Cycle 1
Health 2025-03-26 · Fire 2025-03-26
3 health deficiencies
Top issue: Environmental (1 deficiency)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Mount Vernon, KY
Rockcastle Regional Hospital and Respiratory Care
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
145 Newcomb Avenue, Mount Vernon, KY
(606) 256-2195
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
143
Certified beds
Average residents
116
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-01-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
2.36
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.61
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.74
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
6.71
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
3.97
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
5.77
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
2.03
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
2.56
CMS adjusted total nurse staffing hours
Case-mix index
3.59
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,539
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9969
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
7.85
Performance 31.58% · Measure score 7.85 · Achievement 7.85 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.92
Baseline 1.81 hours · Performance 2.37 hours · Measure score 0.92 · Achievement 0 · Improvement 0.92
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.81 |
1.02
0.8 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.98% |
8.2%
6.2 pts worse
|
Numerator 14 · Denominator 708 |
| Staff flu vaccination coverage | 60.76% |
42%
18.8 pts better
|
Numerator 576 · Denominator 948 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.3 |
1.9
1.6 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.6 · Expected 3.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
2.2
2.2 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
94.3%
0.1 pts worse
|
93.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.6% · Q2 92.9% · Q3 93.0% · Q4 97.4% · 4Q avg 94.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.9% |
96.2%
4.3 pts worse
|
95.5%
3.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.8%
3.1 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 0.0% · Q4 0.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
15.2%
14.4 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 1.1% · Q4 1.1% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
6.7%
4.2 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.9% · Q3 2.7% · Q4 2.6% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 42.6% |
29.6%
13 pts worse
|
19.6%
23 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.5% · Q2 40.5% · Q3 40.4% · Q4 40.5% · 4Q avg 42.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
17.6%
8.5 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 8.7% · Q3 9.3% · Q4 7.4% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.2% |
0.2%
About the same
|
0.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% |
| Percentage of long-stay residents whose ability to walk independently worsened | 35.3% |
17.3%
18 pts worse
|
16.3%
19 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
15.6%
2.3 pts better
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 18.6% · Q3 2.6% · Q4 18.4% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 11.0% |
0.7%
10.3 pts worse
|
1.0%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 11.3% · Q3 9.5% · Q4 13.3% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.7%
0.7 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.8% · Q3 3.5% · Q4 1.7% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.9% |
19.8%
15.9 pts better
|
19.8%
15.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 1.9% · Q3 1.8% · Q4 3.9% · 4Q avg 3.9% |
| Percentage of long-stay residents with pressure ulcers | 11.5% |
5.5%
6 pts worse
|
5.1%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 11.6% · Q3 11.2% · Q4 10.2% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.2% |
83.8%
9.6 pts worse
|
81.7%
7.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 64.3% · Q2 66.7% · Q3 87.5% · 4Q avg 74.2% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.6% |
83.6%
14 pts worse
|
79.7%
10.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-11 · Fire 2019-10-11
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-08-30 · Fire 2018-08-30
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-26
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-03-26
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-03-26
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-03-26
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-26
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-26
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-04-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-26
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-26
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-04-18
D · Potential for more than minimal harm
2018-08-30
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2018-09-30
Penalties and ownership
What sits behind the stars
Ownership
Bastin, Christopher
Corporate Officer · Individual
Estes, Stephen
Operational/Managerial Control · Individual
Estes, Stephen
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Rockcastle Health & Rehabilitation Center
Brodhead, KY
2-star overall rating with 2-star inspections with $15,646 in total fines with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
The Terrace Nursing and Rehabilitation Center
Berea, KY
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Berea Health and Rehabilitation
Berea, KY
4-star overall rating with 4-star inspections with $16,801 in total fines
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