Mt. Sterling Health & Rehab, LLC

Inspectors wroteBased on interview, record review, review of the facility's admission Packet, and review of the facility's policy, the facility failed to ensure residents were provided the right to formulate an advance directive for 12 of 19 sampled residents, Resident (R) 1, R2, R4, R6, R8, R10, R22, R37, R38, R54, R56, and R60. Seven residents had a Health Care Decision Making form on file, with six indicating they had advance directives. However, review of the documentation did not meet the requirements for advance directives.

Inspectors wroteBased on observation, interview, and review of the facility's policies, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles and include the appropriate expiration date when applicable for 3 out of 8 medications carts, the Wisteria Unit medication cart 1 and medication cart 2 and the Lakeview Unit medication cart 1. Observations on [DATE] revealed three expired and/or undated eye drops in the Wisteria Unit's medication cart 1; seven expired and/or undated eye drops in the Wisteria Unit's medication cart 2; and one expired eye drop in the Lakeview Unit's medication cart 1.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policy, 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. The facility failed to implement its infection prevention and control policies and procedures and identify and correct problems relating to infection prevention practices for 6 out of 10 sampled residents, Resident (R) 11, R18, R38, R113, R122, and R133, who were cared for by staff who had not performed the required hand hygiene.

Inspectors wroteBased on observation, interview, record review, review of the facility's job description, and review of the facility's policies, the facility failed to provide adequate supervision and an environment free of accident and hazards for 3 of 5 sampled residents, Resident (R) 10, R82, and R60. Review of R82's electronic medical record (EMR) revealed on 05/19/2025 R82 was left unsupervised in the bathroom and fell. Review of R10's EMR revealed on 09/15/2025 R10 was sitting in a chair in the television area and fell while attempting to self-transfer. The resident sustained a fractured nose, abrasion to the right eyebrow, and complained of pain in the right shoulder. Observation on 03/03/2026 of R60 revealed a medication cup containing crushed medication mixed in pudding, with a spoon inside, was left on the bedside table in front of R60, who was awake and sitting in her wheelchair.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with physician orders and professional standards of practice for 2 out of 3 sampled residents, Resident (R) 11 and R93.1. Observation on 03/03/2026 revealed R11's oxygen was set at 4.5 liters per minute (LPM) when his physician order was for continuous oxygen at 4.0 LPM. Further observation on 03/03/2026 and 03/05/2026 revealed the resident was not wearing his oxygen tubing and not receiving oxygen, and staff did not return to R11's room to place the oxygen back on the resident. 2. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to provide residents who required dialysis services an ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility for 1 of 1 sampled resident who received dialysis services, Resident (R) 38. Record review revealed R38 received hemodialysis three times a week on Monday, Wednesday, and Friday. However, the facility provided incomplete documentation for pre-and-post dialysis assessments on the following dates: 02/04/2026, 02/05/2026, 02/16/2026, 02/23/2026, and 02/25/2026. Also, the facility did not provide ongoing assessment and monitoring for the months of January 2026 or March 2026.

Inspectors wroteBased on interview, record review, review of the facility's investigation, and review of the facility's policies, the facility failed to ensure its staff practiced safe transfer techniques, utilizing a mechanical lift, to prevent injuries for 1 of 5 sampled residents, Resident (R) 1. On 04/02/2025, R1 was transferred from the bed to a chair by two State Registered Nurse Aides (SRNA) using a mechanical lift. SRNA4 was operating the lift, while SRNA1 was holding onto the lift pad during maneuvering. SRNA4 moved the lift from the bed to the chair, positioned the lift device under the chair, and failed to extend the legs, necessary for balancing the device. SRNA1 pulled on the lift pad to position R1 into the chair resulting in unbalanced weight distribution that caused the lift to tilt. The bar attachment struck R1 on the back of her head causing a laceration. [...]

Inspectors wroteBased on interview, record review, and review of the facility's investigation, the facility failed to immediately notify the resident's representative (s) when there was an identified injury, an accident, or a significant change in the resident's physical status, for 1 of 1 sampled resident, Resident (R) 2.

