Inspection visit
Inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0685
Assist a resident in gaining access to vision and hearing services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
Findings include:
R29's Care Plan dated 10-5-21 documents, I (R29) have impaired visual function related to my diagnosis of
Glaucoma and a detached retina of my right eye. I wear prescription eyeglasses daily to help correct my
visual deficits. Due to my cognitive impairments, my visual acuity is hard to assess. I am able to see/follow
large objects without difficulty and I am able to make eye contact with staff when I am wearing my glasses. I
will maintain optimal quality of life within limitation imposed by my visual function by continuing to watch TV
(Television) daily and looking out my bedroom window to watch the birds. Arrange consultation with my eye
care practitioner as required/requested. (Staff) will have to put my eyeglasses on me each morning and
remove them at bedtime. Please help me to keep them clean and in a safe place when I am not wearing
them.
R29's Minimum Data Set assessment dated [DATE] documents R29 has impaired vision and requires
corrective lenses (glasses).
On 10/04/21 from 10:46 AM to 1:23 PM, R29 was sitting up in his wheelchair, in front of the television,
without his glasses on.
On 10/06/21 from 9:27 AM to 10:45 AM, R29 was lying in bed without his glasses on.
On 10/04/21 at 11:08 AM V8 (R29's Family Member) stated, I am really upset. (R29) has been without his
glasses for two and a half months. I came into visit him and he did not have his glasses on. Nobody had
called me and let me know (R29) did not have his glasses. Somehow, they were broke or lost. The facility
made an appointment two months ago to get (R29's) glasses and vision checked. Me and my sister showed
up to the appointment and were told that the facility had canceled the appointment due to transportation
issues. I was never told the appointment got canceled or I would have made sure (R29) had transportation.
My poor son can only see out of one eye and has been without glasses for months.
On 10/05/21 at 9:32 AM, V7 (Licensed Practical Nurse) stated, Around three months ago (R29) had a room
move and his glasses got lost during the move. An appointment was scheduled two months ago for (R29)
to get new glasses, but our transportation canceled the appointment. I am not sure why (R29) just got into
the optometrist yesterday. (R29) really does need the glasses to see the TV and help
(continued on next page)
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
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
145820
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145820
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mount Sterling Health and Rehab Center
435 Camden Rd
Mount Sterling, IL 62353
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0685
with his eyes.
Level of Harm - Minimal harm
or potential for actual harm
On 10/06/21 at 01:34 PM V2 (Director of Nursing) stated, The facility lost (R29's) glasses around three
months ago when his room was moved. We (the facility) had an appointment for (R29) to get new glasses
around two months ago, but we had to cancel the appointment due to not having a transport aide to take
(R29) to the optometrist. It is not ideal that (R29) would have to go for three months without glasses.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145820
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145820
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mount Sterling Health and Rehab Center
435 Camden Rd
Mount Sterling, IL 62353
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
The Facility's Bed Rails policy dated 1/10/2018, states, Prior to the use of bed rails for a resident, the facility
will document assessment of use, obtain Physician orders for use, and obtain consent from the responsible
party or (Power of Attorney for Health Care). When bed rail consent is received, the facility will utilize the
rails designated on the assessment at times when the resident is in bed unless otherwise specified.
On 10/04/21 at 11:43 a.m., R3's bed had bilateral quarter bed rails in an upright position. On 10/6/21 at
1:30 p.m., R3 was lying in bed with bilateral quarter bed rails in an upright position. At this time, V3
(Restorative Nurse) stated R3 is not supposed to have bed rails up at any time. V3 stated V3 had them tied
to the bed frame but someone must have cut the ties or changed the bed that R3 was in.
R3's Minimum Data Set assessment dated [DATE], documents R3 has severely impaired cognition and
requires extensive assistance of two staff for bed mobility, transfers, and ambulation in her room.
R3's Care Plan and current Physician orders, do not include documentation that R3 uses bed rails.
R3's Bed Rail Evaluation dated 9/28/21, documents R3's bed does not have side rails.
On 10/04/21 at 10:25 a.m., R14's bed had bilateral quarter side rails in an upright position.
R14's Physician Order Summary dated 10/5/21, documents bilateral quarter side rails to aid in bed mobility
and that R14 has diagnoses which include, Psychosis, Delusional Disorder, Vascular Dementia, and Major
Depressive Disorder.
R14's Minimum Data Set assessment dated [DATE], documents R14 has severely impaired cognition with
short and long-term memory problems, is unable to ambulate, and requires extensive assistance of two
staff members for bed mobility and transfers.
