Cycle 1
Health 2025-03-13 · Fire 2025-03-13
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Mount Sterling, KY
Windsor Care Center
1-star overall rating with 1-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
125 Sterling Way, Mount Sterling, KY
(859) 498-3343
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
144
Certified beds
Average residents
123
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Regency Care
Operator or chain grouping
Approved since
1990-12-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 3 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.31
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.13
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.37
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,243
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.95% · Performance 24.69% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.78
Baseline 11.42% · Performance 8.03% · Measure score 4.78 · Achievement 0 · Improvement 4.78
Total nurse turnover
1.82
Baseline 52.03% · Performance 56.25% · Measure score 1.82 · Achievement 1.82 · Improvement 0
Adjusted total nurse staffing
3.13
Baseline 3.41 hours · Performance 3.97 hours · Measure score 3.13 · Achievement 3.13 · Improvement 1.85
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.89% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 220 · Observed rate 15.45% · Lower 95% interval 9.95% |
| Discharge to community | 56% |
50.57%
5.4 pts better
|
No Different than the National Rate · Eligible stays 201 · Observed rate 48.76% · Lower 95% interval 49.45% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.18% |
95.27%
2.9 pts better
|
Numerator 108 · Denominator 110 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 110 |
| Discharge self-care score | 42.67% |
53.69%
11 pts worse
|
Numerator 32 · Denominator 75 |
| Discharge mobility score | 46.67% |
50.94%
4.3 pts worse
|
Numerator 35 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 1.82% |
2.29%
0.5 pts better
|
Numerator 2 · Denominator 110 · Adjusted rate 1.56% |
| Healthcare-associated infections requiring hospitalization | 8.03% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 133 · Observed rate 9.02% · Lower 95% interval 5.56% |
| Staff COVID-19 vaccination coverage | 1.46% |
8.2%
6.7 pts worse
|
Numerator 2 · Denominator 137 |
| Staff flu vaccination coverage | 55.84% |
42%
13.8 pts better
|
Numerator 110 · Denominator 197 |
| Discharge function score | 53.33% |
56.45%
3.1 pts worse
|
Numerator 40 · Denominator 75 |
| Transfer of health information to provider | 90.63% |
95.95%
5.3 pts worse
|
Numerator 29 · Denominator 32 |
| Transfer of health information to patient | 91.84% |
96.28%
4.4 pts worse
|
Numerator 45 · Denominator 49 |
| Resident COVID-19 vaccinations up to date | 14% |
25.2%
11.2 pts worse
|
Numerator 7 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.9
0.3 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.8 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.2
0.1 pts better
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.3 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.2%
3.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.8%
1.2 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.4% · Q3 4.7% · Q4 6.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.2%
15.2 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
6.7%
0.2 pts better
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 5.1% · Q3 6.4% · Q4 6.3% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.5% |
29.6%
1.1 pts better
|
19.6%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 24.3% · Q3 31.1% · Q4 35.4% · 4Q avg 28.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.3% |
17.6%
9.7 pts worse
|
16.7%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 27.8% · Q3 28.8% · Q4 25.9% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.8% |
17.3%
8.5 pts worse
|
16.3%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.7% · Q2 27.9% · Q3 26.1% · Q4 21.1% · 4Q avg 25.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.8% |
15.6%
9.2 pts worse
|
14.9%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 27.8% · Q3 25.3% · Q4 22.1% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.7%
1 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 2.4% · Q3 2.4% · Q4 1.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.7%
0.7 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 1.0% · Q4 2.1% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.5% |
19.8%
3.7 pts worse
|
19.8%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 28.4% · Q3 20.9% · Q4 22.5% · 4Q avg 23.5% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.5%
0.5 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.0% · Q3 6.0% · Q4 5.0% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
83.8%
15.4 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
13.9%
1.8 pts better
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 12.0% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.8%
0.2 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.1% · Q3 2.2% · Q4 1.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
83.6%
16.4 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.6% |
24.5%
1.1 pts worse
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 26.7% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-03 · Fire 2024-05-03
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
12 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Cycle 3
Health 2019-08-29 · Fire 2019-08-29
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-03-13
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-16
F · Potential for more than minimal harm
2024-05-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-06-11
F · Potential for more than minimal harm
2024-05-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-05-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-11
F · Potential for more than minimal harm
2024-05-03
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-06-11
F · Potential for more than minimal harm
2024-05-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-11
F · Potential for more than minimal harm
2024-05-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-05-03
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-05-03
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-05-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-05-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-05-03
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-05-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-11
F · Potential for more than minimal harm
2019-08-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-29
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-29
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-29
K524 · Services Deficiencies
Fire Safety
Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-10-10
Inspection history
Recent health citations
G · Actual harm
2025-11-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-11-14
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-11-14
E · Potential for more than minimal harm
2025-03-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-03-13
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-03-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-13
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-04-16
F · Potential for more than minimal harm
2024-05-03
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-06-12
F · Potential for more than minimal harm
2024-05-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-12
E · Potential for more than minimal harm
2024-05-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-12
E · Potential for more than minimal harm
2024-05-03
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-06-12
E · Potential for more than minimal harm
2024-05-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-03
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-03
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-03
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-06-12
G · Actual harm
2019-08-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-29
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-10-10
D · Potential for more than minimal harm
2019-08-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-10-10
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Ridgeway Nursing & Rehabilitation Facility
Owingsville, KY
1-star overall rating with 1-star inspections with abuse icon flag with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Fountain Circle Care & Rehabilitation Center
Winchester, KY
2-star overall rating with 2-star inspections with 4 recent health deficiencies
#3
Stanton Nursing and Rehabilitation Center
Stanton, KY
3-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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