Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Barbourville Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to manage falls effectively, with 346 falls recorded over six months, including 42 with injuries. Despite this, no root cause analysis was conducted for falls experienced by several residents, leading to serious injuries. Interviews with staff revealed a lack of awareness and communication regarding fall management, with the Administrator acknowledging the issue but delaying action until after it was identified by the State Survey Agency.
The facility failed to effectively revise care plans and conduct root cause analyses to prevent falls among residents, leading to multiple incidents and injuries. Several residents experienced repeated falls without adequate investigation or care plan updates, indicating a systemic issue in fall management.
The facility failed to prevent falls and accidents for several residents due to inadequate supervision and monitoring. Despite a high number of falls, the facility did not conduct thorough investigations or develop individualized care plans. One resident suffered a fractured femur, and another sustained a humeral fracture, with no root cause analysis performed. Observations and interviews revealed care plan interventions were not consistently implemented, and communication issues contributed to the deficiency.
The facility failed to maintain an effective QAPI program for managing falls, with 346 falls over six months and no documented root cause analysis or interventions. Staff interviews revealed confusion over responsibility for tracking falls, and the issue was not addressed by the QAPI Committee until identified by the State Survey Agency.
A resident with intact cognition refused a Rocephin injection due to nausea, but nursing staff administered it despite his refusal, violating his rights. The resident, who had diabetes and other health issues, expressed fear and anger over the incident. The facility's policy on resident rights was not followed, and the physician was not notified of the refusal.
A resident with dementia and Alzheimer's disease suffered an injury of unknown origin, which was not reported to state agencies within the required timeframe. The resident was found with bruising and swelling on the left arm, later diagnosed as a fracture. The facility's Administrator and DON, both new to their roles, failed to report the incident promptly, despite a witness statement indicating the injury occurred during a bath.
A resident with contractures suffered an angulated spiral fracture during a bath, but the facility delayed the investigation and failed to interview all involved staff. The DON and Administrator, inexperienced in handling such incidents, did not complete the necessary steps, and the hospital reported the injury to Adult Protective Services.
The facility failed to promptly notify physicians and resident representatives following incidents involving three residents. One resident with a history of falls was not reported to the physician or state guardian until the day after a fall, resulting in a delayed diagnosis of a serious fracture. Another resident's injury was not reported for two days, and the facility failed to notify state agencies. A third resident's refusal of an antibiotic injection due to adverse effects was not communicated to the medical provider, leading to a delay in addressing the issue.
Failure to Conduct Root Cause Analysis for Resident Falls
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to manage falls among residents, as evidenced by the lack of root cause analysis (RCA) for falls experienced by five sampled residents. Over a six-month period, the facility recorded 346 falls, with 42 resulting in injuries. Despite this high number of falls, the administration did not conduct RCAs to identify the causes and revise care plans to prevent further incidents or injuries. This deficiency was highlighted by the absence of documented investigations into the falls of residents who sustained serious injuries, such as fractures. Interviews with facility staff, including LPNs, the MDS Nurse, the Quality Nurse/Staff Development Coordinator/Infection Prevention Nurse, the Nurse Practitioner, the Director of Nursing, and the Medical Director, revealed a lack of awareness and communication regarding the number of falls and the absence of a systematic approach to addressing them. Staff members expressed uncertainty about the tracking and trending of falls, with some unaware of the total number of falls in the past six months. The Administrator, responsible for tracking and trending falls, acknowledged the issue but did not initiate a Performance Improvement Plan (PIP) until after the State Survey Agency identified the problem. The facility's failure to conduct RCAs and implement timely interventions for fall prevention compromised the residents' well-being. The Administrator admitted that the facility did not begin investigating each resident's fall until August, despite being aware of the high number of falls since May. The lack of a proactive approach to fall management and the delayed response to the issue contributed to the deficiency in providing the highest practicable physical, mental, and psychosocial well-being for the residents.