Inspectors wroteBased on interview, record review, and review of the facility's documents and policy, the facility failed to notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood as soon as practicable. The facility further failed to ensure the notice included the reason, date, and location for the transfer, as well as a statement of the resident's appeal rights and the contact information for the state Long-Term Care Ombudsman. The deficient practice was identified for 8 out of 10 residents reviewed for transfer and/or discharge, Resident (R) 30, R35, R44, R62, R66, R68, R91, and R94.

Inspectors wrote4. Review of R30's admission Record revealed the facility admitted the resident on 10/07/2021 with diagnoses of acute on chronic diastolic heart failure, chronic respiratory failure with hypercapnia, and COPD. Review of R30's Nurse's Note, dated 09/11/2024, revealed R30 had a decreased oxygen saturation of 78% on 5 Liters (L) per minute of oxygen and was sent to the emergency room (ER). Review of R30's Transfer to Hospital Summary, dated 10/16/2024, revealed the facility transferred the resident to the hospital on that date for oxygen saturation of 75% on 4 Liters (L) per minute via nasal cannula, wet lung sounds, and lethargy. Review of R30's Health Status Note, from 12/01/2024, revealed R30's oxygen saturation dropped to 71% after getting a nebulizer treatment which failed to stabilize R30's oxygen saturation. R30 was sent to the hospital. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to establish or maintain an effective infection prevention and control program, which was essential for providing a safe, sanitary, and comfortable environment while preventing the development and spread of infectious diseases for 5 of 50 sampled residents, Resident (R) 30, R17, R74, F90, and R325. 1. Observation on 03/11/2025 and 03/12/2025 revealed R30's oxygen nasal cannula tubing was dated 02/18/2025, and the humidification water bottle was undated. 2. Observation on 03/11/2025 revealed State Registered Nurse Aide (SRNA) 3 and SRNA5 were seen not hand sanitizing between passing lunch trays for R17, R74, and R90. Further observation on 03/12/2025 revealed SRNA13 touched R90's food with no gloves on and hand hygiene not performed. 3. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to develop and/or implement a Comprehensive Care Plan (CCP) to ensure it met the residents' medical, nursing, mental, and psychosocial needs as identified on his/her comprehensive assessment and other assessments for 2 of 26 sampled residents, Resident (R) 30 and R31. Review of R30's Comprehensive Care Plan [CCP] revealed staff failed to follow the interventions based on the physician's orders for the administration of oxygen. Review of R31's CCP revealed the facility failed to develop a care plan for R31's dialysis catheter.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents requiring respiratory care were provided such care consistent with professional standards of practice for 1 out of 3 residents sampled for respiratory care, Resident (R) 30. Observation on 03/11/2025 at 9:32 AM revealed R30's oxygen concentrator was set on 5 Liters (L) per minute via nasal cannula (NC), and on 03/12/2025 at 11:59 AM, R30's oxygen concentrator was set on 4.5 L per minute via NC. However, review of R30's Physician's Orders revealed R30 had orders for oxygen to be administrated continuously at 4 L per minute via NC.

Inspectors wroteBased on observation, interview, review of the facility's documents, and review of the facility's plan of correction (PoC), dated 05/27/2024, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) process. The facility failed to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focused on indicators of the outcomes of care and quality of life that were achieved and sustained for 1 of 50 sampled residents, Resident (R) 325. Observation on 03/12/2025 at 9:21 AM revealed State Registered Nurse Aide (SRNA) 8 and SRNA7 entered R325's room, who was on droplet precautions, performed resident care, then exited the room with a used, uncleaned gait belt placed in SRNA7's pant pocket. [...]

Inspectors wroteBased on observation, interview, review of the Centers for Disease Control and Prevention's (CDC) document, review of medication package inserts, and review of the facility's policy, it was determined the facility failed to ensure drugs, biologicals, and vaccines were stored per currently accepted professional principles and failed to ensure appropriate environmental controls were used to preserve their integrity. This deficient practice was found in three of four medication storage rooms. Observations of the facility's treatment carts revealed improper storage of medications was found in three of four treatment carts affecting nine residents, Resident (R) 30, R31, R34, R37, R43, R46, R58, R68, and R94. Observation of the Lakeview and Sterling Units' medication refrigerators revealed one influenza vaccine was improperly stored in the door of the medication refrigerators. [...]

