Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Mt. Sterling Health & Rehab, Llc during CMS and state inspections, most recent first.
Failure to Properly Document Advance Directives: The facility did not ensure advance directive rights were properly supported for multiple residents. Several records contained only a general POA instead of documentation for health care decision making, some residents had no Health Care Decision Making form or advance directive on file, and some forms were incomplete or did not match the documents in the chart. The AC stated she reviewed the admission packet and asked about advance directives, while the SSD said the records suggested residents and families were not educated on the purpose and elements of an advance directive.
Expired and undated eye drops were found on multiple med carts, including Wisteria Unit carts 1 and 2 and Lakeview Unit cart 1. Surveyors observed several opened eye drops and an eye ointment for multiple residents that were not dated or were past the usual 28- to 30-day discard timeframe. Staff, including the KMA, Pharmacy Consultant, DON, and ADON, stated eye drops should be dated when opened and checked before administration.
Staff failed to follow infection control practices during resident care and routine tasks. An NA was observed wearing contaminated gloves in the hallway, entering multiple resident rooms without hand hygiene, and not removing PPE inside the room. Another NA passed ice and water by filling cups over the open ice chest and leaving the scoop on top of the ice, while moving between residents without hand hygiene. Leadership stated staff were expected to perform hand hygiene before and after resident contact, after glove removal, and to follow proper PPE and sanitary ice-handling practices.
The facility failed to provide adequate supervision and a hazard-free environment for three residents, resulting in two falls and unsafe medication handling. One resident, cognitively intact but requiring two-person assistance and supervision for toileting, was transferred to the bathroom by a single aide and left alone on the commode, where the resident was later found on the floor. Another resident with severe cognitive impairment and high fall risk, care planned for two-person transfers but without specific supervision interventions for time spent in a common area, sustained an unwitnessed fall from a chair in the TV area, resulting in facial injuries and a nasal fracture. A third resident with severe cognitive impairment, not assessed to self-administer medications, was observed with a cup of crushed medications in pudding left unattended at the bedside, contrary to facility policies requiring direct observation of medication administration and secure storage.
A facility failed to provide ordered respiratory care for two residents with COPD and other medical conditions. One resident was observed without oxygen in place, with tubing out of reach, and the concentrator set above the ordered flow rate; staff did not return to replace the oxygen during the observation. Another resident’s concentrator was observed set below and above the ordered 3 LPM. Facility leaders stated staff were expected to follow physician orders and verify the oxygen flow rate at the prescribed setting.
Incomplete dialysis assessment and communication documentation: A resident receiving hemodialysis had missing pre- and post-dialysis assessments and incomplete dialysis communication forms across multiple treatments. The facility’s records lacked required details such as VS, meal information, nurse contact information, dialysis results, and post-treatment monitoring documentation, and staff interviews confirmed the forms were expected to be completed before transport and reviewed on return.
A resident with severe physical and cognitive impairments was injured during a transfer when two SRNAs failed to extend the legs of a mechanical lift and improperly pulled on the lift pad, causing the device to tilt and strike the resident's head. The incident resulted in a laceration and required emergency medical care. Investigation confirmed the lift was functioning properly and the injury was due to staff not following established safe transfer procedures.
A resident with severe cognitive impairment and multiple medical conditions developed significant bruising on her chest, which was observed by nursing staff and assessed by the DON. However, the resident's family was not notified of the injury until several days after it was first identified, resulting in a delay in communication about the resident's condition.
Multiple lapses in infection prevention and control were observed, including failure to change and date oxygen equipment as required, lack of hand hygiene by staff during meal service and wound care, improper cleaning of shared equipment such as gait belts, and inadequate use of personal protective equipment when handling soiled linens. These actions and inactions were inconsistent with facility policies and contributed to the deficiency.
Two residents did not have complete or properly implemented care plans: one lacked a care plan for a dialysis catheter despite visible signs of redness and dried blood, and another received oxygen at rates above physician orders, with staff failing to consistently check and match oxygen settings to care plans. Staff interviews confirmed gaps in care planning and monitoring for both residents.
A resident with chronic respiratory conditions was observed receiving oxygen at rates higher than the physician-ordered 4 L/min via nasal cannula on multiple occasions. Staff interviews confirmed that the oxygen concentrator was not always set according to orders, and the resident experienced repeated hospitalizations for respiratory issues. Facility policy and leadership expected staff to check and follow oxygen orders, but this was not consistently done.
A facility failed to sustain an effective QAPI program, resulting in a repeat deficiency when staff exited a resident's room on droplet precautions with a used, uncleaned gait belt. Despite prior education and audits, staff did not consistently clean shared equipment between uses, and monitoring of these practices had ceased, leading to ongoing infection control concerns.
