Rockcastle Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Rockcastle Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 29, 2024

  Based on observation, interview, record review and review of the facility's policies, the facility failed to have an effective system in place to ensure each resident received adequate supervision and assistive devices to protect them from accidents and injury for 2 of twenty sampled residents (R) ( R29 and R41). 1. On 06/25/2024, R41 stated he had fractured his right leg two times since residing at the facility, once in 2020, and again in 2022. Per R41, the first time occurred when he was being transported in his wheelchair to be weighed without the right foot pedal being on the wheelchair. He stated his leg got tired and dropped and was pulled under the wheelchair. The first incident resulted in R41 sustaining a fracture to his right distal femur. […]

• Actual harm, isolatedF656Jun 29, 2024

  Based on observation, interview, record review, and review of the facility's policies, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs for two of 20 sampled residents (R), (R29 and R242 ) 1. R29's Comprehensive Care Plan, revised 12/21/2022, revealed an intervention to utilize a mechanical lift with two (2) staff members for transfers. However, on 04/05/2023, Certified Nursing Assistant (CNA) 4 and CNA 8, transferred R29 from the bed to the wheelchair without using the mechanical lift as per the care plan, and on 04/10/2023, staff observed both the resident's upper arms had yellow/purple bruising and bruising around the clavicle. […]

• No harm, potential for more than minimal, patternF609Aug 29, 2025

  Based on interview, record review, and facility policy review, the facility failed to immediately report (within no more than two hours) allegations of abuse to the state survey agency (SSA) for three residents (R) (R)3, R64 and R72) of three sampled residents reviewed for abuse. The facility failed to inform the SSA of an allegation of sexual abuse in which one resident (R72) was alleged to have masturbated in front of another resident (R64) without R64's consent, which meets the definition at S483.5 of non-consensual sexual contact of any type with a resident. The facility also failed to report an allegation of verbal abuse, when R3 initially reported that a nurse yelled at him. […]

• No harm, potential for more than minimal, isolatedF554Aug 29, 2025

  Based on observation, interview, record review, and review of facility policy, the facility failed to ensure 1 of 1 sampled resident reviewed for self-administration of medications was assessed to determine if this practice was clinically appropriate and safe related to self-administration of potassium chloride, Resident (R)35.The findings include: Review of the facility's policy titled, Medication Administration Self-Administration by Resident, dated 01/2023, revealed, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe, and the medications are appropriate and safe for self-administration. […]

• No harm, potential for more than minimal, isolatedF559Aug 29, 2025

  Based on interview, record review, and facility policy review, the facility failed to provide written notification of a room change, including the reason for the change for 1 of 40 residents (Resident #3) sampled for room change, prior to relocating the resident to another room in the facility. The findings include: Review of the facility's policy titled, Room/Roommate Change Notification Policy, revised 01/31/2025, revealed a POLICY STATEMENT noting the facility would provide notice to the resident prior to changing the resident's room or roommate. Per policy review, the interdisciplinary team (IDT) was to participate in making all resident room relocation decisions. The policy specified, 2. Notice of intra-facility transfers will be made before the relocation except when: a. […]