Mount Sterling Health and Rehab Center

In the surveyor’s words

From the most serious findings on record at Mount Sterling Health and Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jan 10, 2026

  Based on observation, interview, and record review the facility failed to de-escalate a resident's behaviors and protect a cognitively impaired resident from staff-to-resident physical abuse for one of three (R1) residents reviewed in the sample of four. These failures resulted in a staff member (V4/Registered Nurse) kicking a resident (R1), who has a diagnosis of Dementia and known physical behaviors, three times above the left hip on 11/1/25 after R1 exhibited behaviors towards V4, which caused R1 to experience psychosocial and physical harm of fear, mental anguish, and pain.These failures resulted in an Immediate Jeopardy:While the immediacy was removed on 1/3/26, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation… […]

• Immediate jeopardy, isolatedF626Aug 30, 2022

  Based on record review and interview the facility failed to allow a resident (R1) to return to the facility after being sent to the hospital for an acute behavioral and medical condition, failed to document all measures the facility took to meet R1's needs that could not be met by the facility along with developing and implementing a care plan to meet those needs, failed to involve R1, R1's Power of Attorney (POA), and the Ombudsman to develop a plan to meet R1's needs, failed to notify the resident, resident's representative, and long term care Ombudsman in writing and verbally of R1's discharge, including notification of appeal rights, and failed to establish and follow a written policy on allowing a resident to return to the facility after hospitalization for one of three residents (R1)… […]

• Actual harm, isolatedF689Jul 25, 2022

  Based on observation, record review and interview, the facility failed to ensure two qualified staff were present to assist a resident with bed mobility, dressing, transfer and a gait belt was utilized according to facility policy, for one of three residents (R1) reviewed for falls, in a sample of three. These failures resulted V4 (Certified Nursing Assistant) independently dressing R1 and attempting to transfer R1 without a gait belt resulting in R1 falling to the floor sustaining an Acute Displaced Right Distal Femoral Periprosthetic Fracture. Findings include: The facility policy, titled Fall Assessment and Management Policy (revised 4/2019), documents It is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall. […]

• Actual harm, isolatedF686May 20, 2022

  Based on interview and record review the facility failed to revise pressure relief measures or change treatment orders for one of three residents (R1) reviewed for pressure ulcers in a sample of three. These failures resulted in R1 developing a stage four pressure ulcer to the coccyx with wound infection, a deep tissue injury (DTI) to the right heel and a stage three pressure ulcer to the left heel which required hospitalization . Findings include: A Wound & Ulcer Policy and Procedure dated 1/10/18 states, It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. […]

• No harm, potential for more than minimal, widespreadF679Aug 25, 2025

  Based on interview and record review the facility failed to provide activities on weekends and evenings. This failure has the potential to affect all 67 residents residing within the facility. Findings include:The Administration Code Section 300.1410 Activity Program (undated) documents a) The facility shall provide an ongoing program of activities to meet the interests and preferences and the physical, mental, and psychosocial well-being of each resident, in accordance with the resident's comprehensive assessment. The activities shall be coordinated with other services and programs to make use of both community and facility resources and to benefit the residents. […]