Inspection Reports for
Rockcastle Health and Rehabilitation Center
371 WEST MAIN STREET, BRODHEAD, KY, 40409
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
4.8 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
2% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 29, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards, specifically focusing on activities of daily living and personal hygiene assistance for residents.
Findings
The facility failed to provide adequate grooming care for one resident dependent on staff assistance, specifically failing to keep the resident's fingernails trimmed and clean despite care plans and staff responsibilities.
Deficiencies (1)
F 0677: The facility failed to provide needed assistance to maintain good grooming for one resident by not trimming and cleaning the resident's fingernails as required by care plans and facility policy.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 29, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding inadequate supervision and failure to use assistive devices during resident transfers, which resulted in fractures for two residents (R29 and R41).
Complaint Details
The investigation was complaint-driven, triggered by reports of fractures sustained by residents R29 and R41 due to improper transfers and lack of adherence to care plans. The Immediate Jeopardy was removed prior to the survey date after the facility implemented corrective actions.
Findings
The facility failed to ensure adequate supervision and proper use of assistive devices during resident transfers, leading to multiple fractures in two residents. The facility's investigation confirmed incidents of improper transfers, including failure to use gait belts and mechanical lifts as required by care plans.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision and use of assistive devices, resulting in fractures for 2 of 20 sampled residents. Resident R41 sustained fractures due to improper wheelchair transport and rushed transfers without gait belts. Resident R29 sustained bilateral humeral neck fractures after staff manually transferred her without using the mechanical lift as required.
Report Facts
Residents sampled: 20
Residents affected: 2
Dates of incidents: 2020, 2022, 04/05/2023, 04/10/2023, 06/29/2024 (survey date)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA3 | Certified Nursing Assistant | Staff involved in transporting R41 during the first incident; no documented education or reprimands found. |
| CNA1 | Certified Nursing Assistant | Witnessed transfer of R41; stated no gait belt was used during transfer. |
| CNA2 | Personal Care Assistant | Assisted in transfer of R41; no direct interview obtained. |
| CNA4 | Certified Nursing Assistant | Manually transferred R29 without mechanical lift, causing fractures; terminated after investigation. |
| RN3 | Registered Nurse | Provided assessment and care for R29; emphasized staff education and care plan adherence. |
| Director of Nursing | Director of Nursing | Provided information about staff and investigation related to R41 incidents. |
| Director of Rehabilitation | Director of Rehabilitation | Provided information on transfer training and care for R41. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 25, 2024
Visit Reason
The investigation was conducted due to complaints regarding resident safety, care plan adherence, and respiratory care for residents R29, R41, and R242.
Complaint Details
The investigation was complaint-driven, focusing on allegations of inadequate supervision, failure to follow care plans, resulting in fractures for residents R29 and R41, and failure to provide appropriate respiratory care for resident R242. Immediate Jeopardy was identified but later removed after corrective actions.
Findings
The facility failed to provide a safe environment, adhere to resident care plans resulting in fractures for R29 and R41, and failed to develop a respiratory care plan and maintain oxygen equipment properly for R242.
Deficiencies (4)
F0584: The facility failed to maintain a safe, clean, and homelike environment, including loose fall hazard tape creating a fall risk and a sink with a malfunctioning hot water knob in a resident's room.
F0656: The facility failed to develop and implement complete care plans with measurable objectives for residents R29 and R242, resulting in R29 sustaining bilateral humeral neck fractures due to staff not following the mechanical lift transfer plan and R242 lacking a respiratory care plan for oxygen therapy.
F0689: The facility failed to ensure adequate supervision and use of assistive devices, causing resident R41 to sustain two fractures during transfers and R29 to sustain fractures due to improper transfers without mechanical lifts.
F0695: The facility failed to provide safe and appropriate respiratory care for resident R242, including failure to develop a respiratory care plan and maintain clean oxygen concentrator filters.
