their care plans and had Safe Smoking assessments in their records showing they had demonstrated ability to safely smoke. Their records also showed a range of diagnoses including cerebral infarction, diabetes, nicotine dependence, hypertension, COPD, chronic kidney disease, major depressive disorder, schizophrenia, anxiety, muscle weakness, and varying levels of cognitive impairment and ADL dependence. Record review showed the facility policy required residents who smoke to be evaluated on admission to determine smoking status and ability to smoke safely, with re-evaluation quarterly and upon significant change. During interview, the SW stated she was responsible for smoking assessments and said they should be completed on admission and quarterly, but she was not aware Resident #38 was a smoker until the week before the survey and had not completed his safe smoking assessment until the day of the interview. The DON stated she was not aware the assessments were not being completed on admission and quarterly and said the recent switch to new electronic medical record software resulted in smoking assessments not being scheduled. The ADM also stated he was not aware smoking assessments were not being completed on admission and quarterly. He confirmed the SW was responsible for the assessments and stated they should be completed quarterly and with any change of condition. The report also states that all staff had been trained on the facility smoking policy. Resident #38’s assessment, completed after surveyor intervention, indicated he could safely smoke with direct visual supervision.
Broken Bathroom Sink Left Unrepaired
Penalty
Summary
The facility failed to ensure a safe, functional, sanitary, and comfortable bathroom environment for one resident when the bathroom sink in the resident’s room was observed broken and detached from the wall. The resident was a female admitted to the facility with a diagnosis of cerebral infarction due to thrombosis of an unspecified cerebral artery, and her MDS assessment showed a BIMS score of 3, indicating severe cognitive impairment. During the observation, the resident could not be interviewed because of her cognitive status. The broken sink was observed during an interview with the DON, who stated she was aware of the condition and believed the MD had already repaired it. Later interviews with the DON, ADM, and MD showed that the facility used an online system and phone notifications for maintenance requests, and that the sink repair was considered high priority because it could pose a safety concern. The MD stated he attempted to repair the sink on the day it was reported but was unable to complete the work after becoming sick, and he acknowledged he should have advised the ADM so arrangements could have been made to move the resident. The facility policy stated that maintenance work orders are to be prioritized, with emergency requests given priority for necessary repairs.
Discontinued Controlled Medications Not Stored in Double-Locked, Secure Compartment
Penalty
Summary
The facility failed to ensure discontinued controlled medications were stored in accordance with accepted professional principles and its own policy. During observation of the ADON office closet, discontinued medications were found stored in a black box on the floor that was not secured to the floor, and discontinued narcotics were also found in a plastic basket on the top shelf of the closet that was not secured. The medications observed included Acetamin/Codeine 300/30 mg tablets, Ativan 1 mg tablets, Pregabalin 75 mg tablets, Hydrocodone-APAP 7.5-325 mg tablets, and Tramadol 50 mg tablets. During interview, the ADON stated she removed discontinued narcotic medications from the medication cart and placed them in the basket in her closet, and that the black box was used for non-narcotic medications. She stated the black storage box did not have a lock and was not secured, and that the closet door being locked would only create a double lock if her office door was also closed and locked, which she did not always do. The DON and ADM stated they were not aware the discontinued narcotics were not being stored with double locks. The facility policy stated controlled substances are to be separately locked in permanently affixed compartments, and controlled substances remaining after discontinuation are to be securely locked in an area with restricted access until destroyed.
Lack of Accessible Grievance Process for Residents
Penalty
Summary
The facility failed to ensure that information on how to file a grievance or complaint was available to residents, affecting 7 out of 7 confidential residents reviewed for grievances. During confidential interviews, these residents reported not knowing about the grievance process, where to obtain or submit a grievance form, or that they could file a grievance anonymously. They were unaware of who their grievance officer was, and the grievance procedure had not been discussed in Resident Council or upon admission. Observations confirmed the absence of visible grievance forms or postings with instructions on filing grievances in areas accessible to residents. Interviews with the Assistant Director (AD) and Administrator (ADM) revealed that grievance forms were not readily accessible to residents without staff assistance. The AD stated that she completed grievance forms for residents when complaints were made during Resident Council meetings, primarily concerning missing laundry. The ADM confirmed that grievance forms were filled out by staff and submitted to the relevant department manager for resolution, but there was no process for residents to file anonymous grievances. The ADM acknowledged the lack of a grievance posting in the facility and the absence of a location for residents to obtain grievance forms independently.