The facility failed to properly store and handle medications, biologicals, and vaccines, leading to deficiencies in three medication storage rooms. Vaccines were improperly stored, and refrigerator temperatures were not maintained, affecting medication integrity. Medication carts were left unlocked, and keys were improperly stored, risking unauthorized access. Staff lacked awareness of proper storage practices, and documentation for controlled substances was incomplete.
The facility failed to maintain sanitary food storage conditions in three nourishment unit refrigerators. Ice packs were improperly stored in the Sterling and Bluegrass Unit freezers, and the Lakeview Unit refrigerator lacked a thermometer and temperature log. Staff interviews confirmed the risk of cross-contamination and the absence of required temperature monitoring.
The facility failed to provide appropriate care for residents with limited range of motion (ROM) due to the absence of a restorative nursing program (RNP). Observations and interviews revealed that residents with ROM impairments were not receiving targeted interventions, and staff lacked training and guidance in providing restorative care. The facility's staffing records showed no restorative staff on duty, and the program had not been reinstated since the COVID-19 pandemic.
The facility failed to follow proper infection control practices, including inadequate cleaning of shared medical equipment like glucometers and mechanical lifts, improper storage of supplies, and use of expired disinfecting wipes. Staff did not adhere to hand hygiene protocols, and a medication was administered after contact with a contaminated surface. These deficiencies were observed despite infection control training being provided.
A facility failed to refer a resident for a level II PASARR after a new diagnosis of unspecified psychosis. The resident, initially admitted with metabolic encephalopathy, dementia, and anxiety, was later diagnosed with psychosis but did not have a new PASARR submission. Despite severe cognitive impairment and behavior issues, the facility did not coordinate with the PASARR program as required. The Social Services Director admitted the oversight, and the Administrator expected resubmission after the resident's psychiatric hospitalization.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. A resident developed an infection at the gastric tube site due to staff not following physician's orders. Another resident's care plan interventions for skin protection were not consistently applied, resulting in skin tears. Additionally, a resident with diabetes did not have a care plan for podiatry services, leading to untrimmed toenails and potential complications.
A resident with impaired skin integrity was not provided care according to their plan, which included keeping fingernails short and using Geri-sleeves. Observations showed the resident with long nails and no protective sleeves, leading to skin picking and injuries. Staff interviews revealed communication lapses and inconsistent implementation of the care plan.
A resident with diabetes did not receive necessary podiatry services as required by the facility's policy. Despite the resident's long, untrimmed, and thick toenails causing pain, and a request from the resident's daughter, no referral was made for podiatry services. Interviews with staff confirmed the absence of a referral, and the importance of professional foot care for diabetic residents was emphasized by the PCP.
A resident with a gastric tube infection did not receive the prescribed care due to a nurse's failure to apply a bacterial ointment as ordered. The resident, who was dependent on tube feedings and had a severely impaired mental status, was observed to have an infected gastric tube site. Despite physician orders for specific care, the nurse was unaware of these orders, and no root cause analysis was conducted for the infection.
The facility failed to document COVID-19 vaccination education and status for a KMA and a DA, increasing the risk of communicable diseases. The DA's file lacked evidence of vaccine education or offering, while the KMA's file showed a request for religious exemption but no education documentation. Interviews with the IP, DON, and Administrator highlighted the importance of maintaining proper documentation for infection control.
Failure to Properly Document Advance Directives
Penalty
Summary
The facility failed to ensure residents were provided the right to formulate an advance directive for 12 of 19 sampled residents. Review of the facility policy stated the facility would support and facilitate a resident's right to formulate an advance directive, and if requested, provide information about that right. The admission packet included a Health Care Decision Making form asking whether a resident had an advance directive, what type it was, and whether the resident wanted to proceed further with Social Services, but the documentation on file for multiple residents did not meet those requirements. For Resident 1, the responsible party completed the form indicating no advance directive, but the form did not answer whether the resident wanted to proceed further with Social Services. Resident 2 had no Health Care Decision Making form on file, and guardianship documentation did not delineate responsibility for health care decision making. Resident 4, Resident 6, Resident 8, Resident 37, and Resident 60 each had a Health Care Decision Making form indicating an advance directive such as a durable power of attorney for health care, but the records contained only a general power of attorney that did not address health care decision making. Resident 10 had a form indicating a durable power of attorney for health care and no desire to proceed further with Social Services, but no further documentation was on file. Resident 22 had no Health Care Decision Making form, and the general power of attorney on file did not address health care decision making. Resident 38 and Resident 54 had no Health Care Decision Making form and no advance directive on file. Resident 56 had no Health Care Decision Making form, and the emergency guardianship order on file did not address advance directives. During interviews, the Admissions Coordinator stated she reviewed the form on admission and asked about advance directives, but also stated she had limited training with the prior AC. The Social Services Director stated no resident or representative had expressed interest in an advance directive and, after reviewing several records, stated it looked like residents or families were not educated on the purpose and elements of an advance directive. The DON and Administrator stated advance directives were expected to be discussed and followed, and the Administrator stated discrepancies suggested confusion about what constituted an advance directive.
