Health inspection·August 25, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few common bath 300. She was shown the DC 33 spray cleaner stored among the toiletries in the cabinet. She stated the chemicals should not be mixed in with the toiletries; they should be with the towels. She added they were told not to store them with toiletries. She stated that she was told someone used spray chemical on the wrong item prior to her working at the facility. She then took the spray bottle of disinfectant and moved it to the adjacent cabinet area and placed it next to resident wash cloths. The CNA was asked what could happen if the spray bottle spilled or leaked onto the washcloths. She stated disinfectant could be used on the resident. On 8/24/22 at 3:37 PM an interview was conducted with the DON in the hall 400 resident common bath . She was shown the spray bottles of DC33 disinfectant stored amongst the resident toiletries. She stated, staff should not have spray cleaners with toiletries. She stated staff were told not to put chemicals with toiletries and to keep them out of reach of residents. She added residents could have skin issues if chemicals were not stored with resident toiletries. She further stated she and ADON were responsible for ensuring chemicals were stored safely in the baths; they make rounds to monitor this. She added she verbally tells staff, has skill days and one on one training. She was also asked why the chemicals were stored in an unsafe manner. She stated, after showers staff just stuck everything in the cabinet. On 8/25/22 at 10:07 AM an interview was conducted with the Administrator regarding the resident common baths . Regarding the storage of chemicals, she was asked why staff stored chemicals with resident toiletries. She stated staff just put them out of sight. She was asked who was responsible for ensuring that chemicals were stored properly, she stated, nursing was. She was also asked what could result from the chemicals being stored in an unsafe manner. She stated that chemicals could spill on items. She stated she expected staff to store the chemicals separate from resident use items. Record review at the facility policy titled Safety and OSHA Compliance Manual, April 2009, 5.10.1, revised 6/2015, Hazard Communication, OSHA Standard 1910.1200, revealed the following documentation, This OSHA standard applies to: all employees who may be exposed to hazardous chemicals when working, whether it's part of their job duties, or by possible or accidental exposure. Employees Responsibilities: comply with chemical safety requirements of this program. General Chemical Safety. Assume all chemicals are hazardous. Chemical Storage. The separation of chemicals (solids or liquids), during storage is necessary to reduce the possibility of unwanted chemical reactions caused by accidental mixing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 2 of 14 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 455509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen. The facility failed to designate a person to serve as the Dietary Manager who met the required qualifications. The designated Dietary Manager had not completed the state dietary managers course and did not have any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings include: Record review of the personnel file for the Dietary Manager revealed there was no documentation of completion of the state required dietary managers course or documentation which indicated she met any of the other qualifying education levels/credentials Record review of the Food Handler Certificate of Completion for the Dietary Manager revealed that it was issued on 3/31/22 and was valid through 3/31/2024. On 8/24/22 at 12:55 PM an interview was conducted with the Dietary Manager. She was asked about her qualifications as a Dietary Manager. She stated she had not taken the required dietary managers course and was not a certified dietary manager. She stated she had received training on printing dietary tickets so far (resident tray tickets). She added she had moved up to the Dietary Manager position approximately two months ago. She was asked when she was going to take the required courses for dietary manager. She stated the facility have not given her a date to start the courses. On 8/24/22 at 2:26 PM an interview was conducted with the Administrator regarding the Dietary Manager qualifications. She stated the current Dietary Manager was hired as dietary manager on 4/15/22 and that she was in the process of qualifying and has not started the training yet. She added the last Dietary Manager left suddenly, and this was the available pool. She was asked what could result from the Dietary Manager not being fully qualified. She stated the residents may not get