Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mount Sterling Health And Rehab Center during CMS and state inspections, most recent first.
A resident with a history of repeated falls, impulsive behavior, and need for contact-guard assist with a front-wheeled walker was transported by the facility’s Transportation Director to the resident’s apartment without prior safety assessment of the home environment or accompaniment by licensed/certified staff. The apartment was reported to be unsanitary and cluttered. While the Transportation Director was moving boxes at the resident’s request, the resident rose from a recliner, walked a few steps without using the walker, and fell, sustaining a laceration above the brow that required EMS transport to the ED. This occurred despite care plan interventions to maintain a clutter-free environment, reinforce assistive device use, and provide supervision for ambulation, and despite the facility’s policy that residents transported by facility vehicle must have safe and secure transport.
A cognitively impaired resident with dementia, traumatic brain injury, and a history of trauma and behavioral issues frequently sat on the floor and sometimes required staff assistance for transfers. On one occasion, an RN, already stressed from the day, directed two CNAs to help place a mechanical lift sling under the resident to move him from the floor, despite the resident yelling "no" and becoming combative. Witnesses reported that after the resident pushed and pinched the RN, she responded by kicking him three times above the left hip/buttock with the side of her shoe, causing him to cry, complain of being kicked, and demand that she leave his room. The CNAs refused to continue the transfer, identified the behavior as abuse, and the RN later admitted bringing her knee up and striking the resident, leading surveyors to cite the facility for failing to de-escalate behaviors and protect the resident from staff-to-resident physical abuse, with the situation determined to constitute Immediate Jeopardy.
A resident was readmitted with multiple pressure ulcers to the toes, coccyx, and buttocks, with hospital discharge orders for specific wound treatments, offloading boots, and scheduled repositioning. Facility policies required that such physician orders be obtained, processed, and recorded on the treatment administration record (TAR) with clear treatment details. However, the ordered pressure ulcer treatments were not transcribed onto the TAR and were not provided for approximately eight days after readmission. Later observation showed the wound nurse performing wound care to existing ulcers, and the DON acknowledged that the pressure ulcer treatments had not been entered on the TAR and that the resident did not receive the ordered treatments during that period.
The facility did not provide structured activities during evenings or weekends for its residents, as confirmed by activity calendars and staff interviews. Multiple residents reported that there was nothing to do during these times and expressed a desire for more activities, especially on weekends. The absence of activities was acknowledged by both the administrator and the activity director, who cited staffing limitations as a reason.
Multiple residents experienced significant delays in call light response, with reports of waiting up to an hour or more for assistance. Residents described staff turning off call lights and not returning, and ongoing complaints were documented in grievance logs and resident council minutes. The issue persisted despite being reported to facility leadership.
The facility failed to ensure a clean and safe environment for residents, with observations revealing dried feces on floors, cluttered closet spaces, and unclean bathrooms. Housekeeping services were inadequate, as confirmed by a CNA and the administrator, with residents expressing concerns about having to take out their own trash. The facility's housekeeping vendor's procedures were not followed, leading to unsanitary conditions.
Failure to Assess Home Environment and Supervise High-Fall-Risk Resident During Transport Visit
Penalty
Summary
Failure to assess safety risks and provide adequate supervision occurred when the facility transported a resident with a history of repeated falls and impulsive behavior to her apartment without ensuring a safe environment or appropriate staff support. The resident had diagnoses including repeated falls, CKD, bipolar disorder, anxiety, major depression, and intrahepatic bile duct cancer, and was documented as alert and oriented but impulsive. Her care plan interventions included keeping the environment free from clutter, reinforcing use of assistive devices, observing for unsteady gait and balance, and instructing her to avoid sudden position changes. Physical therapy records showed she required a front-wheeled walker and contact guard assist for ambulation, and occupational therapy did not recommend ambulation without assistance. Despite this, the Transportation Director, who was not currently certified, transported the resident to her apartment with the expectation from the Administrator that the resident would remain in her wheelchair during the visit. During the home visit, the resident chose to use her walker in the apartment and left her wheelchair in the hallway. The Transportation Director reported the apartment was unsanitary, with dried feces, gloves, and empty packages on the floor from a previous EMS call, and the Administrator confirmed the apartment had not been assessed for safety prior to the visit. While the resident was sitting in a recliner sorting papers, the Transportation Director began moving boxes away from the bedroom doorway at the resident’s request. The resident then stood up, took a few steps without using her walker, and fell, sustaining a laceration above her right brow that required EMS transport to the emergency room. The facility’s own Transportation Policy stated it was responsible for ensuring any resident transported by facility vehicle would have a safe and secure transport, and the Administrator verified that a certified/licensed staff member had not been sent along with the transportation driver for this visit.
