Mount Sterling Health and Rehab Center

Inspectors wroteBased on Interview and Record Review, the facility failed to ensure a resident with a new onset of low heart rate was assessed for blood pressure and heart rate before administering Metoprolol (beta-blocker, antihypertensive medication) and ensure residents with diagnoses of Hypertension and Heart disease were provided care plans and interventions to promote safe, comprehensive care for three of three residents (R1, R2, R3) reviewed for Hypertension in the sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess safety risks and provide supervision for one (R1) of three residents reviewed for falls in a total sample of six.

Inspectors wroteBased 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 and effectiveness of their removal plan and Quality Assurance monitoring.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician ordered pressure ulcer treatments were transcribed to the treatment administration records and provided as ordered by the physician for one of three residents (R2) reviewed for pressure ulcers in the sample of four.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to respond to resident call lights in a timely manner for nine of 11 Residents (R2, R3, R4, R5, R7, R8, R9, R10 and R11) reviewed for call light response in a sample of 11.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure trash cans were emptied daily and resident rooms, floors, and bathrooms were clean and free of stains and debris for four of four residents (R1-R4) reviewed for housekeeping services in the sample of four.

Inspectors wroteBased on interview and record review the facility failed to follow PASARR (Preadmission Screening and Resident Review) requirements for one resident (R29) of three residents reviewed for PASARR in a total sample of 20. Findings Include: R29's Level II PASARR (Preadmission Screening and Resident Review) dated 8/8/23 documents You fall into the category of having a diagnosis that the PASRR program was designed to assess. Your condition is likely to require expert treatment in the future. That diagnosis is: A serious mental health condition. At this time, you meet PASRR inclusion criteria. You have a Level II PASRR condition of Depression Disorder which has impacted your functioning and need for ongoing treatment support. You also have the diagnoses of Anxiety Disorder, PTSD (Post Traumatic Stress Disorder) and Narcolepsy. Rehabilitative services: [...]

Inspectors wroteBased on observation, interview and record review the Facility failed to perform hand hygiene and prevent cross contamination, for three separate wounds, during wound/skin care for one of five Residents (R37) reviewed for wound/skin care in a sample of 20

Inspectors wroteBased on interview and record review the Facility failed to investigate a fall for one of four residents (R50) reviewed for falls in a sample of 20.

Inspectors wroteBased on record review and interview the facility failed to provide any treatment or counseling for a residnet with a diagnosis of PTSD (Post Traumatic Stress Disorder) and failed to identify triggers for PTSD for one resident (R29) of three residents reviewed for PTSD in a total sample of 20. Findings Include: The Facility's undated Trauma Informed Care Procedure documents Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers. R29's Care Plan dated 03/01/23 documents I suffered a traumatic life event. I was physically assaulted which resulted in bodily harm. I require ongoing support and intervention with a counselor. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to wash their hands and change gloves between two different residents (R8 and R33) of four residents reviewed for personal cares in a total sample of 20. Findings Include: The Facility's Standard Precautions Policy dated 6/19/22 documents Standard Precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. On 2/26/24 at 1:30 PM, V4 (Certified Nurse Aide) rolled R33 to his side, touched his buttocks while pointing out multiple small open areas. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure antipsychotics were utilized as abuse incident interventions without behaviors to warrant the use and obtain a stop date for a PRN (as needed) antipsychotic for one of one resident (R1) reviewed for antipsychotics in the sample of five.

Inspectors wroteBased on interview and record review the facility failed to maintain privacy and confidentiality of personal and health information for two residents (R8 and R9) of 4 residents reviewed for medical records in the sample of 10.

Inspectors wroteBased on observation, interview and record review the facility failed to accurately assess residents for the use of bed rails and ensure bed rails were not left in the up position for residents who could not turn or reposition independently in the bed for five of five residents (R21, R1, R22, R26, R18) reviewed for bed rail safety in a sample of 19.

Inspectors wroteBased on record review and interview the facility failed to complete a comprehensive MDS (Minimum Data Set) assessment within 14 days following a significant change in condition for one of one residents (R18) reviewed for change in condition in the sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement restorative programs and a plan of care to treat R18's decline in Activities of Daily Living (ADL's) for one of one resident (R18) reviewed for ADL decline in the sample of 19.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's toenails were trimmed for one of two residents (R21) reviewed for activities of daily living (ADL) care in a sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the development of a Deep Tissue Injury (DTI) for one of one resident (R21) reviewed for pressure ulcers in a sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of one residents (R26) reviewed for range of motion in a sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to document behaviors to justify the use of anti-psychotic medications and failed to implement non-pharmacological behavioral interventions prior to the use of anti-psychotic medications for one of three residents (R27) reviewed for anti-psychotic medications with the diagnosis of Dementia in the sample of 19.

Inspectors wroteBased on interview and record review, the facility failed to state in their arbitration agreement that the agreement can be rescinded within 30 days of signing it and that it is not required to sign an agreement for binding arbitration as a condition of admission to, or to continue to receive care at, the facility. The facility also failed to have the resident, or their representative acknowledge if they understood the agreement. This had the potential to affect all 37 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt alternatives prior to the use of bed rails, document the risk of injury with the use of bed rails, document interventions to decrease the risk of injury, and to keep side rails down or off the bed for residents evaluated not to use bed rails for six of six residents (R3, R14, R18, R22, R32, R36) reviewed for bed rails in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident had prescription eyeglasses to maintain his visual function for one of one resident (R29) reviewed for vision/hearing in the sample of 24.