what they are supposed to nutritionally. On 8/24/22 at 3:11 PM an interview was conducted with the Administrator regarding Dietary Manager qualifications. She stated they scheduled the Dietary Manager for dietary orientation, but the Dietary Manager could not go because the facility did not have adequate dietary staff at the time. On 8/24/22 at 3:56 PM an interview was conducted with the Administrator. She was asked who was responsible for ensuring the Dietary Manager was qualified. She stated the regional dietary representative and the past administrator. Record review of the facility Job Description for the Dietary Manager dated April 2017 revealed the following documentation, Function: Manages the facility food and nutrition services department. Provides nourishing, palatable and well-balanced meals to meet their daily nutritional and special dietary needs of each resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 3 of 14 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 455509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556 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 0801 Level of Harm - Minimal harm or potential for actual harm Qualifications: The requirements listed below are representative of the knowledge, skills and/or ability required. Education and/or Experience: high school diploma or equivalent. Successful completion or current enrollment and course approved by their Dietary Managers Association. Residents Affected - Few Continuing Education: attends in-service, continuing education and educational programs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 4 of 14 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 455509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to ensure the menu was followed for 6 of 6 residents (Resident #'s 9, 15, 30, 36, 49 and 118), in that: Residents Affected - Some The facility failed to ensure 6 residents received the correct portions that were called for on the menu. These failures could place residents at risk for unwanted weight loss and hunger. The findings include: Record review of the facility's Order Listing Report dated 8/23/22 revealed that Resident #15 had a physician's diet order of enhanced diet mechanical soft texture, thin consistency, revision date 8/17/22 Record review of the facility's Order Listing Report dated 8/23/22 revealed that Resident #118 had a physician's diet order of regular diet purée texture, thin consistency. Revision date 8/18/22. Record review of the facility's Order Listing Report dated 8/23/22 revealed that Resident #30 had a physician's diet order of regular diet purée texture, then consistency, fortified foods related to dysphasia, oral pharyngeal phase. The revision date was 8/5/21 Record review of the facility's Order Listing Report dated 8/23/22 revealed that Resident #9 had a physician's diet order of enhance that regular texture, then consistency. Revision date was 8/17/22. Record review of the facility's Order Listing Report dated 8/23/22 revealed that Resident #49 had a physician's diet order of regular diet mechanical soft texture, thin consistency, super cereal at breakfast for supplement with a revision date of 8/05/21. Record review of the facility's Order Listing Report dated 8/23/22 revealed that Resident #36 had a physician's diet order of regular diet purée texture, thin consistency with a revision date of 6/21/22 On 8/23/22 at 5:06 PM an observation tour was conducted in the kitchen and concluded at 6:02 PM: On the service line there was: Vegetable soup served with a 4-ounce ladle Tuna salad served with a # 16 (1/4 cup) scoop and on ice Macaroni salad served with a # 16 (1/4 cup) scoop and on ice Chicken soup served with a 4-ounce ladle Green beans served with a 4-ounce ladle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 5 of 14 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 455509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556 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 0803 Potatoes and ham dish served with a 4-ounce ladle. Level of Harm - Minimal harm or potential for actual harm The chicken soup, green beans and potato and ham dish were the alternate meal. Fruit cocktail was already distributed in bowls. Residents Affected - Some Observation of the meals served by Dietary staff A revealed all regular and mechanical soft diets were served one 4-ounce ladle of the vegetable soup and then at times Dietary staff A would add another partial ladle of vegetable juice to the serving. He also served one #16 (1/4 cup) scoop of macaroni salad and one #16 (1/4 cup) scoop of tuna salad. There was no pureed bread observed or served from the service line. Record review of the Tuesday (facility) SS 2022 SHR Week 3 diet evening meal menu revealed that: