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 Rockcastle Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and moderate cognitive impairment, who was dependent on staff for ADLs, did not receive needed fingernail care. Over several days, observations showed the resident's nails remained long and unclean, despite facility policy and staff expectations. Interviews revealed confusion among CNAs and nursing staff about responsibility for nail care, especially for residents with diabetes, resulting in the resident not receiving appropriate hygiene assistance.
Two residents suffered fractures due to inadequate supervision and improper use of assistive devices. One resident was injured during wheelchair transport and transfer without a gait belt, while another was manually transferred against the care plan, resulting in humeral fractures. The facility failed to follow policies for gait belts and mechanical lifts, leading to these deficiencies.
A facility failed to implement comprehensive care plans for two residents, resulting in significant deficiencies. One resident, requiring a mechanical lift for transfers, was manually transferred by CNAs, leading to bilateral humeral neck fractures. Another resident, with COPD, did not have a respiratory care plan reflecting their continuous oxygen therapy. These incidents highlight lapses in care plan adherence and documentation, impacting resident safety.
The facility failed to provide a safe and homelike environment, with loose flooring strips creating fall hazards and a malfunctioning sink requiring rubber bands to turn off the water. Staff interviews revealed a lack of awareness and documentation of these issues, with the resident expressing dissatisfaction with the temporary solution.
A facility failed to provide adequate respiratory care for a resident with COPD, as they did not develop a comprehensive care plan for the resident's oxygen therapy. Despite a physician's order for continuous oxygen at 2 LPM, the resident's oxygen concentrator filter was observed to be dusty over several days. Staff interviews revealed confusion about responsibilities for maintaining the oxygen equipment, with some believing it was the oxygen company's duty, while others stated it should be done by night shift nurses. The DON and Administrator expected filters to be clean, but there was a lack of consistent action to ensure this.
Failure to Provide Needed Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary personal hygiene services to a resident who was dependent on staff for assistance with activities of daily living (ADLs), specifically in maintaining clean and trimmed fingernails. The resident, who had a history of type 2 diabetes mellitus, muscle weakness, osteoarthritis, and cancer, was assessed as having moderate cognitive impairment and required substantial to maximal staff assistance for personal hygiene. Despite facility policy requiring staff to assist residents unable to perform their own ADLs, multiple observations over several days showed the resident's fingernails remained long, jagged, and unclean. Family members confirmed that the resident's nails needed trimming and expressed that they expected the facility to provide this care. Interviews with CNAs and nursing staff revealed confusion regarding responsibility for nail care, particularly for residents with diabetes. CNAs stated they were responsible for nail care on shower days unless the resident had diabetes, in which case the nurse was to be notified. However, the resident's assigned CNA had not noticed the condition of the nails and had not provided the necessary care, while the nurse had not been alerted to the need. The DON and Administrator both stated their expectation that residents' nails be kept clean and trimmed as allowed, but the resident continued to have untrimmed and unclean nails throughout the period of observation.
Failure to Prevent Accidents and Injuries Due to Inadequate Supervision and Assistive Device Use
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents and injuries for two residents. One resident, who had a history of leg amputation and other health issues, suffered two fractures while residing at the facility. The first incident occurred when the resident was being transported in a wheelchair without the right foot pedal, causing his leg to drop and fracture. The second incident happened during a transfer to a wheelchair without using a gait belt, resulting in a tibial fracture. The facility did not report the incidents to the State Survey Agency, and there was no documented investigation for the first incident. Another resident, who was nonverbal and required total care, was transferred manually instead of using a mechanical lift as per the care plan. This resulted in bilateral humeral neck fractures. The facility's investigation revealed that the fractures were caused by the manual transfer performed by a CNA who did not follow the care plan. The resident was later found with bruising and swelling, and an x-ray confirmed the fractures. The facility's policies and procedures for using gait belts and mechanical lifts were not followed, leading to these deficiencies. The CNAs involved in the incidents did not adhere to the care plans, and there was a lack of proper supervision and training. The facility's failure to implement effective systems and ensure staff compliance with care plans resulted in significant injuries to the residents.
Failure to Implement Comprehensive Care Plans Leads to Resident Harm
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to significant deficiencies. For one resident, the care plan required the use of a mechanical lift with two staff members for transfers. However, on two occasions, CNAs transferred the resident manually, contrary to the care plan. This resulted in the resident sustaining bilateral humeral neck fractures, which were later confirmed by x-ray. The facility's investigation concluded that the fractures were caused by the manual transfer, and the CNA responsible was terminated for not following the care plan. Another resident was admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) and required continuous oxygen therapy. Despite this, the facility failed to develop a respiratory care plan that included the resident's oxygen usage. Observations confirmed that the resident was on oxygen therapy as ordered, but the care plan did not reflect this requirement. Interviews with the DON and Administrator revealed an expectation that all physician orders, including oxygen therapy, should be included in the care plans, but this was not done for the resident. The deficiencies highlight a failure in the facility's processes to ensure that care plans are comprehensive and adhered to by staff. The lack of adherence to the care plan for the first resident resulted in physical harm, while the omission of a respiratory care plan for the second resident indicated a gap in the facility's documentation and care planning processes. These incidents underscore the importance of accurate and complete care plans to ensure resident safety and well-being.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several observations and interviews. During an initial tour, it was noted that the flooring at the entrances to the East Wing and another wing had yellow/black strips that were loose and cracked, creating a potential fall hazard. Additionally, in one resident's room, the hot water knob on the sink was in disrepair, requiring the use of rubber bands to turn it off, which was ineffective as water continued to run. The resident expressed dissatisfaction with this makeshift solution, stating it did not feel homelike. Interviews with staff revealed a lack of awareness and action regarding these issues. The Maintenance Assistant admitted to not noticing the loose tape despite frequent walks over it and acknowledged the fall hazard it posed. The Director of Nursing and the Administrator both recognized the risks associated with the flooring and the sink issue but noted that the resident had refused maintenance work on the sink. However, there was no documentation of such refusals. The Administrator was unaware of any work orders for the flooring issue, indicating a communication gap in addressing maintenance problems.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 242, who required oxygen therapy. The resident was admitted with diagnoses including type 2 diabetes mellitus and chronic obstructive pulmonary disease (COPD). Despite a physician's order for continuous oxygen therapy at two liters per minute via nasal cannula, the facility did not develop or implement a comprehensive respiratory care plan for the resident's oxygen usage. Observations over several days revealed that the resident was wearing oxygen, but the oxygen concentrator's filter was covered in dust, indicating a lack of maintenance. Interviews with staff, including a Licensed Practical Nurse (LPN), a Registered Nurse (RN), the Director of Nursing (DON), and the Administrator, revealed inconsistencies in the understanding and execution of responsibilities regarding the maintenance of oxygen equipment. The LPN and RN believed the oxygen company was responsible for changing filters, while the DON stated that cleaning should occur during night shifts and as needed. The Administrator expected nurses to clean filters during routine rounds. The failure to maintain clean oxygen filters could potentially lead to respiratory distress and improper oxygen delivery, although the DON stated that a dusty filter posed no risk to the resident.
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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 Brodhead
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rockcastle Regional Hospital And Respiratory Care | 5.7 mi | — | 0 | 0 |
| The Terrace Nursing And Rehabilitation Center | 14.6 mi | — | 0 | 0 |
| Berea Health And Rehabilitation | 15.3 mi | — | 0 | 0 |
| Stanford Crossing | 16.5 mi | — | 0 | 0 |
| Landmark Of Lancaster Rehabilitation And Nursing C | 17.5 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.