RN Kicks Cognitively Impaired Resident During Attempted Floor Transfer
Penalty
Summary
The deficiency involves the facility’s failure to de-escalate a cognitively impaired resident’s behaviors and to protect the resident from staff-to-resident physical abuse. The facility had an Abuse Policy and Employee Handbook that prohibited abuse and workplace violence, including physical abuse such as kicking, and required staff to report any allegation or witnessed abuse immediately. Despite these policies, a registered nurse (V4) engaged in physical abuse toward a resident (R1) with known behavioral issues, resulting in psychosocial and physical harm. R1 was a severely cognitively impaired resident with diagnoses including profound intellectual disabilities, depression, traumatic brain injury, and vascular dementia with agitation. R1’s care plan documented a history of trauma, childlike behaviors, and a pattern of placing himself on the floor and stating he had fallen in attempts to get his mother to visit. The care plan also indicated that R1 was generally independent with transfers but at times required one-person physical assistance, and that staff were to provide reassurance to help R1 feel safe and secure. On the date of the incident, R1 was on a floor mat, a behavior described as not abnormal for him, and was noted to be agitated and combative when staff attempted to move him using a mechanical lift sling. According to progress notes, written statements, and staff interviews, V4 obtained a mechanical lift sling and directed CNAs (V21 and V23) to assist in placing the sling under R1 to transfer him from the floor, despite R1 yelling “no” and becoming combative. Witness statements from V21 and V23 describe R1 pushing and pinching V4 while staff attempted to position the sling, and both CNAs reported that V4 responded by kicking R1 three times above the left hip/left buttock with the side of her shoe. R1 cried, had visible tears, yelled that he had been kicked, and demanded that V4 leave his room. V21 refused to continue assisting with the sling, told V4 that no title gave her the right to kick a resident, and identified the behavior as abuse. V23 similarly characterized the kicking as physical abuse and noted that V4’s stern communication appeared to further agitate R1. In a subsequent interview, V4 acknowledged bringing her knee up and hitting R1 in the left hip after being pinched, and the administrator later confirmed that kicking a resident three times under these circumstances constituted physical abuse. The incident resulted in R1 experiencing fear, mental anguish, and pain, and was determined by surveyors to constitute an Immediate Jeopardy situation beginning on the date of the kicking incident. The facility’s own investigation and administrative summary documented that a CNA witnessed the RN make contact with R1’s left upper leg with her foot after R1 either pinched or hit her while staff were attempting to de-escalate his behaviors and assist with a transfer. R1’s power of attorney was informed of the event and described being stressed about the situation, stating that staff, including V4, should know how to deal with difficult residents and characterizing the kicking as physical abuse that would have hurt R1’s feelings and led him to cry or lash out. The combination of R1’s known behavioral and trauma history, his resistance to the sling transfer, and V4’s physical response to his behaviors formed the basis of the cited deficiency for failure to prevent abuse and to appropriately de-escalate a resident’s behaviors. The Immediate Jeopardy was later determined to have been removed, but the facility remained out of compliance at a lower severity level pending evaluation of the implementation and effectiveness of its removal plan and Quality Assurance monitoring.
Removal Plan
- V4 was suspended immediately and then terminated from employment.
- The Director of Nursing completed skin assessments on R1 post incident with no signs of injury related to the incident.
- The Social Service Director completed trauma risk assessments on R1 to ensure R1 had no concerns post incident.
- V1 and the Corporate Nurse Consultant completed all staff in-servicing regarding abuse and de-escalation training including contracted staff.
- All staff were in-serviced prior to their shift on stress management, caregiver strain, and burnout.
- The QAA team completed a full QAA identification and QAPI plan of correction for R1's incident.
- R1's Care Plan was updated with interventions to instruct staff on what to do if R1 chooses to sit on the floor.