Lack of Privacy for Resident Council Meetings
Penalty
Summary
The facility failed to provide a private space for Resident Council meetings, which compromised the residents' ability to voice their grievances in private. During a survey, it was observed that the Resident Council meeting was held in the dining room, which had two open doorways without closures, allowing staff to walk through during the meeting. This setting made it difficult for residents to hear each other due to noise from the hallway and distractions from staff entering the area. Residents expressed that the dining room was always used for these meetings, and there was no alternative private area available. Interviews with the Activities Director (AD) and the Administrator (ADM) revealed that the dining room had been the consistent location for Resident Council meetings, despite the lack of privacy. The AD acknowledged the issue but had not considered alternative locations, while the ADM recognized the lack of privacy and the distractions caused by staff movement and hallway noise. The facility's policy stated that Resident Council meetings should be held in a private space, but this was not adhered to, as evidenced by the observations and interviews conducted during the survey.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to ensure that food provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was observed during a meal service where three different food forms (Regular, Mechanical Soft, and Pureed) were evaluated. During the meal observation, issues were noted with the palatability of the food, particularly with the white rice being described as sticky, thick, and bland, and the biscuits being dry and overcooked. These observations were corroborated by resident interviews, where four out of twelve residents expressed dissatisfaction with the taste and seasoning of the food, describing it as bland and lacking flavor. The Dietary Manager (DM) admitted to not consistently tasting the food before serving it to residents and acknowledged that the food served during the observed meal was not tasted beforehand. The DM also mentioned that while she had been trained on seasoning and tasting food, she did not always follow this practice. The Assistant Dietary Manager (ADM) confirmed that the DM was responsible for food tasting and stated that the dietary staff had been trained on food palatability. Despite these issues, the facility's grievance log showed no recorded complaints about food palatability, and the ADM noted that alternate food options were available if residents were dissatisfied with their meals.
Deficiency in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain proper food storage and cleanliness standards in the kitchen, as observed during a survey. Specifically, the freezer handles were found to have dry, sticky substances, indicating they had not been cleaned as required. Additionally, several food items in the refrigerator and freezer, including a box of biscuits, a bag of turkey sandwich meat, a gallon-sized bag of shredded cheese, and a bag of corn tortillas, were not properly sealed and had been opened for several days. These observations were made during a kitchen tour, and the Dietary Manager (DM) acknowledged that the freezer handles had not been cleaned that day and that food should be stored fully sealed. Interviews with the DM and the Assistant Dietary Manager (ADM) revealed that the DM was primarily responsible for ensuring proper food storage and kitchen cleanliness, although all dietary staff were trained and expected to maintain these standards. The DM admitted to providing reminders to staff about food storage and cleanliness every few days. The ADM expressed uncertainty about why these issues occurred, given the training provided to staff. The facility's policies from 2018 outlined the need for proper food storage and kitchen sanitation to prevent foodborne illness, emphasizing the importance of clean and sanitary conditions in refrigerators, freezers, and other kitchen areas.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.69% due to two errors out of 26 opportunities. These errors involved two residents during medication administration. The first error occurred when LVN A administered Midodrine to a resident with hypotension, despite the resident's blood pressure being outside the parameters specified in the physician's order. The resident's blood pressure was 124/88, which required the medication to be held, but LVN A proceeded with the administration. The second error involved another resident who was prescribed Tylenol Extra Strength for pain management. LVN A administered two tablets of Tylenol 500 mg instead of the one tablet as per the physician's order. This error was identified during a medication administration observation, where LVN A acknowledged the mistake and expressed uncertainty about why the error occurred, despite being experienced in medication administration. Interviews with LVN A, the Administrator, and the Director of Nursing revealed that the facility had protocols in place for medication administration, including regular training and audits by the Corporate Nurse and Pharmacy Consultant. However, the errors were attributed to lapses in following these protocols, as LVN A did not adhere to the physician's orders during the medication pass. Both residents were monitored for adverse reactions following the errors, and no adverse effects were reported.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of two CNAs who did not adhere to Enhanced Barrier Precautions (EBP) while providing care to a resident. The resident, a female with multiple diagnoses including dysphagia, major depressive disorder, and reduced mobility, was on EBP due to having a feeding tube. Despite signage indicating the need for PPE, the CNAs did not wear gowns and gloves during a transfer and clothing change. Interviews with the CNAs revealed a lack of compliance with EBP protocols. CNA A admitted to not wearing PPE because she did not think it was necessary and could not recall recent training on EBP. CNA B acknowledged the requirement for PPE during care activities and attributed the oversight to the presence of surveyors, indicating a lapse in adherence to infection control measures. The facility's administration, including the Administrator and the Director of Nursing (DON), were unaware of the non-compliance prior to the survey. The DON was responsible for staff training on EBP, and monitoring was conducted through rounds. The facility's policy on EBP required PPE for high-contact activities, but this was not followed, leading to a deficiency in infection control practices.
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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) |
|---|---|---|---|---|
| Sterling Hills Rehabilitation And Healthcare Cente | 1.7 mi | ★★★★★ | 5 | 0 |
| Merkel Nursing Center | 21.6 mi | ★★★★★ | 34 | 5 |
| Mitchell County Nursing And Rehabilitation Center | 29.7 mi | ★★★★★ | 9 | 0 |
| Homeplace Manor Healthcare Center | 31.5 mi | ★★★★★ | 25 | 0 |
| Avir At Snyder | 33 mi | ★★★★★ | 12 | 0 |
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