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Inspection Reports for Breathitt Health & Rehabilitation

420 JETT DRIVE, JACKSON, KY, 41339

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Inspection Report Summary

The most recent inspection on March 3, 2025, found no deficiencies during an abbreviated survey. However, the prior complaint investigation completed on February 7, 2025, identified multiple deficiencies related to resident abuse, failure to protect residents’ rights, delayed reporting of abuse allegations, infection control, and food sanitation. The complaint was substantiated, involving verbal abuse by a certified nursing assistant and lapses in timely reporting, leading to the suspension of the staff member involved. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility showed improvement by the latest inspection following the substantiated complaint and cited deficiencies.

Deficiencies (last 1 years)

Deficiencies (over 1 years) 5 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

6% worse than Kentucky average
Kentucky average: 4.7 deficiencies/year

Deficiencies per year

8 6 4 2 0
2025
High (Actual Harm) Moderate (Potential Harm) Unclassified
State average

Inspection Report

Abbreviated Survey
Deficiencies: 0 Date: Mar 3, 2025
Visit Reason
An Abbreviated Survey was initiated and concluded on 03/03/2025 to investigate KY#00045145.
Findings
No deficient practice was identified during the abbreviated survey.

Inspection Report

Complaint Investigation
Census: 54 Deficiencies: 5 Date: Feb 7, 2025
Visit Reason
A Standard Recertification Survey and Abbreviated Survey investigating Complaint KY00043181 was initiated on 02/02/2025 and concluded on 02/07/2025. The visit was complaint-related due to allegations of abuse and failure to protect residents' rights.
Complaint Details
Complaint KY00043181 alleged abuse by Certified Nursing Assistant (CNA)2 toward Resident (R)2, including verbal threats and rough care. The complaint was substantiated with findings of verbal abuse and failure to report allegations timely. CNA2 was suspended pending investigation. The facility was found not in substantial compliance and required corrective actions.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483, subpart B, with deficiencies cited at the highest Scope and Severity of 'G'. The facility failed to ensure residents were free from abuse and protect residents' rights to privacy and communication. Multiple interviews and record reviews confirmed verbal abuse by a Certified Nursing Assistant and failure to report allegations of abuse timely.
Deficiencies (5)
Failure to protect residents' rights to privacy and communication, including sending and receiving unopened mail.
Failure to ensure residents were free from abuse; verbal and physical abuse by Certified Nursing Assistant (CNA)2 toward Resident (R)2.
Failure to report allegations of abuse to appropriate authorities within required timeframes.
Failure to maintain effective infection prevention and control program, including failure to don appropriate PPE and handle linens properly.
Failure to store, prepare, distribute, and serve food in a sanitary manner, including discarding expired food items.
Report Facts
Survey Census: 54 Sample Size: 19 Deficiency Severity Level G: 2 Deficiency Severity Level F: 1 Deficiency Severity Level D: 1 Expired Food Items: 8 Food Temperatures Checked: 6 Random Staff Interviews: 5
Employees mentioned
NameTitleContext
Hailey AdamsEventus Whole HealthConducted interviews and assessments related to resident rights and abuse investigation
AdministratorNotified of abuse allegations, conducted interviews, and educated staff on abuse policies
Director of NursingConducted interviews, educated staff, and monitored compliance with abuse prevention
Assistant Director of NursingParticipated in interviews and staff education on abuse prevention
Certified Nursing Assistant (CNA)2Alleged perpetrator of verbal and physical abuse toward Resident R2
Registered Nurse 1 (RN1)Reported abuse allegations and participated in investigation interviews
Business ManagerInvolved in mail handling and resident communication issues
Dietary ManagerResponsible for food safety deficiencies including expired food and temperature checks
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