Expired and Undated Eye Drops Found on Multiple Medication Carts
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with currently accepted professional principles, including the appropriate expiration date when applicable, for 3 of 8 medication carts. Surveyors observed expired and/or undated eye drops in the Wisteria Unit medication cart 1, Wisteria Unit medication cart 2, and the Lakeview Unit medication cart 1. The observations included opened bottles and tubes of eye drops and eye ointment for multiple residents that were either not dated when opened or were past the expected discard timeframe. On the Wisteria Unit medication cart 1, surveyors found three eye drops that were expired and/or undated, including Systane eye drops for one resident, Lumigan eye drops for another resident, and Refresh eye drops that were opened and not dated. On the Wisteria Unit medication cart 2, surveyors found seven expired and/or undated eye drops and eye ointment, including gentamycin eye drops, Systane eye drops, bimatoprost eye drops, tobramycin eye drops, and erythromycin eye ointment for several residents. On the Lakeview Unit medication cart 1, surveyors found one bottle of brimonidine eye drops that had been opened and dated. Staff interviews showed the KMA, Pharmacy Consultant, ADON, DON, and Administrator all acknowledged that eye drops should be dated when opened and generally discarded after about 28 to 30 days, but the observations showed several were not dated or were beyond the expected timeframe.
Failure to Follow Hand Hygiene, PPE, and Ice-Handling Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. Review of CDC guidance and the facility’s infection prevention and control policy showed that hand hygiene was required immediately before and after resident care, gloves were not a substitute for hand hygiene, and PPE was to be used and removed according to policy. The policy also stated staff received infection control education and training related to their job duties. During observation, Nurse Aide State Registered 5 was seen exiting one resident’s room wearing gloves and holding a plastic trash bag containing soiled briefs, disposing of the bag in a laundry cart, removing contaminated gloves, and then donning new gloves and entering another resident’s room without performing hand hygiene. He was later observed exiting a resident’s room after transferring the resident with a mechanical lift while still wearing gloves and again not performing hand hygiene. In interview, he stated PPE should be removed inside the resident’s room and hand hygiene should be performed before exiting, but he could not explain why he failed to remove gloves inside the room or perform hand hygiene after resident care and before entering another resident’s room. Another nurse aide was observed passing ice and water to residents by filling cups while holding them over the open ice chest, placing the scoop on top of the ice instead of in its holder, and moving from room to room without performing hand hygiene between resident contacts. The ADON/IP, DON, Administrator, and Medical Director all stated staff were expected to perform hand hygiene before and after resident contact, after removing gloves, and to follow PPE and sanitary ice-handling practices. The observations showed staff did not follow those practices for residents including R11, R18, R38, R113, R122, and R133.
Failure to Provide Adequate Supervision and Safe Medication Handling
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free of accident hazards for three residents, resulting in falls and unsafe medication handling. One resident with lumbar disc degeneration, movement disorder, and cardiomegaly was assessed as cognitively intact but required two-person assistance for transfers and supervision when toileting, and was identified as high risk for falls on the Morse Fall Scale. Despite this, a nurse aide transferred the resident alone to the bathroom commode, left her unsupervised, and instructed her to use the call light when finished. The aide left the bathroom to go to the nurse’s station, and upon returning a short time later, found the resident on the floor beside the commode after the resident had apparently attempted to manage independently. Another resident with acute respiratory failure, dementia, and anxiety was assessed as severely cognitively impaired and at high risk for falls on the Morse Fall Scale. The care plan identified fall risk related to gait and balance and required two staff for transfers between surfaces, but did not include specific interventions for supervision while in a common area or up in a chair. The resident was later found face down on the floor in front of a chair in the TV/common area after an unwitnessed fall from a Broda chair, with documented injuries including a swollen, bleeding nose, a new laceration over the right eyebrow, facial bruising, and right shoulder pain, and was diagnosed with a closed nasal fracture. Staff interviews revealed that some aides and nurses did not consistently review care plans, and one LPN reported not recalling training on assessing residents for fall risk prior to the incident. A third resident with severe cognitive impairment and not assessed to self-administer medications was observed seated in a wheelchair at her bedside table with a medication cup containing multiple crushed medications mixed in pudding and a spoon left unattended in front of her. The Medication Administration Record showed that several oral medications, including antihypertensives, aspirin, vitamin D, stool softener, urinary tract infection prophylaxis, beta-blocker, and acetaminophen, were documented as given that morning by a medication aide. The medication aide stated the unattended cup was from the previous night and admitted she had not removed it when she entered earlier to administer the morning medications. Facility policies required medications to remain under direct observation during administration or be secured, and required staff to observe residents consuming medications, but the unattended medication cup at the bedside demonstrated a failure to follow these policies and to ensure medications were not left accessible or unmonitored.
