Health inspection·May 2, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Record reviewed Resident #1's progress notes dated 03/28/2023, LVN #1 reflected resident returned to facility with foley catheter. Record reviewed Resident #1's progress notes dated 03/28/2023, LVN #2 reflected resident returned to facility oxygen at 2 liters per minute via nasal cannula as needed. Residents Affected - Some Record reviewed Resident #1's progress notes dated 03/29/2023, Wound Care RN reflected resident returned to facility three pressure ulcers to left buttock and one to coccyx (tail bone) have declined and have worsened. The three ulcers on the buttock are now stage three due to slough (base of ulcer is covered by yellow, tan, gray, green or brown) to wound bed. Resident states that she was not turned while at the hospital. Record reviewed Resident #1's quarterly MDS assessment dated [DATE] revealed the following: Resident #1 now has an indwelling catheter, has four Stage 3 pressure ulcers (admitted with three stage 2 and one stage 3), and on oxygen therapy Record reviewed Resident #1's physician orders: Order Date 04/20/2023: Keep HOB (head of bed elevation) at 10 degrees except for meals; rotate between right and left side every 2 hours. Order Date 04/27/2023: Resident to be out of bed for all meals and is to return to bed after meals three times a day. Record reviewed Resident #1's care plan dated 03/20/2023 and revised on 04/05/2023 reflected: Focus: Pressure Ulcers (pu) stage 2 on left lower buttock, stage 2 to left mid buttock, stage 2 to left upper buttock, stage 3 to coccyx. -03/29/2023 readmitted from hospital and the stage 2 pu were upstaged to a Stage 3 -04/07/2023-Stage 3 pu to left mid buttock merge stage 3 lower upper buttock Interventions/Task: Resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. In an interview and observation on 05/01/2023 at 4:30 PM, Resident #1 stated she was left in her wheelchair last Friday (4/28/2023) until after 2:00 AM in her room with the door shut. Her call light was at the top of the bed in the middle of the pillow, and she could not reach it. The wheelchair pedals stuck out to far and she cannot lean over because of the cancer in her spine. She could not get over to the door for her roommate had a fall mat on the floor and she could not roll the wheelchair over it. Resident #1 continued stating last time she had seen a staff member, or anybody was at 9:30 PM that evening. She stated no one came to her room until after she called her family member at about 2:00 AM (04/29/2023) and then they came in and asked her are you still up in your chair. Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 2 of 5 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 05/02/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated she was in severe pain in her back, her butt, and her bladder (observed resident wiping tears from her eyes). She stated she was really scared that no one came in the room even when she was screaming for help. She stated due to some recent health issues with her heart and lungs, she was afraid for something like that to happen again and no one was there to help her. Resident #1 stated the catheter was causing a lot of pain and she asked the nurse to take it out and in which that relieved some of the pressure and pain. In an interview on 05/01/2023 at 5:05 PM, the wound care RN stated the pressure ulcers were not any worse after the resident was left in her wheelchair for 5 plus hours, however, she was not happy about the situation. In an interview on 05/01/2023 at 5:10 PM, the DON stated she found out about the incident with Resident #1 in her wheelchair for five plus hours this morning (05/01/2023) at 8:30 AM. The DON stated confirmed the nurse on the night shift (04/28-29/2023) was an agency nurse. She stated she had been calling the that particular agency nurse to question the agency nurse related to the incident with Resident #1 of no one checking on the residents, however, the agency nurse was not answering the phone or returning the phone messages. The DON stated Resident #1 did admit with three stage 2 pressure ulcers and one stage 3. The DON stated the night shift tonight was the shift that worked 04/28-29/2023 and she planned on speaking with them all. In an interview on 05/01/2023 at 6:58 PM, CNA #2 stated she (CNA #2) did work 04/28-29/2023. She stated CNA #1 came in late for her shift at 6:00 PM, she came in about 8:00 PM and then she left about 9:30 PM. CNA #2 stated CNA #1 asked her to watch for call light on her hall (Hall 3). She stated she did not put Resident #1 back to bed but did go in the room when the nurse asked for them to help her. She stated Resident #1 was in a lot of pain in her bladder, legs, and