Mount Sterling Health And Rehab Center

prevent accidents.

observation, interview, and record review the facility failed to assess safety risks and provide

include:The facility's Transportation Policy dated 7/1/23 documents It is the facility's responsibility that any resident being transported by the facility vehicle will have a safe and secure transport.R4's medical record documents R4 was admitted to the facility on [DATE] with diagnoses to include Repeated Falls, Chronic Kidney Disease, Bipolar Disorder, Anxiety, Major Depression, and Intrahepatic Bile Duct Cancer. R4's Skilled Care assessment dated [DATE] at 1:56 PM documents R4 is alert and oriented to person and place, her memory is OK and she is able to recall the current season and she is in a facility.R4's care plan documents interventions dated 3/3/26 include Keep environment free from clutter, Reinforce use of assistive devices, Observe for unsteady gait and balance, and Instruct to avoid sudden position changes. R4's Physical Therapy Treatment Encounter dated 3/3/26 documents R4 required a front wheeled walker and contact guard assist for ambulation. R4's Health Status Note dated 3/4/26 at 1:10 PM documents V7 (Transportation Director) took R4 to R4's apartment to pay her rent. R4 said she would use her walker in the apartment and left her wheelchair in the hallway. R4 had to be prompted to stand up to the walker. R4 asked V7 to remove the boxes from her bedroom doorway so she could get into her bedroom to find her clothes. V7 started moving the boxes and R4 got up and took a couple of steps without using her walker and fell to the floor and had a laceration above her right brow.R4's Verification of Incident Investigation/Administrative Summary dated 3/3/26 documents R4's fall and V7 (Transportation Director) called EMS (Emergency Medical Services) to have R4 transported to the emergency room for evaluation and returned to facility after evaluation. On 3/25/26 at 10:41 AM V7 (Transportation Director) reported she took R4 to her apartment on 3/4/26 to get her checkbook. R4 wanted to use her walker in the apartment so she left her wheelchair in the hallway. V7 reported R4's apartment was unsanitary with dried feces, gloves and empty packages on the floor from a previous EMS (Emergency Medical Services) call. V7 reported R4 was sitting in her recliner sorting through papers so V7 started moving boxes away from the bedroom doorway so R4 could go into her bedroom. R4 stood up and took a couple of steps without her walker and fell. R4 received a laceration above her right brow. V7 reported she applied pressure to the laceration and called EMS to transport R4 to the emergency room for an evaluation.On 3/25/26 at 11:56 AM R4 was sitting in a wheelchair self propelling in the Main Dining Room. R4 stated I fall all the time.

The doctor put me here for physical therapy. R4 reports she uses both a walker and a wheelchair.On 3/25/26 at 12:58 PM V2 (DON) reported R4 is very impulsive. V2 reported V7 (Transportation Director) used to be a CNA, but she is no longer certified. On 3/25/26 at 2:21 PM V1 (Administrator) reported R4 left in a wheelchair and the expectation was that R4 would stay in her wheelchair during home visit. V1 reported R4 can be impulsive. V1 reported R4 required assistance with ambulation. V1 verified R4's apartment had not been assessed for safety prior to R4 going on the home visit and the facility should have sent a certified/licensed staff member for the visit as well as the transportation driver.On 3/26/26 at 11:13 AM V17 (Occupational Therapy Assistant) reported she would not recommend R4 ambulate without assistance with walker.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE