Health inspection·September 13, 2022

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admitted because she had had a stroke and she had weakness on her left side. She stated the resident had a cognitive delay but had not been formally assessed and given a BIMS score. She stated the resident also had speech and swallowing concerns that may affect her diet due to her stroke. She stated there was not a system in place to address late admissions on Friday's and this was the reason she believed the baseline care plan was not done. She stated if a person did not have a baseline care plan completed the staff would not know what a person needed to provide to perform their activities of daily living or what their cognitive status would be. The DON stated the resident could need assistance and may not receive it because the baseline care plan was not completed. She stated the resident could also fall. She stated she was not familiar with the resident's fall but that she had fallen the day after admission and again on 09/12/22. She could not say if this could have been prevented through the implementation of the baseline care plan. In an interview on 09/12/2022 at 10:22 AM the DON said the reason why the baseline care plan for the resident was not complete was because the admission was done late Friday (09/09/22) afternoon. She stated that she needed to train her staff on what to do when they have late admissions. She stated there was not a system in place at this time to address baseline care plans for late admissions on Friday, late afternoon. She stated she felt that there was no adverse risk to the resident if the baseline care plan was not completed within 48 hours because she felt there were other systems in place that would keep the resident safe. She did not name those systems at the time of the interview. She stated the MDS Coordinator was responsible for completing the baseline care plan. She stated the baseline care plan should be done within 48 hours of admission. She stated the resident had had a fall since admission. She stated as a result of the fall she would have the bed lowered and put a fall mat in place. She was not aware that a fall mat had been put in place already. In an interview on 09/12/2022 at 10:35 AM the Administrator stated the baseline care plan should be done within the appropriate time frame listed in the facility policy. He stated the MDS Coordinator was responsible for completing the baseline care plan. He stated all staff used the baseline care plan to provide care to the resident. He said if a baseline care plan was not completed the resident was at risk because the resident could not receive the care that was needed. He stated that there were no systems put in place to address late admissions on Friday evenings. In an interview on 09/12/2022 at 11:05 AM the MDS Coordinator stated she was responsible for completing the baseline care plans. She said they should be completed within 48 hours. She said the reason why Resident #154 baseline care plan was not done was because she was a late admission on Friday (09/09/22) and she (MDS Coordinator) was not in the facility. She stated she had been trained how to do baseline care plans and was aware of the deadline expectation according to the facility policy. She stated if the baseline care plan was not completed that it could affect the care that the residents receive. She stated the resident being a fall risk or having a do not resuscitate order would have been included in the baseline care plan so the staff providing care would know. She stated if there was no baseline care plan then the staff would not have access to this information. She stated anyone could pull the baseline care plans up and use them to provide care to the resident. She stated there was no system in place at this time that addressed late admissions on Friday's. Record review of the facility policy Care Plans- Baseline, Comprehensive Person-Centered, (Revised December 2016), revealed the following documentation: Policy Statement: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455946 If continuation sheet Page 2 of 12 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 455946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sweetwater Healthcare Center 1600 Josephine St 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 0655 Policy Interpretation and Implementation Level of Harm - Minimal harm or potential for actual harm (1) Residents Affected - Few To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident admission. (2) The interdisciplinary team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician orders; c. Dietary orders; d. Therapy services e. Social Services; and f. PASARR recommendation; if applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455946 If continuation sheet Page 3 of 12 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 455946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sweetwater Healthcare Center 1600 Josephine St 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 4 of 18 residents (Residents #8, #11, #21, #26) reviewed for care plans as follows: Resident #8 did not have a care plan for vision, activities of daily living, dental, pressure ulcer and psychotropic drug use. Residents #21, #11, #26 did not have a care plan for smoking. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings include: Resident #8 Record review of Resident #8's undated admission record revealed an [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include heart failure, dry eye syndrome, difficulty walking, anxiety, edema (swelling), and hypertension (high blood pressure). Record review of Resident #8's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was cognitively intact. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 05. ADL Functions/Rehabilitation Potential 15. Dental Care 16. Pressure Ulcer 17. Psychotropic Drug Use Section B 1000. Vision Enter Code: 1 - Impaired - sees large print, but not regular print in newspapers/books. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455946 If continuation sheet Page 4 of 12 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 455946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sweetwater Healthcare Center 1600 Josephine St 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 0656 Level of Harm - Minimal harm or potential for actual harm Section G0100. Activities of Daily Living (ADL) Assistance revealed bed mobility, transfer, walk in room, locomotion on unit, locomotion off unit, dressing, eating, toilet use was all coded 1 = supervision oversight, encouragement or cueing and 2 = one-person physical assist. Personal hygiene was coded 3 = extensive assistance - resident involved in activity, staff provide weight bearing support and 2 = one-person physical assist. Residents Affected - Some Section G0120. Bathing revealed physical help in part of bathing activity and coded 2 = one-person physical assist. Section G0300. Balance During Transitions and Walking revealed moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair) was all coded 1 = not steady, but able to stabilize without human assistance. Section L Oral/Dental Status

L0200. Dental B. No natural teeth or tooth fragment. Section M Skin Conditions M0150. Risk of pressure ulcers/injuries Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes Section N Medications

N0410. Medication Received Indicate the number of DAYS the resident received the following medications during the last 7 days or since admission/entry or reentry if less than 7 days. C. Antidepressant - 7 days Record review of Resident #8's care plan, dated 08/17/22, revealed no care plan for vision impairment, activities of daily living, dental status, pressure ulcer risk and psychotropic drug use. Resident #11 Record Review of Resident #11's face sheet dated 09/13/22 revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Pruritus (severe itching), hypoxemia (decrease partial pressure of oxygen in the blood), chronic viral hepatitis C (swelling in the liver), Anemia (low amount of red blood cells), Hypertension (high blood pressure), and pulmonary disease (inflamed airways). Record Review of Resident #11's comprehensive MDS dated [DATE] revealed the following: Section C - Cognitive Patterns - C0500. BIMS Summary Score= 10 which was rated as moderately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455946 If continuation sheet Page 5 of 12 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 455946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sweetwater Healthcare Center 1600 Josephine St 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 0656 cognitively impaired (alert and oriented x time, place, and person). Level of Harm - Minimal harm or potential for actual harm Section J - Other Health Conditions - J1300. Current Tobacco Use = 1. Yes. Residents Affected - Some Record Review of Resident #11's observations indicated a smoking assessment was completed on Resident #11 on 05/17/22. Record review of the facility's undated list of active smokers, provided on 9/11/22 revealed Resident #11's name Record Review of Resident #11's Care Plan dated 07/24/22 revealed the care plan did not address smoking. Surveyor witnessed Resident #11 smoking. Resident #21 Record review of Resident #21's face sheet dated 09/1/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: mental disorder, difficulty in walking, Post-traumatic stress disorder (stress as a result of a traumatic event), constipation, arthritis (joint pain), dry eye syndrome, hypertension (high blood pressure), Complete loss of teeth, Obesity (overweight), and Hyperlipidemia (high cholesterol). Record Review of Resident #21's comprehensive MDS dated [DATE] revealed the following: Section C - Cognitive Patterns - C0500. BIMS Summary Score = 14 cognitively intact (alert and oriented x time, place, and person). Section J - Other Health Conditions - J1300. Current Tobacco Use = 1. Yes. Record Review of Resident #21's observations indicated a smoking assessment was completed on Resident #21 on 09/7/22. Record review of the facility's undated list of active smokers, provided on 9/11/22, revealed Resident #21's name. Record review of Resident#21's care plan dated 4/21/22 revealed the care plan did not address smoking. Surveyor witnessed Resident #21 smoking. Resident #26 Record Review of Resident #26's face sheet dated 09/13/22 revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Mental disorder, Repeated falls, acute respiratory disease (difficulty breathing), Urinary tract infection (inflammation of the bladder/kidneys), pain in unspecified ankle and joints of unspecified foot, Hypertension (high blood pressure), heart failure, complete loss of teeth, decreased white blood cell count, Type 2 diabetes (unable to regulate the amount of sugar in the blood), and Obesity (overweight). Record Review of Resident #'s comprehensive MDS dated [DATE] revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455946 If continuation sheet Page 6 of 12 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 455946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sweetwater Healthcare Center 1600 Josephine St 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Section C - Cognitive Patterns - C0500. BIMS Summary Score = 07 severely impaired cognitively (not alert and oriented x time, place, and person). Section J - Other Health Conditions - J1300. Current Tobacco Use = 1. Yes answer. Record Review of Resident #26's observations indicated a smoking assessment was completed on Resident #26 on 09/07/22. Record review of the facility's undated list of active smokers, provided on 9/11/22, revealed Resident #26's name. Record Review of Resident #26's Care Plan dated 09/9/22 revealed care plan did not address smoking. This Surveyor witnessed Resident #26 smoking. During an interview on 9/13/22 at 09:24 AM the DON, she stated, vision, activities of daily living, dental, pressure ulcer risk and psychotropic drug use was not care planned for Resident #8. She stated she did not know why the care areas were not care planned. She stated the CCM was responsible for completing the comprehensive care plans and any quarterly changes. She stated care plans are developed using the triggered care areas, admission paperwork and family wishes. She stated not all triggered care areas need to be care planned, only the ones the resident is having issues with. She stated care plans are used for staff to know what care needs to be provided to the resident. She stated, A triggered care area that is not care planned would not change the residents care and there would not be any negative outcome if the care plan was not done. She stated the facility has no system in place to audit or follow-up on care plans. During an interview on 9/13/22 at 09:41 AM with CCM, she stated she is responsible for care plans and has been trained on how to develop care plans. She stated she is the one that does comprehensive care plans and updates when she completes the MDS. She stated, I have been behind and this one (Resident #8 care plan) just slipped through the cracks. She stated care plans are used to identify problems and goals for each resident. She stated all staff who care for residents use the care plan. She stated the potential negative outcome for the residents could be gaps in residents' care. She stated It was my error when asked why the triggered care areas were not care planned. She stated there is no system in place to follow-up or audit care plans. During an interview on 9/13/22 at 10:00 AM with LVN A, she stated the care plan is available to view in the resident EMR. She stated it is used to let staff know what care to provide the residents. During an interview on 9/13/22 at 10:00 AM with CCM, she stated she is responsible for care plans and has been trained on how to develop care plans. The CCM states all staff should be utilizing the care plans to guide patient care. The CCM states all the information she accumulates for the care plan is found in the resident's electronic medical record. The CCM states if care plans are not thoroughly completed, if triggered areas are missed then there could be gaps in care for the residents; furthermore, she stated these gaps in the care could be dangerous for the residents. The CCM states no one monitors care plans for accuracy, there is no auditing of care plans. The CCM states there is a schedule for residents to smoke, they smoke on the patio at the end of Hall C, there are always staff monitoring the smoking, and smoking aprons are used as needed. The CCM states nurses keep all the residents' smoking materials in a lock box at the nurse's station. The CCM states the charge nurses are responsible for completing smoking assessments. When asked what the potential outcome could be if residents are not care planned for smoking, she stated, Residents may not be safe smokers and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455946 If continuation sheet Page 7 of 12 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 455946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sweetwater Healthcare Center 1600 Josephine St 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some there could be fire hazards and injuries to the residents. The CCM states it is necessary to care plan for smoking so that residents are properly protected and supervised when smoking. During an interview on 9/13/22 at 10:15 AM with TNA A, she stated she does have access to the resident's care plans. She stated the care plan is used to know what care is needed for the residents. She stated the potential negative outcome if care areas are not care planned could be missed care. During an interview on 9/13/22 at 10:37 AM with the DON, she stated Residents #21, #11, and #26 smoke. The DON stated the CCM is responsible for forming care plans. The DON stated she is responsible for acute care plans. The DON states there is no one assigned to follow up on the accuracy of care plans; in addition, the DON stated no one audits care plans. The DON reviewed Matrix with this Surveyor present; the DON stated during her review of Matrix residents #21, #11, and #26 were not care planned for smoking. The DON states there is no reason the residents were not care planned. She stated, There is obviously a problem. The DON stated residents #21, #11, and #26 all had smoking assessments. The DON states the smoking assessments are completed by the nurses and are more important than care plans. The DON stated the comprehensive MDS for all three residents indicated they all three use tobacco. When asked by what would be the negative outcome for smoking not being care planned the DON stated, There would not be one negative outcome for smoking not being care planned. The DON stated, Some staff may use care plans, but they are not necessary because there are other systems in place. When asked who utilizes the care plan at the facility the DON stated, Any and all staff can utilize care plans. The DON states there are scheduled times for residents to smoke and smoking occurs outside the door at the end of Hall C. The DON states residents' cigarettes and lighters are kept in a lock box which is kept locked in the medication storage. Lastly, the DON states smoking aprons are used as needed and the facility has plenty of smoking aprons. During an interview on 9/13/22 at 11:20 AM with the Administrator, she stated the CCM is responsible for completion of the care plans. The Administrator stated there are no audits or double checking of care plans for accuracy. The Administrator stated all staff utilize care plans to care for residents; furthermore, he