Residents on regular diet should have received: 6 ounces of garden vegetable soup 1/3 cup tuna salad 1/2 cup of macaroni salad. Residents on a regular purée diet should have received: 6 fluid ounces of puréed garden vegetable soup 1/3 cup puréed tuna salad 1/2 cup puréed macaroni salad 1/4 cup puréed bread and 1/3 cup puréed fruit. Residents on regular mechanical soft diet should have received: 6 fluid ounces of garden vegetable soup 1/3 cup tuna salad 1/2 cup macaroni salad Record review of the meal tray ticket for a Resident #49 revealed that the resident was on a regular/Mechanical soft diet dated for Supper: Tuesday, August 23, 2022. The resident should have received six fluid ounces thin garden vegetable soup, 1/3 cup tuna salad, 1/2 cup macaroni salad. Observation on 8/23/22 at 5:11 PM Resident #49 was served a 4-ounce bowl of vegetable soup, one #16 scoop (1/4 cup) of macaroni salad, one #16 scoop of tuna salad and a bowl of fruit cocktail. The resident should have received 6 ounces of garden vegetable soup, 1/2 cup of macaroni salad and 1/3 cup tuna salad as called for on the menu. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 6 of 14 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 455509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the meal tray ticket for Resident #15 revealed she was on a regular/mechanical soft diet dated for Supper: Tuesday, August 23, 2022. The resident should have received six fluid ounces thin garden vegetable soup, 1/3 cup tuna salad, 1/2 cup macaroni salad. Observation on 8/23/22 at 5:15 PM Resident #15 was served a 4-ounce bowl of vegetable soup, one #16 scoop of macaroni salad, one #16 scoop of tuna salad and crackers. The resident should have received 6 ounces of garden vegetable soup, 1/3 cup tuna salad, and 1/2 cup of macaroni salad as called for on the menu. Record review of the meal tray ticket for Resident #9 revealed that she was on an enhance/regular diet dated for Supper: Tuesday, August 23, 2022. The resident should have received six fluid ounces thin garden vegetable soup, 1/3 cup tuna salad, 1/2 cup macaroni salad. Observation on 8/23/22 at 5:29 PM Resident #9 received a 4-ounce bowl of vegetable soup, one #16 scoop of macaroni salad, and one #16 scoop of tuna salad. The resident should have received 6 ounces of garden vegetable soup, 1/3 cup tuna salad, and 1/2 cup of macaroni salad as called for on the menu. Record review of the meal tray ticket for Resident #30 revealed that she was on an enhanced/puréed diet dated for Supper: Tuesday, August 23, 2022. The resident should have received six fluid ounces thin purée garden vegetable soup, 1/3 cup pureed tuna salad, 1/2 cup puréed macaroni salad, and 1/4 cup puréed bread slice. Observation on 8/23/22 at 5:47 PM Resident #30 received puréed tuna, puréed fruit, puréed macaroni salad and applesauce in bowls. The resident did not receive puréed soup or puréed bread as called for on the menu. Record review of the meal tray ticket for Resident #36 revealed she was on a regular NAS (no added salt)/puréed diet dated for Supper: Tuesday, August 23, 2022. The resident should have received 6 fluid ounces thin purée garden vegetable soup, 1/3 cup puréed tuna salad, 1/2 cup puréed macaroni salad and 1/4 cup puréed bread slice. Observation on 8/23/22 at 5:49 PM Resident #36 received bowls of puréed macaroni salad, puréed tuna salad, puréed fruit. She was fed by staff. The resident did not receive any puréed bread or puréed soup as called for on the menu. On 8/23/22 at 5:52 PM Resident #118 was observed in her room. The resident received bowls of puréed soup, puréed tuna salad, puréed fruit and puréed macaroni salad. She did not receive any puréed bread as called for on the menu. She also received water and was fed by staff. On 8/23/22 at 6:02 PM an interview was conducted with Dietary staff A . He stated he used incorrect scoops because he mixed up the scoops and put away the correct scoops that had been set out and used the wrong scoops. He stated he just grabbed a scoop without thinking about the size so he did not use the 6 ounce ladle. He was also asked why he had not served any puréed bread. He stated they usually do not prepare pureed bread and had not seen anyone prepare it. He added that they usually serve 3 foods at meals: 2 hot and one cold. He stated he had been employed in the facility for approximately one and a half months. At that time the surveyor asked why two residents did not receive any puréed soup (Resident #30 and 36). Dietary staff A went to the steamer and there were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 7 of 14 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 455509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556 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 