butt. She was crying when they got in the room. In an interview on 05/01/2023 at 7:15 PM, CNA #3 stated CNA #1 got the facility about 8:00 PM for her shift and then CNA #3 took a break about 9:00 and got back to facility about 11:30 PM. She stated CNA#2 asked her to help with Hall 3. She stated she did help put Resident #1 back to bed. She stated Resident #1 was in a lot of pain and crying. In an interview on 05/01/2023 at 7:43 PM, CNA #4 stated she normally works the day shift, but CNA #1 was coming in late, and she stayed to help until CNA #1 came into work. She stated when CNA #1 came in she said there were three residents had not been laid down, Resident #1 was one of them. She stated Resident #1 was waiting for friend to come by. CNA #4 stated per the wound care RN orders, Resident #1 needs to be turned every two hours and not in her wheelchair longer than two hours. During in observation on 05/02/2023 at 10:00 AM, Resident #1 was lying in bed on her right side. In an interview on 05/02/2023 at 12:20 PM, DON stated she has not been able to reach the agency nurse from the night shift 04/28-29/2023. She stated I am very upset with situation. I expect more from my staff. A resident should be seen every hour; CNA rounds every two hours and the nurse rounds on the opposite two hours. She stated that particular agency nurse will not be coming back to the facility. In an interview on 05/02/2023 at 2:03 PM, Resident #1 stated she did not know the facility's number and all she could think of was to call her family member for help. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 3 of 5 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 05/02/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 05/02/2023 at 3:16 PM, Resident #1's family member stated she received three calls from Resident #1. First call came in at 2:02 AM with a voicemail, Resident #1 was crying saying she had been up for about 5 hours; second call came 2:08 AM; and third call and voicemail came at 2:24 AM. She stated when she heard Resident #1's voice crying and telling her what was going on, she immediately called the nurses' station and talked to the nurse. The next morning, she spoke with Resident #1 and Resident #1 told her she really had been up in her wheelchair since before dinner last night, approximately 10 hours. In an interview on 05/02/2023 at 3:38 PM, CNA #1 stated she drives from another town, and she let the facility know she was going to be late for her shift. She stated CNA #4 had covered for her until she got to the facility. CNA #4 reported to her a couple of the residents wanted to stay up, Resident #1 and her roommate. CNA #1 stated about 9:30 PM, she went to Resident #1's room and changed her roommate and put her to bed and Resident #1 was waiting for a friend and wanted to stay up a little bit longer. CNA #1 stated she took her break at 10:00 PM and told CNA #2 to catch her call lights until she got back. She stated when she returned from break it was about 1:00 AM by the time she got to Resident #1's room and was shocked Resident #1 was still sitting in her wheelchair. CNA #1 stated she apologized to resident for not getting her to bed and Resident #1 stated she wanted to call her family member and wheeled herself to the nurse's station. In an interview on 05/02/2023 at 5:15 PM, the administrator stated, the situation was unacceptable, and the CNA #1 will be terminated. She stated there has been training with all staff of monitoring residents during the day and night. In an interview on 05/02/2023 at 5:25 PM, the DON stated she has already revamped her orientation/training for all agency staff. She stated she had also started competency check with all staff. Record reviewed facility policy title Repositioning Level II (revised date May 2013) states the following: Purpose The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed - or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Interventions 3. Residents who are in bed should be on at least an every two (q2 hour) repositioning schedule. 5. Residents who are in a chair should be on every one-hour (q1 hour) repositioning schedule. Reporting 1. Notify the supervisor if the resident refuses the procedure. 2. If the resident refuses care, an evaluation of the basis for refusal, and the identification and evaluation of potential alternatives is indicated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 4 of 5 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 05/02/2023 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 0684 3. Report other information in accordance with facility policy and professional standards of practice. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455509 If continuation sheet Page 5 of 5