Incorrect and Inconsistent Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who had physician orders for continuous oxygen therapy. One resident was admitted with COPD, chronic respiratory failure with hypercapnia, and myocardial infarction, and had an order for oxygen at 4 LPM via nasal cannula every day and night shift. Another resident was admitted with diagnoses including atrial fibrillation, expressive language disorder, gout, and COPD, and had an order for oxygen at 3 LPM via nasal cannula every day and night shift. Facility policies stated oxygen was to be administered in accordance with physician orders and the prescribed flow rate was to be maintained. For the first resident, observation showed the oxygen concentrator was set at 4.5 LPM instead of the ordered 4.0 LPM. On another observation, the resident was not wearing the nasal cannula, the tubing was on the floor and out of reach, and staff did not return during the observation period to replace the oxygen. The resident stated staff had removed the oxygen during transfer from bed to chair and that he could not adjust the flow due to limited mobility. The resident’s care plan also listed oxygen at 5 LPM via nasal cannula. For the second resident, observation showed the oxygen concentrator was set at 2 LPM on one occasion and 3.5 LPM on another, both different from the ordered 3.0 LPM. The resident was observed wearing the nasal cannula during one observation. Interviews with the ADON/IP, DON, Administrator, and Medical Director confirmed staff were expected to follow physician orders for oxygen therapy and verify the concentrator was set at the prescribed liters per minute.
Incomplete dialysis assessment and communication documentation
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for a resident who required hemodialysis three times weekly. Resident 38 was admitted with diagnoses including dependence on renal dialysis, type 2 diabetes mellitus, and metabolic encephalopathy. The resident’s care plan identified the need for hemodialysis related to renal failure and included a goal to avoid complications from dialysis. The facility’s policy stated that each resident’s care and services would include ongoing assessment and oversight before, during, and after treatments, with monitoring for complications and communication with the dialysis facility. Record review showed incomplete or missing pre- and post-dialysis documentation for multiple treatments in February 2026, including 02/04/2026, 02/05/2026, 02/16/2026, 02/23/2026, and 02/25/2026. The facility also did not provide ongoing assessment and monitoring documentation for January 2026 or March 2026. Several dialysis communication forms had blank sections, including missing vital sign details, meal information, facility nurse contact information, dialysis results, and other required entries. Some forms were prefilled with the nurse’s name and resident information, and staff stated the forms should be completed before the resident left the facility and should reflect the resident’s current condition at the time of transport. The record also included nursing notes and dialysis communication forms that showed incomplete information after dialysis, including missing documentation of the resident’s condition on return and missing dialysis treatment details from the dialysis facility. One form noted the resident should eat before leaving for dialysis because once the fistula was accessed, the resident could not move her right arm, and another noted the resident’s bandage needed to be removed before transport because it prevented access to the site. Interviews with an LPN, the ADON/IP, the DON, the Administrator, and the Medical Director confirmed the facility’s process required complete dialysis communication, review of the form on return, documentation of a nursing note after dialysis, and contact with the dialysis provider if information was missing.
Failure to Follow Safe Mechanical Lift Transfer Procedures Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow safe transfer techniques while using a mechanical lift to transfer a resident with significant physical and cognitive impairments. The resident, who had hemiplegia, hemiparesis, dementia, and was dependent in all self-care and mobility, required a mechanical lift with two staff for all transfers. During a transfer from bed to chair, two State Registered Nurse Aides (SRNAs) operated the lift, but did not extend the legs of the device as required for stability. One SRNA pulled on the lift pad to position the resident, causing the lift to become unbalanced and tilt. As a result of the improper use of the mechanical lift, the device's bar struck the resident on the back of the head, causing a laceration and hematoma. The resident required emergency medical attention, including staple closure of the wound and a CT scan to assess for further injury. Documentation and witness statements confirmed that the lift's legs were not extended due to the way the device was positioned under the chair, and that the staff involved did not follow established procedures for safe resident handling and transfer. The facility's investigation found that the incident was not due to equipment malfunction, as maintenance staff confirmed the lift was functioning properly. The incident was attributed to staff not adhering to the facility's policies and procedures for mechanical lift use, specifically the failure to extend the lift's legs and improper handling during the transfer. The staff involved were interviewed, and one was terminated for failure to use proper lifting techniques and non-compliance with training.