0803 Level of Harm - Minimal harm or potential for actual harm still two bowls of puréed soup in the warmer. He stated he did not know how he missed it. He stated he made the menu errors because he tried to do too many things at once and was nervous. He stated malnutrition and weight loss could result from residents not receiving the correct servings of food and lesser amounts of foods. He stated his initial dietary department training was three days of training and he shadowed the Dietary Manager and Dietary staff C. Residents Affected - Some On 8/24/22 at 11:40 AM an observation tour was conducted in the kitchen and concluded at 12:34 PM: The Dietary Manager was observed preparing purée food. She prepared pureed fried okra, and pureed shepherd's pie. Dietary staff B prepared pureed carrot cake. No additional bread was observed pureed or added to one of these pureed foods. Observation of the steamtable revealed the following foods were present: Rolls Shepherd's pie served with a 4-ounce ladle Fried okra served with a #8 scoop (1/2 cup) Carrot cake served in approximately 2-inch squares Puréed carrot cake in bowls in the refrigerator Puréed shepherd's pie and pureed fried okra were in bowls in the steamer. There was also soup, ribs and cabbage served with a #8 scoops as an alternate meal. Observation on 8/24/22 at 12:05 PM revealed the meal service started and the Dietary Manager was serving the meal trays. Observation of the meal service revealed that residents on regular and mechanical altered diets received one 4-ounce ladle of shepherd's pie and at times she would add one and a half scoops randomly. These residents also received one #8 scoop of fried okra. Observations at this time revealed that the utensil drawer had an 8-ounce ladle and a 6-ounce ladle available. Record review of the facility's Wednesday (facility) SS 2022 SHR Week 3 menu revealed that: Residents on a regular diets should have received: 3/4 cup of shepherd's pie 1/2 cup of fried okra One roll One square of carrot cake with cheese cream cheese icing. Residents and regular purée diets should have received: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 8 of 14 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 455509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556 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 0803 3/4 cup puréed shepherd's pie Level of Harm - Minimal harm or potential for actual harm 1/3 cup puréed vegetable 1/4 cup purée dinner roll Residents Affected - Some 1/2 cup puréed carrot cake with cream cheese icing. Residents on Regular/mechanical soft diet should have received: 3/4 cup shepherd's pie 1/2 cup fried okra One dinner roll One square carrot cake with cream cheese icing. Record review of the meal tray ticket for Resident #15 revealed the resident was on a regular/mechanical soft diet dated for Lunch: Wednesday, August 24, 2022. The resident should have received 3/4 cup of shepherd's pie. Observation on 8/24/22 at 12:16 PM Resident #15 received ½ cup fried okra, roll, cake, 4 ounces shepherd's pie. The resident should have received 3/4 cup of shepherd's pie as called for on the menu. Record review of the meal tray ticket for Resident #9 revealed that the resident was on an enhanced/regular diet dated for Lunch: Wednesday, August 24, 2022. The resident should have received 3/4 cup shepherd's pie. Observation on 8/24/22 at 12:19 PM Resident #9 received 4 ounces shepherd's pie, ½ cup fried okra, rolls, and cake. The resident should have received 3/4 cup of shepherd's pie as called for on the menu. Record review of the meal tray ticket for Resident #30 revealed she was on an enhanced/purée diet dated for Lunch: Wednesday, August 24, 2022. The resident should have received 1/3 cup puréed barbecue pork riblet, 1/3 cup puréed vegetable, and 1/4 cup puréed dinner roll. Observation on 8/24/22 at 12:34 PM Resident #30 received puréed cake, purée shepherd pie, and puréed okra but did not receive any puréed roll as called for on the menu. Record review of the meal tray ticket for Resident #36 revealed she was on a regular NAS/purée diet dated for Lunch: Wednesday, August 24, 2022. The resident should have received 3/4 cup shepherd's pie, 1/3 cup vegetable, and 1/4 cup puréed dinner roll. Observation on 8/24/22 at 12:35 PM Resident #36 received puréed okra, puréed shepherd's pie, and puréed cake but did not receive a puréed roll as called for on the menu. Record review of the meal tray ticket for Resident #118 dated Lunch: Wednesday, August 24, 2022, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 9 of 14 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 455509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed the resident was on a regular/purée diet and should have received 3/4 