R14's Bed Rail Consent Form dated 4/28/21, documents Risks associated with bed rail use:
Incontinence/increase incontinence; Reduced range of motion; Decreased ability to ambulate; Decreased
ability to get out of bed; Fall Risk; Entrapment; Skin Integrity issues; and Symptoms of
withdrawal/depression/reduced social constant.
R14's Bed Rail Evaluation dated 7/20/21, documents that R14 depends on staff for mobility in and out of
bed, and R14 is at risk for falls. R14's Bed Rail evaluation dated 7/20/21, does not include documentation of
alternatives attempted prior to R14's use of bed rails or how these alternatives
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145820
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145820
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mount Sterling Health and Rehab Center
435 Camden Rd
Mount Sterling, IL 62353
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
failed to meet R14's assessed needs.
Level of Harm - Minimal harm
or potential for actual harm
R14's Occurrence Report dated 7/8/21 at 12:00 p.m., documents R14 fell while attempting to get out of bed
without assistance. This same Occurrence Report documents R14 has no safety awareness for himself or
his surroundings and transfers himself to and from bed without waiting for staff assistance.
Residents Affected - Some
R14's Care Plan last updated 8/17/21, does not document R14's risks associated with the use of bilateral
quarter bed rails or interventions to decrease the risks associated with bed rail use.
On 10/04/21 at 10:12 a.m., R22's bed had one quarter bed rail (closest to the door) in an upright position.
On 10/6/21 at 1:20 p.m., R22's bed had no bed rails in an upright position. At this time, V3 (Restorative
Nurse) stated that R22 is not supposed to use bed rails and V3 noticed on 10/5/21 that R22's bed had one
bed rail up. V3 stated that V3 tied the bed rail down to the bed frame so staff could not put the bed rails
back up. V3 stated, Someone must have cut the tie so they could put (R22's) bed rail up. They should be
down at all times.
R22's Minimum Data Set assessment dated [DATE], documents R22 has moderately impaired cognition,
requires extensive assistance of two staff for bed mobility and transfers and is unable to ambulate.
R22's Care Plan and current computerized Physician Orders do not include documentation that R22 is to
use bed rails.
R22's Care Plan dated 10/5/21, documents R22 is unaware of her physical and cognitive deficits and that
R22 has no regard for own safety or inabilities.
R22's Bed Rail Evaluation dated 9/28/21, documents R22's bed does not have side rails.
On 10/5/21 at 11:57a.m. V5 CNA (Certified Nurse Aide) and V6 CNA were in R18's room assisting R18 to
transfer to the wheelchair. R18 was confused and disoriented. V5 placed a transfer belt around R18's waist
then V5 and V6 used extensive assistance to stand R18 then transfer her to the wheelchair. V5 and V6
stated that R18 has taken a decline recently and can only sometimes assist with transfers and bed mobility.
At 2:20 p.m. R18 was lying in bed with bilateral quarter side rails in the upright position.
On 10/6/21 at 10:35 a.m. V9 CNA and V10 (Licensed Practical Nurse) stated they were R18's nursing staff
on that day. V9 and V10 stated that R18 is unable to use the bilateral quarter side rails on her bed for bed
mobility without staff assistance during cares.
R18's Physician's order summary dated 10/5/21 documents R18 may use quarter bed rails to aid in bed
mobility and positioning.
R18's list of current diagnoses includes Anxiety Disorder, Parkinson's Disease, Dementia, Major
Depressive Disorder, unsteadiness on feet, muscle wasting and atrophy, difficulty walking.
R18's Minimum Data Set (MDS) assessment dated [DATE] documents that R18 has a long and short-term
memory problem, requires extensive assistance from two people for bed mobility and transfers, and has
fallen three times since the previous MDS assessment 6/14/21.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145820
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145820
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mount Sterling Health and Rehab Center
435 Camden Rd
Mount Sterling, IL 62353
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Minimal harm
or potential for actual harm
R18's bed rail consent dated 2/18/21 documents Risks associated with bed rail use: Incontinence/increase
incontinence; Reduced range of motion; Decreased ability to ambulate; Decreased ability to get out of bed;
Fall Risk; Entrapment; Skin Integrity issues; and Symptoms of withdrawal/depression/reduced social
constant. This consent further documents R18's risks associated with bed rail use include falls and
entrapment.
Residents Affected - Some
R18's Bed Rail Evaluation dated 8/5/21 documents R18 is partially dependent on staff with or without
assistive devices for mobility in and out of the bed, is unable to physically release the side rails, and is at
risk for falls. This same evaluation does not include documentation of alternative attempted prior to R18's
use of bed rails or how these alternatives failed to meet R14's assessed needs.
