Sterling Hills Rehabilitation And Healthcare Cente
STERLING HILLS REHABILITATION AND HEALTHCARE CENTE in SWEETWATER, TX — inspection on March 26, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview with the ADM on 03/26/2026 at 09:49 a.m. she stated the purpose of
had training on MDS completion and time frames.
She stated the discharge assessment should be
transmitted until today.
She stated the potential negative outcome could affect the billing process.
Record review of facility policy dated 06/02/2025, titled MDS Coding Policy revealed: affiliated facilities utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident assessment, timely and accurately.The most current RAI manual may be found on the CMS.gov website.
Review of the RAI manual dated October 2025 revealed: . 09.
Discharge assessment - Return not anticipated (A0310F=10) .Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days) .
455509 03/26/2026
Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556
causes, adjust care plans, and implement new interventions as needed. 5.
Pain should be assessed
455509 03/26/2026
Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556
delivery.
The nurse receiving the medication, along with the person delivering the medication, must
resident who will be receiving a controlled substance. Do not enter more than one (1) prescription per
received;d. number on hand;e. name of the prescriber;f. prescription number;g. name of issuing pharmacy;h. date and time receivedi. time of administration;j. method of administration;k. signature of person receiving medication; andl. signature of nurse administering medication.
Dispensing and Reconciling Controlled Substances1.
Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/ follow-up.2.
The system of reconciling the receipt, dispensing and disposition of controlled substancesincludes the following:a.
Records of personnel access and usage;b.
Medication administration records;c.
Declining inventory records; andd.
Destruction, waste and return to pharmacy records.12.
Some controlled substances may be stored in the emergency medication supply.
Reconciliation of controlled substances in the emergency supply is conducted at intervals established by the director of nursing services.
455509 03/26/2026
Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556
Assurance and Performance Improvement) committee to inform process changes and/or the need for
on the MAR.
Documentation RequirementsAfter administration, the nurse documents:- Date and time
when required- Signature and credentials.
Record review of facility policy titled, Pain Management Program Policy , reviewed 3/03/2026, revealed in part: Monitoring Pain Assessment/Interventions/Orders and Care Planning1.
Pain evaluation will be completed for each resident upon admission, readmission, quarterly, and with significant changes in condition. 2. If pain is identified, the following steps are initiated:- Create a pain care plan using standardized pain assessment tools.- Obtain orders for pharmaceutical and/or non-pharmaceutical interventions. 3.
Nurses will assess residents' pain every shift using the appropriate pain evaluation tool and document the effectiveness of interventions.
455509 03/26/2026
Sterling Hills Rehabilitation and Healthcare Cente 705 NE Georgia Avenue Sweetwater, TX 79556
During an interview on 3/26/26 at 11:45AM with the ADM, she stated the DON was the infection preventionist.
She stated infection control training was conducted quarterly.
She stated in-services were also conducted regularly and as needed.
She stated she expected nursing staff to follow policies and procedures when performing incontinence care, including utilizing hand hygiene between glove changes.
She stated the potential negative outcome of not utilizing hand hygiene between glove changes could be spreading infections between residents or themselves.
She stated she was not aware staff was not utilizing hand hygiene between glove changes.
Record review of facility policy titled Handwashing-Hand Hygiene Policy and Procedures last revise 10/2020 revealed: 7.
This facility considers hand hygiene the primary means to prevent the spread of infections.use an alcohol base hand rub contain at least 62% alcohol or alternatively soap.and water for the following situations.b. before and after direct contact with residents;.m. after removing gloves.9.
The use of gloves does not replace hand washing/hand hygiene.