states the information collected for care plans come from Matrix. The Administrator states if triggered areas of care are not completed in care plans, then the staff would not know how to properly care for a resident. The Administrator stated smoking should be care planned for residents to ensure safe smoking for these residents. The Administrator stated there is no reason smoking should not be care planned for Residents #21, #11, and #26. The Administrator states there is an obvious issue with properly completing care plans and this will be addressed. The Administrator states there is a set schedule for smoking; smoking occurs outside a the end of Hall C, all residents are monitored by staff while smoking, and residents' cigarettes and lighters are kept by the nurses in a locked box at the nurses' station. The Administrator stated smoking aprons are used as needed and he feels the facility has plenty of aprons. The Administrator stated the potential outcome for residents not being care planned for smoking is the resident may not know the rules for smoking at the facility, they may cause fire hazards, or injure themselves while smoking. The Administrator stated if smoking is an issue for the resident, it should be carefully care planned and a smoking assessment should be completed. The Administrator states the nurses are responsible for smoking assessments. Record review of the facility policy Care Plans, Comprehensive Person-Centered, Revised December 2020, revealed the following documentation: Applicability: this policy sets forth the procedures relating to developing a comprehensive, person-centered care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455946 If continuation sheet Page 8 of 12 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 455946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sweetwater Healthcare Center 1600 Josephine St 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 0656 Policy Statement Level of Harm - Minimal harm or potential for actual harm A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the Resident's physical, psychosocial and functional needs is developed and implemented for each resident. Residents Affected - Some Policy Interpretation and Implementation: #8. The comprehensive, person-centered care plan will: Include measurable objectives and time frames. 1. Describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. 2. Incorporate services that would be provided for the above, however, they are not provided due to the resident exercising his or her rights. 3. Include the resident's goals upon admission and desired outcomes. #10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the Resident, are the endpoint of an interdisciplinary process. Record review of the facility policy for Smoking Residents revised August 2019, revealed the following documentation: Applicability: this policy sets forth the procedures relating to developing a policy for safe smoking practices. Policy Statement This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation #18. Resident care plans will reflect that the resident is a smoker and if a protective smoking apron is indicated for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455946 If continuation sheet Page 9 of 12 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 455946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sweetwater Healthcare Center 1600 Josephine St 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 reviews the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to sanitize and clean 1 of1 ice machine located outside the kitchen. Theis failure could place the residents who were served from the kitchen at risk for health complications and foodborne illnesses. Findings included: Observation on 09/11/2022 at 12:15 AM, of the outside of the freezer located outside of the kitchen revealed thee filter on the front of the ice machine had lint in the vent and visible pieces of lint were on the front of the vent. The right side of the ice machine was dirty and there was an unknown dirty substance along the seams of the machine. Observation on 09/12/2022 at 2:00 PM, of the outside of the freezer located outside of the kitchen revealed the filter on the front of the ice machine had lint in the vent and visible pieces of lint were on the front of the vent. The right side of the ice machine was dirty and there was unknown dirty substance along the seams of the machine. After the Kitchen Aide unlocked the ice machine observations on the inside of the machine revealed the lip of the door inside the machine right above the ice had a black wet substance. Observation on 09/13/2022 at 10:45 AM, of the outside of the freezer located outside of the kitchen revealed the filter on the front of the ice machine had lint in the vent and visible pieces of lint were on the front of the vent. The right side of the ice machine appeared to have been wiped but smeared with streaks. After the Dietary Manager unlocked the ice machine observations on the inside of the machine revealed the lip of the door inside the machine right above the ice had a black wet substance. A white napkin was used to wipe the lip of the door and the black wet unknown substance came off on the white napkin. In an interview on 09/12/2022 at 10:35 AM the Administrator stated the kitchen staff was responsible for cleaning the ice machine. He stated the reason why the ice machine was not cleaned was because the inconsistency with who was responsible for doing it. He restated that at one point maintenance and the housekeeping staff were cleaning the ice machine because of staffing issues. He said the kitchen staff were short at the time. He stated he expected for the ice machine to be cleaned at least one time a week. He stated if the ice machine was not clean that it would put the residents at risk of receiving contaminated ice and could