Failure to Immediately Notify Family of Resident Injury
Penalty
Summary
The facility failed to immediately notify a resident's representative when an injury was identified. The resident, who had chronic lymphocytic leukemia, chronic kidney disease, and severe cognitive impairment, was found to have significant bruising on her chest by a registered nurse. The nurse observed the bruise on the resident's chest, described its size and color, and noted that the resident often clasped her hands tightly against her chest, which was consistent with the location of the bruising. The Director of Nursing (DON) was notified of the bruising and conducted an assessment, determining that the bruising was likely due to the resident's own actions and her medical condition, which made her prone to bruising. The findings were discussed in a staff meeting, but the DON became ill and left work before a report was initiated. The facility's documentation indicated that the bruising was not reported to the resident's family until several days after it was first observed. The family was only informed after the bruise was already in the process of healing, and the delay in notification was confirmed by both the family and the facility's administrator. The administrator acknowledged that the family was upset about not being contacted promptly when the bruising was discovered. The deficiency centers on the facility's failure to immediately notify the resident's representative of the injury as required.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to establish or maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices involving both staff and residents. For one resident receiving oxygen therapy, the oxygen nasal cannula tubing was found to be in use well past the date it should have been changed, and the humidification water bottle was undated. Review of records confirmed that the tubing was not changed as scheduled, and interviews with staff and administration confirmed that both the tubing and bottle should be changed and dated weekly to prevent infection. During meal service, several State Registered Nurse Aides (SRNAs) were observed not performing hand hygiene between passing lunch trays to residents, and one aide touched a resident's food without gloves or hand hygiene. Staff interviews confirmed that hand hygiene should be performed between each tray delivery, and gloves should be worn when touching food. Additionally, two SRNAs were observed exiting a resident's room on droplet precautions with a used, uncleaned gait belt, which was then placed in a pocket without being disinfected. Staff interviews revealed inconsistent practices regarding cleaning gait belts between resident use, despite facility policy requiring disinfection after each use. Further deficiencies were observed during wound care, where an LPN failed to perform hand hygiene between glove changes and did not change gloves between treating different wound sites on a resident. The LPN acknowledged the lapse and cited the absence of hand sanitizer in the room as a contributing factor. In the laundry area, staff were observed handling soiled linens without wearing gowns, contrary to facility policy. Interviews with environmental and laundry supervisors indicated a lack of awareness of the policy requirements for personal protective equipment when handling dirty laundry.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with end stage renal disease, heart failure, and diabetes, the care plan did not include any interventions or monitoring instructions for a dialysis catheter, despite the presence of a port in the upper right chest. Observations revealed redness and dried blood at the catheter site, and staff interviews confirmed that the only action being taken was monitoring for infection, with no formal care plan in place for the catheter. For another resident with chronic respiratory failure, COPD, and heart failure, the care plan included an intervention for continuous oxygen therapy at a specified rate per physician's orders. However, observations on multiple occasions showed that the oxygen concentrator was set above the ordered rate. Staff interviews revealed that the resident often removed her oxygen or refused to use her bipap, and that hospitalizations frequently occurred due to exacerbations of her conditions. Staff acknowledged that the oxygen settings were not always checked against the care plan and physician's orders each shift, and that incorrect oxygen administration could lead to increased carbon dioxide levels and lethargy. The facility's own policies require comprehensive, person-centered care plans with measurable objectives and timeframes for all identified needs, as well as notification of staff when interventions are added or changed. Despite this, the care plans for these two residents did not address all assessed needs or ensure that interventions were consistently implemented as ordered.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident requiring continuous oxygen therapy. Observations revealed that the resident's oxygen concentrator was set above the physician-ordered rate on two separate occasions: once at 5 liters per minute and once at 4.5 liters per minute, while the physician's order specified continuous administration at 4 liters per minute via nasal cannula. The facility's policy required oxygen to be administered according to physician orders, except in emergencies, but there was no documentation of an emergency or a corresponding physician order change at the time of the observed discrepancies. The resident in question had a history of acute on chronic diastolic heart failure, chronic respiratory failure with hypercapnia, and COPD, and was assessed as needing continuous oxygen therapy. Interviews with staff indicated that the resident often removed her oxygen or refused to wear her bipap device, which was intended to help manage her carbon dioxide levels. Staff reported that they would reapply the oxygen and educate the resident, but also acknowledged that the oxygen concentrator was sometimes set above the ordered rate, which could contribute to increased carbon dioxide levels and subsequent hospitalizations for the resident. Further interviews with the medical director, DON, and administrator confirmed that staff were expected to check oxygen settings against physician orders at least each shift, and that deviations from the ordered rate could negatively impact residents with COPD. Despite these expectations, the observed discrepancies in oxygen administration were not addressed in a timely manner, and the resident experienced repeated hospitalizations related to improper oxygenation.