R18's current Care Plan documents R18 has impaired cognitive function, impaired thought processes
related to R18's diagnosis of Dementia, requires verbal cues and staff assistance with bed mobility and
transfers. R18's Care Plan does not include R18's risks associated with the use of bilateral quarter side
rails, interventions to mitigate risks associated with side rail use, or what alternatives were attempted prior
to the use of side rails.
On 10/6/21 at 1:40 p.m., V3 stated R14, R18, R32, and R36 did not have any alternatives attempted prior
to utilizing bed rails. V3 also stated that those same resident's care plans did not document their risk of
injury with the use of side rails or interventions to decrease their risk of injury. V3 stated she was not aware
that she needed to attempt alternatives prior to a resident using bed rails or that the Care Plan needed to
document the risk of injury related to side rail use and interventions to reduce the risk of injury. V3 stated
R3 and R22 should not have bed rails on their beds according to their Bed Rail Evaluations. V3 stated that
R18 is cognitively impaired and unable to use the bed rails on R18's bed independently. V3 stated she did
not evaluate R18 for individualized entrapment risks related to bed rail use.
On 10/04/2021 at 10:35 a.m., 10/5/2021 at 8:25 a.m., and 10/6/2021 at 9:10 a.m., R32's bed had bilateral
quarter side rails in an upright position.
R32's Physician Order Summary dated 10/5/2021, documents: May use 1/4 upper side rails to aid in bed
mobility, positioning, and transfers and R32's diagnoses include: Adult failure to thrive, need for assistance
with personal care, Bipolar Disorder, muscle weakness, Cerebral Infarction and history of falling.
R32's Minimum Data Set assessment dated [DATE], documents R32 requires extensive assistance of two
staff.
R32's Bed Rail Consent Form dated 2/18/2021, documents: Risks associated with bed rail use:
Incontinence/increase incontinence; Reduced range of motion; Decreased ability to ambulate; Decreased
ability to get out of bed; Fall Risk; Entrapment; Skin Integrity issues; and Symptoms of
withdrawal/depression/reduced social constant and Alternatives attempted: see assessment. Assessment:
Total dependent on staff for mobility.
R32's Bed Rail Evaluation completed 8/30/21, documents: Weakness, assist with bed mobility. R32's same
Bed Rail Evaluation, does not include documentation of alternatives attempted prior to R32's use of bed
rails or how these alternatives failed to meet R32's assessed needs.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145820
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145820
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mount Sterling Health and Rehab Center
435 Camden Rd
Mount Sterling, IL 62353
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Minimal harm
or potential for actual harm
R32's current Care Plan does not document R32's risks associated with the use of bilateral quarter bed
rails or interventions to decrease the risks associated with bed rail use.
On 10/6/2021 at 1:40 p.m., V3 (Restorative Nurse) stated that R32 cannot use the bed rails to get out of
bed independently and is unable to ambulate.
Residents Affected - Some
On 10/04/21 at 10:45 a.m., 10/5/2021 8:20 a.m., and 10/6/2021 at 10:10 a.m., R36's bed had bilateral
quarter bed rails in an upright position.
R36's Minimum Data Set assessment dated [DATE], documents R36 has moderately impaired cognition
and requires extensive assistance of two staff for bed mobility.
R36's Physician Order Summary dated 10/5/2021, documents top 1/4 bed rails to aid in bed mobility and
R36's diagnoses include: Visual Hallucinations, Unspecified Dementia, restlessness, and agitation, and
need for assistance with personal care.
R36's Bed Rail Evaluation dated 8/23/21, does not include documentation of alternatives attempted prior to
R36's use of bed rails or how these alternatives failed to meet R36's assessed needs.
R36's Bed Rail Consent Form dated 8/23/21, documents Risks associated with bed rail use:
Incontinence/increase incontinence; Reduced range of motion; Decreased ability to ambulate; Decreased
ability to get out of bed; Fall Risk; Entrapment; Skin Integrity issues; and Symptoms of
withdrawal/depression/reduced social constant.
R36's current Care Plan, does not document R36's risks associated with the use of bilateral quarter bed
rails or interventions to decrease the risks associated with bed rail use.
On 10/6/2021 at 1:40 p.m., V3 stated R36 needs cues from staff to use his bed rails and that R36's bed
rails should be down when not being used as he cannot use them independently.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145820
If continuation sheet
Page 6 of 6
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
F700 - Bed Rails
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.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the October 7, 2021 survey of MOUNT STERLING HEALTH AND REHAB CENTER?
This was a inspection survey of MOUNT STERLING HEALTH AND REHAB CENTER on October 7, 2021. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MOUNT STERLING HEALTH AND REHAB CENTER on October 7, 2021?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Assist a resident in gaining access to vision and hearing services."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.