Deficiency in Fall Prevention and Care Plan Management
Penalty
Summary
The facility failed to maintain an effective system for revising care plans to provide necessary interventions for supervision and monitoring to prevent falls and accidents among residents. This deficiency was observed in eight out of ten sampled residents, who experienced multiple falls, some resulting in injuries such as fractures. The facility's policies required comprehensive care plans to be reviewed and revised following any changes in a resident's condition, including falls, but this was not consistently done. For instance, one resident experienced 19 falls over six months, yet there was no documented evidence of root cause analysis or care plan revisions to address these incidents. The facility's failure to conduct thorough investigations and root cause analyses of falls further contributed to the deficiency. Several residents, including those with cognitive impairments and physical limitations, experienced repeated falls without adequate investigation into the causes or appropriate updates to their care plans. In one case, a resident with a history of falls and cognitive impairment sustained a hip fracture, yet the facility did not document any root cause analysis or care plan revisions to prevent further falls. Additionally, the facility did not ensure that care plan interventions were dated, making it difficult to determine whether interventions were implemented in response to specific falls. This lack of documentation and follow-up on fall incidents indicates a systemic issue in the facility's approach to fall prevention and care plan management. Interviews with staff revealed inconsistencies in the process of updating care plans and implementing interventions, further highlighting the deficiency in the facility's fall management system.
Inadequate Fall Prevention and Monitoring in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring to prevent falls and accidents for several residents, as evidenced by the lack of thorough investigation and evaluation of falls to determine their root causes. The facility had a total of 346 falls over a six-month period, with an additional 26 falls in the following month. Despite this high number of incidents, the facility did not develop individualized care plan interventions to prevent further falls or injuries for the residents involved. The facility's policies on falls management and prevention were not effectively implemented, as residents were not consistently screened for fall risk factors, and interventions were not adequately observed or modified as necessary. One resident, admitted with dementia and anxiety, experienced multiple falls, including a significant fall resulting in a fractured left femur. The facility's documentation did not provide evidence of a root cause analysis for these falls, nor did it show whether interventions were implemented or reviewed after each fall. Observations revealed that care plan interventions, such as fall mats and low-rise chairs, were not consistently in place. Interviews with staff indicated a lack of sufficient information on incident reports to determine the effectiveness of care plan interventions. Another resident, with a history of falls and severe cognitive impairment, sustained multiple falls, including one resulting in a left humeral fracture. The facility failed to investigate the incident to determine the root cause and did not complete necessary documentation or notifications. The resident's care plan interventions were not individualized, and there was no evidence of new interventions implemented after falls. Interviews with staff and family members highlighted issues with communication and staffing, contributing to the facility's inability to prevent further falls and injuries.
Failure in QAPI Program for Fall Management
Penalty
Summary
The facility failed to maintain an effective, comprehensive, data-driven Quality Assurance Performance Improvement (QAPI) program focused on outcomes and quality of life related to falls for eight of ten sampled residents. The facility had a total of 346 resident falls over a six-month period, yet there was no documented evidence that the issue of multiple residents' falls was brought to the QAPI Committee prior to August 2024. The facility's QAPI program did not develop and implement plans with corrective actions, such as performing root cause analysis (RCA), to decrease the number of residents' falls and related injuries. The facility's policy required the QAPI Committee to prioritize topics for Performance Improvement Plans (PIPs) based on current needs, including incidents and accidents. However, the facility's administration failed to investigate each resident's falls and perform RCA to identify the root cause of the large number of falls. There was no documented evidence of the development and implementation of interventions to prevent or reduce further resident falls and injuries. Specific residents, such as one who sustained a fractured femur and another with a humeral fracture, experienced multiple falls without documented RCA or interventions. Interviews with facility staff revealed a lack of clarity and responsibility regarding the tracking and trending of falls. The Administrator was responsible for tracking falls but did not initiate a detailed investigation until after the State Survey Agency identified the problem. Staff members, including the Clinical Coordinator, Minimum Data Set Nurse, and Quality Nurse, were unaware of the number of falls or who was responsible for monitoring interventions. The facility's QAPI documentation lacked evidence of RCA for falls, and the Medical Director expected reporting and documentation to be completed but was not involved in detailed discussions of falls.
