Rockcastle Health & Rehabilitation Center

Inspectors wroteBased 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. The facility made the determination to not report allegations to the SSA based on the findings of their investigations, rather than immediately as required by regulation.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide needed services to maintain good grooming for one (Resident (R9) of four sampled residents reviewed for activities of daily living (ADLs). The facility failed to ensure that R9, who was dependent on staff for assistance with personal hygiene, received the care needed to keep the resident's fingernails trimmed and clean.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure services were provided so as to prevent complications of a gastrostomy tube (GT) for one of two sampled residents ((R) 49) who were observed for medication administration through a GT. Staff failed to check placement prior to administering medication, via the GT, to the resident.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure a resident who needs respiratory care, is provided oxygen per the physician's directions for 1 of 1 sampled resident reviewed related to oxygen therapy, Resident (R)9.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide behavioral health services for one (Resident (R) 72) of six residents sampled for behavioral monitoring. The facility failed to monitor/document multiple behaviors displayed by R72. Staff were not consistently informed of and/or aware of significant behaviors which had the potential to affect others. The failure to monitor, be aware of, and/or take prompt actions to address all R72's behaviors affected at least three of his roommates (R64, R5, and R4).

Inspectors wroteBased on interview, record review, and facility document review, the facility failed to assist with/provide medically related social services for one (Resident (R) 23) of one sampled resident reviewed for appointments and referrals. The facility failed to ensure follow-up appointments and referrals were made and/or kept as needed for R23.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to maintain a medication error rate of less than 5% (percent). There were 4 errors in 32 opportunities, for a medication error rate of 12.5%. This affected 4 out of 5 residents observed for medication pass, Residents (R)68, R69, R87, and R95.

Inspectors wroteBased on observation, interview, facility document review, and facility policy review, the facility failed to accommodate food preference for one (Resident (R) 97) of five sampled residents reviewed for food preferences. The facility repeatedly served R97 food which did not honor the resident's identified preferences.

Inspectors wroteBased 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. The second incident happened during a transfer from his bed to the wheelchair when he was going to a physician's appointment. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice for one of two residents (Resident 242).

Inspectors wroteBased on observation, interview, record review, and review of facility policy it was determined the facility failed to accurately code the Minimum Data Set (MDS) assessment for one (1) of twenty-five (25) sampled residents (Resident #51) and one (1) of three (3) closed records (Resident #104). The MDS assessment for Resident #51 did not reflect behaviors the resident was displaying at the time of assessment, and the discharge MDS assessment for Resident #104 did not reflect the resident's accurate discharge status.

Inspectors wroteBased on observation, interview, record review, and review of facility policy it was determined the facility failed to ensure comprehensive care plans were developed to meet the individual needs for one (1) of twenty-five (25) sampled residents (Resident #51). The comprehensive care plan for Resident #51 did not address the resident's sexually inappropriate behaviors.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow the plan of care for one (1) of twenty-five (25) sampled residents (Resident #203). Resident #203 was a new admission to the facility, was continent of bowel and bladder, and assessed to require assistance with transfers and toileting. However, on 04/22/19, the facility failed to provide the resident with assistance to the toilet, and the resident had an incontinence episode in bed.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents (Resident #203) who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene and continence. Resident #203 requested assistance with toileting on 04/23/19. However, staff failed to assist the resident to the toilet, resulting in the resident having an incontinence episode in the bed.

Inspectors wroteBased on observation, interview, and review of the facility policy it was determined the facility failed to ensure medication was stored under safe and secure conditions. Observation on 04/25/19, revealed one (1) of three (3) medication carts contained an unopened bottle of insulin stored in the medication cart unrefrigerated.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy it was determined the facility failed to maintain an infection control and prevention program for one (1) of twenty-five (25) sampled residents (Resident #51). On 04/23/19, transmission-based precautions for Resident #51 were not maintained by the facility staff, including nursing, housekeeping, and maintenance staff.