cup of puréed shepherd's pie, 1/3 cup puréed vegetable, 1/4 cup puréed dinner roll. Observation on 8/24/22 at 12:37 PM Resident #118 received puréed shepherd's pie, and puréed okra. The resident did not receive any puréed roll or puréed cake as called for on the menu. The purée cake was later served. On 8/24/22 at 12:55 PM an interview was conducted with the Dietary Manager, and she was asked why no puréed bread was prepared or served to residents. She stated the rolls were small and she was unsure of how many to use to make the purée. She stated she did not serve 6 ounces of shepherd's pie to the regular and mechanical soft diets because she did not know she had a 6-ounce scoop. On 8/25/22 at 10:07 AM an interview was conducted with the Administrator. She stated she ensured the menu was followed through staff triple checking meal trays, by dietary, nursing and aides. She stated residents could have weight loss if the menu was not followed. She added she expected staff to follow the triple check system and serve the diet as ordered. On 8/25/22 at 10:27 AM an interview was conducted with the DON regarding staff not following the menu. She stated that if the menu was not followed the result could be residents losing weight. She added staff conduct triple checks of meal trays by nurses and nurse aids. On 8/25/22 at 10:54 AM an interview was conducted with the Dietary Manager. She stated the Dietary Manager, cook and those involved in the triple check of trays (nursing) was responsible for ensuring the menus were followed. She stated they check the menu to ensure the menus were followed. She added if the menu was not followed it could leave residents at risk for weight loss. She stated she expected staff to communicate and serve the menu/diet as ordered and documented. She stated she conducted a meeting a week ago and covered dishwashing operations, cleaning, sanitizing your hands. She further added that she did not document this meeting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 10 of 14 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 455509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 3 of 3 staff (Dietary staff A and B and Dietary Manager), in that: 1)The facility failed to ensure Dietary staff (Dietary Manager and Dietary staff A) used sanitizers as directed and sanitizer levels were maintained according to manufacturer recommendations, 2) The facility failed to ensure Dietary staff (Dietary staff A) used good hygienic practices during dietary duties (handwashing/glove changes), 3) The facility failed to ensure foods and food contact equipment were protected from possible contamination during processing and service (Dietary Manager and Dietary staff A and B) These failures could place residents at risk for food contamination and foodborne illness. The findings include: The following observations were made during a kitchen tour that began on 8/23/22 at 10:57 AM and concluded at 11:29 AM: The red bucket solution in the tea station area had a quaternary sanitizer level of 100 ppm. It was tested by the Dietary Manager. Record review of the label on the Solution QA Ultra AutoChlor quaternary sanitizer stated that the level to maintain in order to sanitize food equipment was 200 to 400 ppm. On 8/23/22 at 11:00 AM the Dietary Manager stated during an interview that she prepared the quaternary sanitizer in the tea station red bucket that morning. The following observations were made during a kitchen tour that began on 8/23/22 at 11:45AM and concluded at 12:24 PM: On 8/23/22 at 12:00 PM Dietary staff A used the wiping cloths from the tea station area red bucket and wiped off a rear preparation table. The tea station area red bucket solution was tested, and the quaternary sanitizer level was 100 ppm and the water was dirty and had wet wiping cloths stored in the water. ~ The following observations were made during a kitchen tour that began on 8/23/22 at 3:48 PM and concluded at 4:30 PM: Purée preparation was observed. The Dietary Manager placed soup into the processor and then puréed the mixture. She poured the mixture into three bowls and then took the processor parts to the three-compartment sink and rinsed the parts with water only and failed to sanitize the parts. The inside of the processor still had bits of food and was wet on the interior. Dietary staff A then placed scoops of macaroni salad and milk into the wet processor and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 11 of 14 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 455509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556 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 0812 Level of Harm - Minimal harm or potential for actual harm puréed the mixture. He took the mixture and poured it into three bowls. Dietary