Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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 Hills Rehabilitation And Healthcare Cente during CMS and state inspections, most recent first.
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 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 | — | 26 | 4 |
| Mitchell County Nursing And Rehabilitation Center | 29.4 mi | — | 9 | 0 |
| Homeplace Manor Healthcare Center | 33 mi | — | 24 | 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 August 2026) and official state health department websites.