Repeat Deficiency in QAPI and Infection Control for Shared Equipment
Penalty
Summary
The facility failed to maintain an effective, comprehensive, and data-driven Quality Assurance Performance Improvement (QAPI) program, as evidenced by a repeat deficiency related to infection control practices. Specifically, during an observation, two State Registered Nurse Aides (SRNAs) provided care to a resident on droplet precautions and exited the room with a used, uncleaned gait belt placed in one SRNA's pocket. This occurred despite previous survey findings of similar issues with equipment not being cleaned between resident use and the facility's implementation of a plan of correction that included staff education and audits. Interviews with staff confirmed that gait belts were expected to be cleaned with disinfectant wipes after each use, and that proper cleaning and storage were necessary to prevent infection transmission. The Infection Prevention Nurse and DON acknowledged prior education and monitoring efforts, but the DON stated that audits of equipment cleaning and hand hygiene were no longer being performed. The Administrator reported that quality assurance meetings were held daily and that oversight of QAPI was maintained, but the repeat deficiency indicated that the QAPI process was not effective in sustaining compliance with infection control standards.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and handling of drugs, biologicals, and vaccines, leading to multiple deficiencies in medication management. Observations revealed that medications were improperly stored in three out of four medication storage rooms, affecting nine residents. Specifically, influenza vaccines were found stored in the door of medication refrigerators, contrary to CDC guidelines, which could compromise their efficacy. Additionally, the temperature of the Sterling Unit's medication refrigerator was not maintained within the recommended range, reaching 50 degrees Fahrenheit, which could affect the integrity of the stored medications. Further deficiencies were noted in the management of medication carts and storage rooms. Medications for a discharged resident were not removed from the cart as per facility policy, and medication carts were found unlocked and unattended in the Bluegrass Unit. Keys to medication storage areas were improperly stored in an unattended nurse's station, posing a risk of unauthorized access. The facility also failed to maintain proper documentation for controlled substances, as evidenced by unsigned verification sheets at shift changes. The facility's staff demonstrated a lack of awareness and adherence to professional standards for medication storage. Insulin pens and other medications were not stored in their original packaging, were undated, and were not discarded according to product instructions, increasing the risk of cross-contamination and reduced efficacy. Interviews with staff revealed gaps in knowledge regarding proper storage practices and the importance of maintaining medication efficacy and resident safety. The facility's policies on medication storage and handling were not consistently followed, contributing to the observed deficiencies.
Improper Food Storage and Lack of Temperature Monitoring
Penalty
Summary
The facility failed to store food under sanitary conditions in three of four nourishment unit refrigerators. Observations during the survey revealed that ice packs were stored in the freezer doors of the Sterling and Bluegrass Unit nourishment refrigerators. Additionally, the Lakeview Unit nourishment refrigerator lacked a thermometer and a temperature log for April 2024. The facility's policy required that temperatures be checked and logged at least twice per day, with thermometers placed inside each cooler/freezer and calibrated weekly. The policy also specified that refrigerator storage must be maintained at or below 41 degrees Fahrenheit, and frozen storage at or below -4 degrees Fahrenheit. Interviews with staff, including LPNs, the Director of Rehabilitation, the DON, and the Administrator, confirmed the importance of monitoring refrigerator temperatures and the potential for cross-contamination from storing ice packs with food items. The LPNs indicated that the therapy department had previously used ice packs for rehabilitation, but the Director of Rehabilitation clarified that therapy had not used ice packs in about two years. The DON and Administrator both acknowledged that ice packs should not be stored in the nourishment refrigerators, and there should be a thermometer and temperature log to ensure proper food storage conditions.
