Deficiency Records for Mount Sterling Health and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Mount Sterling Health and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-20 | 2023-10-11 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-14 | 2023-02-16 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-12-15 | 2023-01-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-15 | 2023-01-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-15 | 2023-01-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-15 | 2023-01-13 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-12-15 | 2023-01-13 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-12-15 | 2023-01-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-12-15 | 2023-01-13 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2022-12-15 | 2023-01-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-14 | 2023-01-10 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-12-14 | 2023-01-06 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-12-14 | 2023-01-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-14 | 2023-01-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-14 | 2023-01-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-14 | 2023-01-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-30 | 2022-09-21 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-08-30 | 2022-09-21 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-08-30 | 2022-09-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-25 | 2022-08-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-20 | 2022-06-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-16 | 2022-04-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-16 | 2022-04-29 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-21 | 2021-11-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-21 | 2021-11-12 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-10-07 | 2021-10-18 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-10-07 | 2021-10-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-13 | 2020-02-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Develop a communication plan. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Establish methods for sharing information. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-12-13 | 2020-01-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-12-13 | 2020-01-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-13 | 2020-01-28 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-12-13 | 2020-01-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-12-13 | 2020-01-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-12 | 2020-01-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-12 | 2020-01-03 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-12-12 | 2020-01-03 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-12-12 | 2020-01-03 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-12-13 | 2020-01-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-12-13 | 2020-01-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-13 | 2020-01-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-12-13 | 2019-12-16 | N |