Resident Rights Violation: Injection Administered Despite Refusal
Penalty
Summary
The facility failed to protect and promote the rights of a resident, identified as R95, by administering an injection after the resident explicitly refused it. R95, who had been admitted with diagnoses including neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, urinary tract infections, and Guillain-Barre syndrome, had a BIMS score indicating intact cognition. On the night of the incident, R95 refused a Rocephin injection due to experiencing nausea from previous doses, which had led to a refusal of meals and concerns about managing diabetes without food intake. Despite R95's refusal, the nursing staff proceeded to administer the injection. Interviews revealed that RN1 initially attempted to educate R95 on the importance of the medication and later had another nurse persuade the resident to accept the injection. LPN3 and RN1 were present when the injection was administered, with LPN3 stating that she explained the necessity of the shot to R95. However, R95 reported feeling coerced and unable to physically resist due to weakness, expressing fear and anger over the violation of his right to refuse treatment. The facility's policy on resident rights, which includes the right to refuse treatment, was not adhered to in this instance. The incident was further compounded by the failure to notify the physician of the resident's refusal, as acknowledged by the facility's administrator. The nurse practitioner's subsequent order to discontinue the Rocephin injections due to adverse effects highlights the oversight in respecting the resident's autonomy and addressing his medical concerns appropriately.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, identified as R274, within the required timeframe. According to the facility's policy, any allegations involving suspected abuse, neglect, or injuries of unknown source must be reported immediately, but no later than two hours after the allegation is made. However, the facility did not notify the appropriate state agencies, including law enforcement, about R274's injury. The resident, who was non-verbal and had a history of dementia, Alzheimer's disease, and other conditions, was found with bruising and swelling on the left upper extremity by a registered nurse. The injury was later diagnosed as a fracture of the left humerus at the hospital emergency department, which subsequently reported the incident to Adult Protective Services. The investigation by the facility's Administrator and Director of Nursing (DON) revealed that the injury was identified on 07/08/2022, but there was no documented evidence of timely reporting to state agencies. A witness statement from a Certified Nursing Assistant (CNA) indicated that the injury might have occurred during a bath on 07/06/2022, when the resident's arm was raised, and two pops were heard. Despite this information, the facility did not report the incident as required. The Administrator and DON, both new to their positions, admitted to being unsure of the investigation process and acknowledged their failure to complete the necessary steps for reporting the incident.
Inadequate Investigation of Resident Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident with contractures in both upper and lower extremities. The incident occurred when two CNAs were bathing the resident, and one CNA lifted the resident's left arm, hearing two pops. The injury, identified two days later, was diagnosed as an angulated spiral fracture of the midshaft of the left humerus with mild impaction. The facility's investigation was delayed, and not all staff present during the incident were interviewed. Additionally, the investigation documentation lacked a written statement from the CNA who reported the injury, and all witness statements were undated. The facility's policy required that all allegations of suspected abuse, neglect, or injuries of unknown source be reported to the DON or Administrator, who would then appoint a representative to investigate. However, the investigation was incomplete, as the Administrator and DON were inexperienced and lacked guidance. The Administrator admitted to not knowing the investigation process and acknowledged the failure to complete all necessary steps. The hospital notified Adult Protective Services of the injury, highlighting the severity of the oversight.
Failure to Notify Physician and Representatives of Resident Incidents
Penalty
Summary
The facility failed to immediately notify the physician and the resident's representative following incidents involving three residents. One resident sustained a fall and was not reported to the physician or state guardian until the following day, despite having a history of falls and being at high risk due to conditions such as dementia and osteoarthritis. The resident was later diagnosed with a serious fracture after being transferred to the emergency department. The delay in notification was attributed to a miscommunication between nursing staff, who each assumed the other had completed the necessary documentation and notifications. Another resident suffered an injury that was not reported to the responsible party or physician until two days later. The resident, who had multiple contractures and was non-verbal, was found with swelling and bruising on the upper extremity. The facility's investigation revealed that the injury occurred during a bath when a CNA heard a popping sound while handling the resident's arm. The facility failed to notify state agencies or law enforcement about the injury of unknown origin, and the hospital later reported the incident to Adult Protective Services. A third resident refused an antibiotic injection due to adverse effects, but the facility did not notify the physician or nurse practitioner of the refusal. The resident, who was cognitively intact, reported feeling sick from the medication, leading to the discontinuation of the injections by the nurse practitioner upon her visit. The facility's failure to communicate the resident's refusal and adverse reaction to the medication was noted, with staff acknowledging the oversight in reporting the issue to the medical provider.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Barbourville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christian Health Center Corbin | 12 mi | — | 4 | 3 |
| Corbin Health And Rehabilitation Center | 12.9 mi | — | 0 | 0 |
| The Heritage Nursing And Rehabilitation Facility | 13 mi | — | 0 | 0 |
| Mountain View Rehabilitation And Healthcare Center | 13.3 mi | — | 2 | 0 |
| Hillcrest Health And Rehabilitation Center | 13.4 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.