make them sick especially if there's bacteria in the ice. In an interview on 09/12/2022 at 10:46 AM the Dietary Manager said that dietary was responsible for cleaning the ice machine. She stated she had found out about kitchen being responsible a couple of days ago but she was not aware of the dietary staff being responsible prior to being told a couple of days ago. She stated in the past she had just wiped it down but in the future she would clean the inside. She stated she had not been cleaning the inside because she did not know that dietary staff was responsible. She stated if the inside was not clean then the residents were at risk because mold could build up inside and people could get sick. She stated she had not been trained on how to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455946 If continuation sheet Page 10 of 12 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 455946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sweetwater Healthcare Center 1600 Josephine St 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 clean the ice machine or how to remove anything inside to be clean. She stated the ice machine should be cleaned weekly. She stated she was not aware there was paperwork ( cleaning checklist) until she saws the sign in sheet on the side of the ice machine. She stated even when the dietary staff would clean it it would just be the outside of the ice machine. She stated she was not aware that the door could come out and be cleaned in the dishwasher. Residents Affected - Many In an interview on 09/12/2022 at 10: 53 AM the Kitchen Aide stated she has been working at the facility since 05/28/22. She said she was not sure who was responsible for cleaning the ice machine. She stated she had cleaned the ice machine the day before (09/11/2022) by wiping the outside of the ice machine but did not clean the inside. She stated she had never cleaned the inside. She stated she was not sure who was responsible, and she had not been told who was responsible for keeping the ice machine clean. She stated if the ice machine was not clean according to policy then everyone to get sick and this could include staff and residents who consume ice. In an interview on 09/12/2022 at 10:55 AM [NAME] A said she has been working on an off at the facility for three years. She stated housekeeping was responsible for cleaning the ice machine that she knew of. She stated she has never cleaned the inside of the ice machine. She stated as the cook she does not clean the ice machine but the kitchen aid does. She stated no one has ever trained her on cleaning the ice machine. She stated the ice machine not being clean could put the residence at risk for being sick. She stated mold could grow in the ice machine and get into the ice. In an interview on 09/12/2022 at 11:00 AM the Housekeeping Supervisor stated the kitchen was responsible for cleaning the ice machine. She said last year she was told that housekeeping was responsible, and this is because the kitchen was short staffed, but this is no longer an issue. She said she was never told by anyone that she was no longer responsible but that she had told the DM that she was now responsible for keeping the ice machine clean. She said she told the DM a couple of weeks ago at 7 AM in the morning but the DM did not remember. She said whenever she would clean the ice machine she would empty and then clean out the bin. She stated the door of the ice machine would be removed and ran through the dishwasher. She stated then they would also wipe the inside and outside of the ice machine. She stated failure to clean the ice machine could make residents sick. Record review of the Texas Food Establishment Rules , dated August 2021, revealed the following: Pg. 17 (d) Equipment and Utensils (2) Location and installation. Equipment shall be located and installed and cleaned in a way that prevents food contamination and that also facilitates cleaning. (4) Protection from contamination. Food-contact surfaces of equipment shall be protected from contamination by consumers and other sources. Where necessary to prevent contamination . (f) Ice Usage ( 2) Ice used for human consumption must be stored in a clean sanitized container that . Record review of the facility policy, Kitchen Sanitation to Prevent the Spread of Viral Illness, dated 03/03/2020 revealed the following information: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455946 If continuation sheet Page 11 of 12 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 455946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sweetwater Healthcare Center 1600 Josephine St 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 Policy: The Nutrition & Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of cross contamination and potential illness such as influenza and COVID-19. (f) Kitchen Sanitation Residents Affected - Many Weekly Cleaning lists should be completed and monitored by dietary manager. Record review of the Daily Ice Machine Cleaning Log dated September 2022 revealed employee signatures (DM, Kitchen Aid & the Cook) of all dietary staff signed from 09/01/2022 to 09/13/2022. Record Review of Cleaning Checklist (untitled and undated) revealed the ice machine should be cleaned daily. The person responsible was not completed. Record Review of the facility policy, Cleaning Guidelines for the Ice Machine, undated revealed the following: 1. Unplug ice machine and remove the ice. 2. Wash the interior thoroughly using a detergent solution. Rinsed and drain the interior with clean hot tap water 3. Sanitize 4. Air dry 5. Turn the machine on. 6. Clean the exterior of the machine with a detergent solution. Rinse and allow to air dry. Clean the area underneath and around the machine. The exterior of machine should be cleaned daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455946 If continuation sheet Page 12 of 12