Lack of Restorative Nursing Program for Residents with Limited ROM
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents with limited range of motion (ROM), as evidenced by the lack of a restorative nursing program (RNP) for three residents. The facility's policy on Restorative Nursing Programs outlined the need for maintenance and restorative services to maintain or improve residents' abilities, but the facility did not have an active RNP. Observations and interviews revealed that residents with ROM impairments were not receiving targeted interventions to address their limitations, and staff were not adequately trained or guided in providing restorative care. Resident 1 was observed in her room with functional limitations in both upper extremities, but was not receiving therapy or restorative care. Similarly, Resident 37 had limitations in one lower extremity and was unaware of any staff interventions to assist with her ROM. Resident 79 had impairments in both upper and lower extremities and was not receiving therapy due to insurance denials. Staff interviews indicated that ROM exercises were only performed during activities of daily living (ADLs), without specific guidance or a structured program. The facility's staffing records showed no restorative staff on duty, and interviews with various staff members, including the Director of Nursing and the Administrator, confirmed the absence of a restorative program. The facility had previously employed restorative aides, but the program had not been reinstated since the COVID-19 pandemic. The lack of a structured RNP and trained staff resulted in residents not receiving the necessary care to maintain or improve their ROM, leading to the identified deficiency.
Infection Control Deficiencies in Equipment Cleaning and Storage
Penalty
Summary
The facility failed to adhere to infection prevention and control practices, as evidenced by multiple observations of staff not following proper procedures for cleaning and disinfecting shared medical equipment. Specifically, staff did not clean the glucometer before and after use according to the manufacturer's instructions, and hand hygiene was not performed appropriately. This was observed with two residents, where the glucometer was placed on surfaces without barriers, and the required dwell time for disinfectant wipes was not followed. Additionally, staff failed to clean and disinfect a mechanical lift after use on two residents, storing it in a public area without proper sanitation. This oversight was acknowledged by the staff involved, who admitted to not following the correct procedures for cleaning shared equipment. Furthermore, the facility's clean linen storage room was found to have residents' supplies stored directly on the floor, and the portable vital sign machine was visibly dirty, indicating a lack of routine cleaning and maintenance. The facility also failed to dispose of expired disinfecting wipes, which were used for cleaning glucometers, and a medication was administered to a resident after it had come into contact with a contaminated surface. Interviews with staff, including the ADON/IP and the DON, revealed that while infection control training was provided, there were lapses in adherence to the facility's policies and CDC guidelines. The facility's leadership expressed expectations for staff to follow infection control protocols, but the observations indicated a need for improved compliance.
Failure to Resubmit PASARR for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer a resident for a level II pre-admission screening and resident review (PASARR) after the resident was diagnosed with a newly evident, serious mental illness. The resident, admitted on March 10, 2023, with diagnoses including metabolic encephalopathy, dementia with agitation, and anxiety disorder, was later diagnosed with unspecified psychosis on February 21, 2024. Despite this new diagnosis, the facility did not provide documented evidence of a new PASARR submission. The facility's policy required coordination with the PASARR program to ensure appropriate care for individuals with mental disorders, including prompt referral for a level II review following an inpatient psychiatric admission. The resident's care plan, initially addressing behavior problems such as yelling at other residents, was updated after an altercation with another resident. The resident had been assessed with severe cognitive impairment and was free of aggressive behavior during the look-back period. However, following a psychiatric hospitalization, the resident exhibited hallucinations, delusions, and other disruptive behaviors. The Social Services Director acknowledged the failure to resubmit PASARR information, stating it was not on her radar, while the Administrator expected resubmission following the resident's increased behaviors and psychiatric stay.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, leading to deficiencies in their care. For Resident 100, the care plan included specific interventions for gastric tube site care, as ordered by the physician. However, staff did not follow these orders, resulting in an infection at the site. Observations revealed that the staff did not apply the prescribed betadine and antibiotic ointment, and interviews indicated a lack of awareness of the specific orders among the staff. Resident 23's care plan included interventions to protect the resident's skin, such as keeping fingernails trimmed and using Geri-sleeves. Despite these interventions, observations showed that the resident had long fingernails with blood-like material underneath and was not wearing protective sleeves, leading to skin tears. Interviews with staff revealed that the interventions were not consistently implemented, and the administrator was unaware of the resident's skin-picking behavior. For Resident 11, the facility did not develop a care plan that included podiatry services, despite the resident's diabetes diagnosis, which necessitates professional foot care. Observations showed that the resident had long, untrimmed toenails, and interviews with the resident and their family indicated that a podiatry referral had been requested but not acted upon. The Director of Nursing confirmed the absence of a podiatry referral and acknowledged the potential complications of not providing professional foot care for diabetic residents.