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to store food under sanitary conditions for three of four nourishment unit refrigerators as determined by observations during survey of ice packs stored in two unit nourishment freezers, and one unit nourishment refrigerator with no thermometer, and no temperature log for April 2024.

Inspectors wroteBased on interview, record review, review of the facility's investigation, and review of the facility's policy, the facility failed to ensure alleged violations of abuse were thoroughly investigated for 5 of 11 sampled residents that were reviewed in 7 allegations of resident-to-resident abuse, Resident (R) 27, 168, 368, 94, and 87. The facility failed to provide documented evidence of an investigation in three facility-reported allegations of abuse. These investigations involved R27 and R168, that occurred on 06/30/2023; R368 and R94, that occurred on 07/11/2023; and R368 and R87, that occurred on 09/10/2023.

Inspectors wroteBased on observation, interview, record review, and review of the facility's documents and policy, the facility failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM for 3 of 3 residents sampled for ROM (Resident (R) 1, 37 and 79). Multiple staff interviews revealed the facility currently had no restorative nursing program (RNP).

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the manufacturers' directions for use for the glucometer (blood glucose monitoring device) and disinfectant wipes, and review of the facility's policies, the facility failed to identify and correct problems related to infection prevention practices for 5 out of 57 sampled residents, Resident (R) 31, R37, R43, R49, and R318. Three additional observations of the Bluegrass Unit (BGU) revealed violations of infection control standards. 1. Observation of R37 and R43 revealed staff failed to clean the glucometer (shared equipment) before and after use according to the Environmental Protection Agency (EPA) registered disinfectant manufacturer's instructions. In addition, for both residents, appropriate hand hygiene was not performed. 2. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's documents and policies, the facility failed to protect residents from abuse for 3 of 11 sampled residents investigated for abuse (Resident (R) 87, 94, and 101). On 07/11/2023, R368 struck R94 on the side of the head. On 09/10/2023, R168 kicked R87 in the leg. On 10/26/2023, R94 kicked R101 in the right knee.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to refer the resident for a level II pre-admission screening and resident review (PASARR) with a newly evident, serious mental illness for 1 of 1 residents sampled for PASARR review (Resident (R) 94).

Inspectors wroteBased on observation, interview, record review, and review of the facility's documents and policies, the facility failed to develop and implement a comprehensive, person-centered care plan to meet a resident's medical, nursing, and psychosocial needs for 3 of 30 sampled residents (Residents (R) 11, 23, and 100). R100 had a care plan intervention for staff to follow physician's orders when providing care to the gastric tube insertion site. R100 developed an infection at the gastric tube insertion site; however, staff failed to implement the care plan intervention and follow the physician's orders for R100's gastric tube insertion site care. R23's care plan had interventions for the resident to wear a skin protective device and to keep fingernails trimmed; however, staff did not implement these interventions. R11 needed podiatry services; [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to provide quality care according to the resident's plan of care for 1 of 3 residents sampled for skin care, Resident (R) 23.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to provide podiatry services for foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) for 1 of 5 sampled residents, Resident (R) 11.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to prevent complications of enteral feeding for 1 of 3 residents sampled for tube feeding care, Resident (R) 100. Observation on 05/02/2024 revealed the nurse failed to apply a bacterial ointment to R100's infected gastric tube insertion site as ordered by the physician.

Inspectors wroteBased on interview, record review, review of the Centers for Medicaid and Medicare Services (CMS) document, and review of the facility's policy, the facility failed to maintain documentation of screening, education, offering, and current COVID-19 vaccination status for 2 of 3 sampled staff, Kentucky Medication Aide (KMA) 3, and Dietary Aide (DA) 1. This failure placed the residents and staff at increased risk for communicable diseases and healthcare-associated infections (HAI).