Failure to Transcribe and Implement Physician-Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician-ordered pressure ulcer treatments were transcribed to the treatment administration records (TAR) and implemented for a resident readmitted with multiple pressure ulcers. The facility’s policies on Pressure Ulcer Prevention, Identification, and Treatment and on Physician Orders require that pressure ulcers be assessed, physician orders obtained and processed, and treatments recorded with specific details and carried out by nursing staff. Upon readmission from the hospital, the resident’s skin inspection documented pressure ulcers on the right and left toes, coccyx, and bilateral buttocks. Hospital discharge orders directed daily betadine application to bilateral toe ulcers, use of offloading pressure-relieving boots, alginate and foam dressings to all buttock ulcers with changes every three days, and repositioning every two hours using a wedge. Despite these orders, the resident’s TAR contained no documentation of the ordered pressure ulcer treatments to the bilateral buttocks, coccyx, or toes until eight days after readmission. During a subsequent observation, the wound nurse was seen providing wound care, including zinc application to buttocks ulcers, skin prep to toe ulcers with dark brown scabs, and sodium hypochlorite solution dressings to an unstageable coccyx wound with slough and drainage. In an interview, the DON acknowledged assisting with the readmission orders and stated it was partly her fault that the pressure ulcer treatments were missed, confirming that no pressure ulcer treatments were placed on the TAR and that the resident did not receive the ordered treatments until several days after readmission, and that this lapse should have been noticed earlier.
Failure to Provide Activities on Evenings and Weekends
Penalty
Summary
The facility failed to provide an ongoing program of activities that meets the interests, preferences, and well-being of each resident, as required by the Administration Code Section 300.1410. Specifically, there were no structured activities scheduled after 3:30 PM on weekdays or at any time during weekends for any of the 67 residents. Activity calendars for multiple months confirmed the absence of evening and weekend activities, and both the administrator and activity director acknowledged that no such activities were provided due to staffing limitations. The activity calendars for the North and South Units listed only unstructured or independent activities for weekends, with the administrator unable to confirm if these were actually occurring. Multiple residents, including the resident council president, expressed dissatisfaction with the lack of activities during evenings and weekends, stating there was nothing to do during these times. Residents indicated a desire for more activities, particularly on weekends, noting that the absence of activities made weekends feel long and contributed to feelings of boredom. Family members also noted that the lack of activities affected residents' well-being, with one resident becoming restless and expressing a desire to leave the facility when unoccupied.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner for nine out of eleven residents reviewed. According to the facility's own Call Light Guidance Policy, staff are required to respond to call lights within a reasonable amount of time, and all staff are responsible for responding. The Certified Nursing Assistant (CNA) job description also outlines the responsibility to provide care in accordance with established policies and procedures. Despite these policies, multiple residents reported significant delays in call light response, with some stating that it often took up to an hour or more for staff to respond. Residents also described situations where staff would turn off the call light and promise to return, but then failed to do so, leaving residents waiting for extended periods, especially when assistance from two staff members was required for transfers. Facility records, including the grievance log and resident council minutes, documented ongoing complaints about delayed call light responses and related issues such as unmade beds and lack of water refills. These concerns were consistently raised during resident council meetings, with residents expressing frustration that the problems persisted despite being reported to facility leadership. The administrator acknowledged awareness of the ongoing complaints but had not yet resolved the issues. The deficiency was identified through interviews, record reviews, and documentation of repeated resident concerns over several months.
Inadequate Housekeeping Services Lead to Unclean Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by observations, interviews, and record reviews. The housekeeping services were inadequate, resulting in unclean conditions in resident rooms and bathrooms. Specifically, the floors between the beds of two residents had dried feces, and their closet floors were cluttered with clothes and a dirty gauze. Additionally, the bathroom floors were littered with used paper towels and brown debris. Another pair of residents had a toilet riser with dried feces and a toilet with a brown ring and black-stained caulking around the floor. The facility's housekeeping vendor's deep cleaning procedures were not followed, as indicated by the presence of stains and debris. The Resident Council Minutes from previous months documented ongoing concerns about inadequate cleaning and residents having to take out their own trash. Interviews with a CNA and the facility administrator confirmed the poor state of cleanliness and the need for improvement in housekeeping services. The administrator acknowledged the use of an outside vendor for housekeeping and the expectation that trash should be removed daily.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 13 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mount Sterling
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rushville Nursing & Rehab Ctr | 14.2 mi | ★★★★★ | 1 | 0 |
| Golden Good Shepherd Home | 15.8 mi | ★★★★★ | 10 | 0 |
| Timber Point Healthcare Center | 15.9 mi | ★★★★★ | 2 | 0 |
| Beardstown Health & Rehab Ctr | 18.2 mi | ★★★★★ | 0 | 0 |
| Barry Healthcare & Sr Living | 25.1 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.