staff A then took the parts to the dishwasher and sprayed them with water from the soiled side of the dishwasher. He then rinsed the parts in the three compartment sink along with the pitcher that he used for milk. The parts were only rinsed with clear water. The parts were still wet and Dietary staff A placed scoops of tuna salad and water in the processor and purée the mixture. He poured the mixture into three bowls. Residents Affected - Many Dietary staff A was observed wiping off the prep table where the processor was and the exterior of the processor by using wiping cloths from a solution in a green bucket. After using the wiping cloth, he placed it in the red bucket sanitizing solution that were both located at the front of the kitchen. On 8/23/22 at 4:14 PM an interview was conducted with Dietary staff A regarding the sanitizer and contents of the red and the green buckets. He stated, both buckets had sanitizer in it. He was asked to test the sanitizer concentration in the buckets and the green bucket had less than 100 ppm quaternary sanitizer and the red bucket had 100 ppm quaternary sanitizer. Both buckets had wiping cloths stored in them. After testing the sanitizer concentration in the buckets Dietary Staff A (Cook) failed to change the sanitizer in the buckets. On 8/23/22 at 5:35 PM Dietary staff A was observed dropping a paper tray ticket on the floor at the service line. He picked it up with his gloved hand and then removed that soiled glove and set it on the cart next to pans of tuna and macaroni salad. He then donned another glove by using the gloved hand that removed the soiled glove. He then continued serving meal trays. He failed to wash his hands before donning the glove or completely changing his other glove and washing his hands. On 8/23/22 at 6:02 PM an interview was conducted with Dietary staff A. He stated he did not know what the correct concentration was for quaternary sanitizer and that the bucket solutions were already made/set up by the time he arrived to work. He stated that he did not sanitize the processor because some days he would run it through the dishwasher and sometimes not. He stated these errors occurred because he tried to do too many things at once and was nervous. He stated he had been trained on the correct sanitizer levels in the past. He added that he had not changed the sanitizer in the buckets because it was usually changed when he got to work. He further stated he had been trained to sanitize the processor after use and between uses with food. He stated there would be extra germs and contaminated food if unsanitized equipment and incorrect levels of sanitizer were used. He also stated that his initial dietary department orientation and training was three days and he shadowed the Dietary Manager and Dietary staff C. He added that he had worked in the dietary department about a month and a half. The following observations were made during a kitchen tour that began on 8/24/22 at 11:40AM and concluded at 12:34 PM: The Dietary Manager was observed preparing purée food. She placed scoops of fried okra and water in the processor and pureed the mixture. She poured the mixture into three bowls. She took the processor parts to the dishwasher and ran it through the dishwasher. After removing it from the dishwasher there were still bits of food on the blade. The processor was not allowed to air dry, and the processor blade and pot were wet on the interior. She then placed scoops of shepherd's pie and water in the processor and purée the mixture. She placed it in bowls. She then took the parts and ran them through the dishwasher. The dishwasher cycle ended at 11:55 AM. At 11:56 AM the processor blade and pot were wet on the interior and Dietary staff B added milk and three squares of cake into (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 12 of 14 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 455509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556 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 0812 the processor and puréed the mixture. He placed it in three bowls. Level of Harm - Minimal harm or potential for actual harm Observation and record review of the dishwasher chlorine sanitizer label AutoChlor Super 8 revealed the following, . Sanitizing Food Contact Surfaces 5. Drain and allow food contact surfaces and equipment to air dry Residents Affected - Many On 8/25/22 at 10:07 AM an interview was conducted with the Administrator. She was asked who was responsible for ensuring foods were served in a sanitary manner. She stated dietary trainers and the Administrator. She stated, infection control issues, E. coli and Salmonella could result from the dietary issues that were observed. She stated, she expected dietary staff to follow policy