Report Facts
Residents sampled: 20
Residents affected: 2
Residents affected: 1
Oxygen therapy order: 2
Survey completion date: Jun 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA4 | Certified Nursing Assistant | Named in fracture incident for resident R29 due to failure to use mechanical lift; terminated |
| RN3 | Registered Nurse | Provided witness statements and care for resident R29 |
| LPN5 | Licensed Practical Nurse | Reported x-ray results and care for resident R29 |
| DON | Director of Nursing | Interviewed regarding care plan adherence and facility policies |
| Administrator | Facility Administrator | Interviewed regarding facility oversight and expectations |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Apr 25, 2019
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements for Rockcastle Health & Rehabilitation Center.
Findings
The facility was found to have multiple deficiencies including inaccurate Minimum Data Set (MDS) assessments, incomplete care plans for residents with behavioral issues, failure to follow residents' plans of care, inadequate assistance with activities of daily living, improper medication storage, and failure to maintain infection control precautions.
Deficiencies (6)
F 0641: The facility failed to accurately code the Minimum Data Set (MDS) assessment for two residents, resulting in inaccurate reflection of behaviors and discharge status.
F 0657: The facility failed to develop comprehensive care plans addressing sexually inappropriate behaviors for one resident.
F 0659: The facility failed to follow the plan of care by not providing timely assistance to a resident needing toileting help, resulting in an incontinence episode in bed.
F 0677: The facility failed to ensure a resident unable to perform activities of daily living received necessary assistance with toileting, leading to an incontinence episode.
F 0761: The facility failed to store medication properly by keeping an unopened bottle of insulin unrefrigerated in a medication cart.
F 0880: The facility failed to maintain infection control precautions by staff not donning required personal protective equipment (PPE) when entering a resident's room on transmission-based precautions.
Report Facts
Residents sampled: 25
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication carts observed: 3
Inspection Report
Routine
Deficiencies: 7
Date: Mar 15, 2018
Visit Reason
Routine inspection to assess compliance with regulatory standards including care planning, treatment, medication management, pressure ulcer care, pharmaceutical services, infection control, and resident preferences.
Findings
The facility was found deficient in multiple areas including failure to update comprehensive care plans for residents, failure to provide treatment according to physician orders, inadequate pressure ulcer care documentation, incomplete controlled substance accountability records, improper medication storage, failure to provide resident-preferred beverages, and ineffective infection control practices.
Deficiencies (7)
F 0657: The facility failed to update comprehensive care plans for two residents to meet their needs, including infection control and family concerns about a facility cat.
F 0684: The facility failed to ensure one resident received treatment and care according to physician orders, specifically failing to change a PICC line dressing as ordered.
F 0686: The facility failed to provide necessary treatment and services to promote healing of a pressure ulcer, lacking weekly wound measurements.
F 0755: The facility failed to maintain accurate and complete controlled substance accountability records, with multiple missing shift-to-shift narcotic counts and signatures.
F 0761: The facility failed to ensure proper storage of insulin, with an unopened and undated bottle stored outside the refrigerator.
F 0807: The facility failed to provide drinks consistent with resident preferences, serving only decaffeinated coffee despite resident preference for caffeinated coffee.
F 0880: The facility failed to establish and maintain an effective infection control program for a resident with C-difficile, lacking proper signage and PPE at the resident's room.
Report Facts
Residents sampled: 19
Missing narcotic count signatures: 155
Cases of decaffeinated coffee: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator #3 | Nurse responsible for MDS and care plan updates | Named in deficiencies related to failure to update care plans for Residents #58 and #63 |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including care plan updates, medication management, and infection control |
| Registered Nurse #1 | Registered Nurse | Named in failure to change PICC line dressing and medication storage deficiencies |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in controlled substance accountability deficiency |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Named in infection control deficiency related to Resident #6 |
| Dietary Manager | Dietary Manager | Named in deficiency related to failure to provide resident-preferred coffee |
| Registered Dietitian | Registered Dietitian | Named in deficiency related to failure to provide resident-preferred coffee |
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