Failure to Implement Care Plan for Resident with Skin Integrity Issues
Penalty
Summary
The facility failed to provide quality care according to the resident's plan of care for a resident with impaired skin integrity. The resident, who was severely cognitively impaired and had a history of skin picking, was observed with long fingernails and without protective Geri-sleeves, contrary to the care plan. The resident's care plan included interventions such as keeping fingernails short and using Geri-sleeves to protect the skin, but these were not consistently implemented. Observations revealed the resident picking at his skin, resulting in bleeding and scabbed-over skin tears, with long nails that had a bloody substance under them. Interviews with staff, including a nurse aide, LPN, unit manager, DON, and the administrator, revealed a lack of adherence to the care plan and communication lapses. The nurse aide acknowledged the resident's behavior and the need for nail care but failed to inform the night shift staff. The LPN and unit manager were aware of the resident's needs but did not ensure consistent implementation of the care plan. The DON and administrator were not familiar with the specific details of the resident's care plan or the skin-picking behavior, indicating a gap in oversight and communication within the facility.
Failure to Provide Podiatry Services for Diabetic Resident
Penalty
Summary
The facility failed to provide podiatry services for a resident, identified as R11, who was admitted with diagnoses including type 2 diabetes, essential hypertension, and atherosclerosis. The facility's policy required that residents with complicating disease processes be referred to qualified professionals for foot care, but no such referral was made for R11. Observations revealed that R11's toenails were long, untrimmed, and thick, and the resident reported experiencing pain when his toes touched the footboard of the bed. Despite a request from R11's daughter for podiatry services about a month prior, there was no record of a referral or podiatry services being provided since R11's admission. Interviews with facility staff, including the Social Worker, Director of Nursing, and the Administrator, confirmed the absence of a podiatry referral for R11. The Social Worker was unable to locate any referral for podiatry services, and the Director of Nursing acknowledged that with R11's diabetes diagnosis, professional podiatry care was necessary to prevent complications. The Administrator stated that the facility had an auxiliary service company for podiatry needs, but the process to set up appointments was not followed. The Primary Care Provider emphasized the importance of foot health, especially for diabetic residents, and noted that a podiatrist should evaluate any nail deformities.
Failure to Follow Physician's Orders for Gastric Tube Care
Penalty
Summary
The facility failed to prevent complications of enteral feeding for a resident, identified as R100, who was dependent on tube feedings. The resident was admitted with conditions including hemiplegia, dysphagia, and dysarthria, and had a severely impaired mental status. The facility's policy required interventions to prevent complications of enteral feedings, including cleaning the insertion site to prevent or resolve skin irritation and local infection. Despite this, a nurse failed to apply a bacterial ointment to R100's infected gastric tube insertion site as ordered by the physician. Observations revealed that the nurse cleaned the site with soap and water, rinsed it with sterile water, and applied a split gauze, but did not apply the prescribed betadine and antibiotic ointment. The physician had ordered specific care for the gastric tube site, including the application of Muciprocin ointment and oral antibiotics for infection control. However, the nurse was unaware of these specific orders. Interviews with the primary care physician, unit manager, director of nursing, and administrator revealed expectations for staff to follow physician's orders and facility policy, but there was no evidence of a root cause analysis being conducted for the infection. The director of nursing had not observed staff performing site care, and the administrator noted the lack of an interdisciplinary team investigation into the cause of the infection.
Failure to Document COVID-19 Vaccination Education and Status
Penalty
Summary
The facility failed to maintain proper documentation of COVID-19 vaccination education, offering, and status for two of three sampled staff members, specifically a Kentucky Medication Aide (KMA) and a Dietary Aide (DA). The review of the DA's employee file showed no evidence of receiving or being offered the COVID-19 vaccine, nor any documentation of education about the vaccine's benefits, risks, and potential side effects. The New Hire Checklist indicated that the DA refused all vaccinations, but there was no further documentation to support this. The DA was unavailable for an interview to provide additional information. Similarly, the KMA's file lacked documentation of vaccine education, although the KMA had requested a religious exemption. During an interview, the KMA confirmed not receiving education or an offer for the vaccine from the facility. The Infection Preventionist (IP) acknowledged incomplete vaccination records and emphasized the importance of educating staff and maintaining documentation. The Director of Nursing (DON) and the Administrator both highlighted the necessity of knowing staff vaccination status and maintaining proper documentation as part of the facility's infection control program.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 citations issued around you in the last 12 months — including the immediate-jeopardy cases — 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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) |
|---|---|---|---|---|
| Ridgeway Nursing & Rehabilitation Facility | 12.8 mi | ★★★★★ | 0 | 0 |
| Fountain Circle Care & Rehabilitation Center | 15 mi | ★★★★★ | 0 | 0 |
| Stanton Nursing And Rehabilitation Center | 15.1 mi | ★★★★★ | 0 | 0 |
| Willowbrook Healthcare | 19.1 mi | — | 0 | 0 |
| Menifee Meadows Nursing & Rehab Llc | 19.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mt. Sterling Health & Rehab, Llc.
100% money-back within 48 hours.
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.