and procedures and report issues. On 8/25/22 at 10:54 AM an interview was conducted with the Dietary Manager. She was asked why there were incorrect sanitizing levels , poor hygienic practices and staff not sanitizing equipment. She stated dietary staff try to keep a routine and all be on the same page. She stated that she saw Dietary staff A rushing and drop the tray ticket. She added that staff knew they should be checking the sanitizer and keeping their areas clean. She was asked who was responsible for ensuring that food was prepared and served in a sanitary manner. She stated the cook and the Dietary Manager. She was asked how she ensured that these processes were conducted. She stated she monitors and corrects staff. She was also asked if she had conducted any in-services with the dietary staff. She stated she held a meeting a week ago and went over dishwashing operations, cleaning, and handwashing. She further added that she did not document this meeting. She stated, residents could get sick from the food and contract foodborne illness as a result of the dietary sanitation issues observed. Record review of the facility policy labeled Handwashing/Hand Hygiene, Revision Date 3/1/2020 revealed the following documentation, Handwashing/Hand Hygiene. Policy Statement. This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation. 1. All personnel shall be trained regularly and in-serviced on the importance of hand hygiene and preventing the transmission of healthcare associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap, (antimicrobial or non-antimicrobial) in water for the following situations. f. Before donning sterile gloves. m. After removing gloves. o. Before and after eating or handling food. 10. Hand hygiene is recognized as the best practice for preventing healthcare associated infections. Applying and Removing Gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 13 of 14 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 455509 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556 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 0812 1. Perform hand hygiene before applying non-sterile gloves. Level of Harm - Minimal harm or potential for actual harm 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. Residents Affected - Many Record review of the current undated dietary department training information/guidelines revealed the following documentation, Sanitation and Safety. Protection Against Bacteria. 3. Kill Bacteria. B. Sanitize. The term sanitize means to kill disease causing bacteria. Certain chemicals also kill bacteria. You must follow the guidelines for sanitizing listed on the chemicals listed in the dietary training manual for dishes, utensils, pots and pans. All surfaces should be sanitize using the information in the Sanitizing Pail Training. Record review of the current undated facility dietary department training materials revealed the following documentation, Sanitizer Pails. All working surfaces in the kitchen need to be not only clean but sanitized. Cleaning with only soap and water doesn't kill the germs or in scientific terms bacteria. In order to kill the bacteria, we must clean with a product that kills the bacteria. This is process is called sanitizing. One of the most efficient ways to sanitize surfaces is with the quaternary product that we use to sanitize the pots and pans. The quaternary chemical must be at least 200 ppm. When you come to work, one of the first things on your get ready to work is to fill your sanitizer pail. Fill the pail with the sanitizer from the pot and pan sink, or from the quaternary dispenser in your mop room. Test the sanitizer with the test strip. It must be at least the color green that is next to the 200 ppm Your cleaning cloth should be in the cleaning pail when you are not using it. This keeps the cloth wet with the sanitizing chemicals, so that the area that you are wiping down will be sanitized. The chemical in your pail should be changed every 4 to 6 hours. If you are wiping up large spills, the chemical will be diluted, and then you are no longer sanitizing. Test the water after wiping up the spill, if it is below 200 color, empty your pail and refill it. Record review of the facility's current undated dietary department training materials/guidelines revealed the following documentation, AutoChlor Chemicals. Quat sanitizer - in the pot and pan sink dispenser, used to sanitize all countertops, table tops and of course pots and pans. Put in pail Quat. Test the chemical with the green strips. Must test between 200 and 400 ppm. If the chemical doesn't test at this level, tell supervisor. Keep rags in the solution at all times. Change solution every four hours . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 14 of 14