Inspection Reports for
Breathitt Health & Rehabilitation
420 JETT DRIVE, JACKSON, KY, 41339
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
34% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
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
| Name | Title | Context |
|---|---|---|
| Hailey Adams | Eventus Whole Health | Conducted interviews and assessments related to resident rights and abuse investigation |
| Administrator | Notified of abuse allegations, conducted interviews, and educated staff on abuse policies | |
| Director of Nursing | Conducted interviews, educated staff, and monitored compliance with abuse prevention | |
| Assistant Director of Nursing | Participated in interviews and staff education on abuse prevention | |
| Certified Nursing Assistant (CNA)2 | Alleged perpetrator of verbal and physical abuse toward Resident R2 | |
| Registered Nurse 1 (RN1) | Reported abuse allegations and participated in investigation interviews | |
| Business Manager | Involved in mail handling and resident communication issues | |
| Dietary Manager | Responsible for food safety deficiencies including expired food and temperature checks |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Feb 7, 2025
Visit Reason
The inspection was conducted based on complaints alleging violations of resident rights, abuse, food safety, and infection control at Breathitt Health & Rehabilitation.
Complaint Details
The complaint investigation involved allegations that a resident's mail was opened without permission, a CNA was rough and verbally abusive to a resident, the facility failed to report the abuse allegation to authorities, and the investigation was inadequate. The facility also failed in food safety and infection control practices. The abuse allegations were substantiated with actual harm, and the facility failed to properly investigate and report the incident.
Findings
The facility failed to protect residents' rights to privacy in communications, failed to prevent and properly investigate abuse allegations, failed to timely report abuse to authorities, failed to maintain food safety standards including temperature checks and discarding expired food, and failed to implement effective infection prevention and control practices including proper use of PPE and sanitary handling of urinals and bedpans.
Deficiencies (6)
F 0576: The facility failed to protect a resident's right to receive mail unopened when staff opened a letter addressed to the resident without permission.
F 0600: The facility failed to ensure a resident remained free from abuse when a CNA was alleged to have been rough and verbally threatened the resident.
F 0609: The facility failed to timely report an allegation of abuse to state and local authorities after a resident alleged rough care and verbal threats by a CNA.
F 0610: The facility failed to conduct a thorough investigation of an alleged abuse incident, allowing the alleged perpetrator to continue working without supervision.
F 0812: The facility failed to check six food temperatures on the steam table and failed to discard eight expired food items, risking foodborne illness.
F 0880: The facility failed to maintain an effective infection prevention program by not ensuring staff donned PPE for residents on Enhanced Barrier Precautions and by improper labeling and storage of urinals and bedpans.
Report Facts
Residents affected: 1
Residents affected: 1
Food temperatures not checked: 6
Expired food items: 8
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA2 | Certified Nursing Assistant | Named in abuse allegation involving rough care and verbal threats to Resident R2 |
| RN1 | Registered Nurse | Involved in reporting and responding to abuse allegations for Resident R2 |
| Administrator | Responsible for abuse investigations and facility oversight | |
| Medical Director | Informed about abuse allegations and investigation outcomes | |
| CNA7 | Certified Nursing Assistant | Observed failing to don PPE for resident on Enhanced Barrier Precautions |
| Director of Nursing | DON/Infection Preventionist | Responsible for infection control program and staff education |
| Cook1 | Dietary Staff | Failed to check food temperatures on steam table |
| Dietary Manager | Responsible for food safety and expired food oversight |
Inspection Report
Deficiencies: 0
Date: Aug 29, 2019
Visit Reason
The document is a statement of deficiencies and plan of correction for Breathitt Health & Rehabilitation, related to a regulatory survey completed on 08/29/2019.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jun 7, 2018
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements for Breathitt Health & Rehabilitation nursing home.
Findings
The facility was found to have multiple deficiencies including failure to accommodate resident needs such as call light accessibility, failure to notify physicians of significant changes in resident condition, inadequate maintenance of bed rail padding, improper respiratory care, medication storage and labeling issues, unsanitary kitchen conditions, inaccurate medical record documentation, and lapses in infection prevention and control practices.
Deficiencies (8)
F 0558: The facility failed to reasonably accommodate the needs of residents by not ensuring call lights were accessible to Resident #37 and Resident #64. The facility lacked a policy regarding call lights.
F 0580: The facility failed to notify Resident #37's physician of a need to alter treatment when the resident had increased bowel movements while on Lactulose medication.
F 0584: The facility failed to provide a homelike environment by not maintaining bed rail padding, which was loose and frayed on Residents #10 and #46's beds.
F 0695: The facility failed to provide respiratory care consistent with physician orders for Resident #37 by not ensuring oxygen was administered at the prescribed 4 liters.
F 0761: The facility failed to ensure drugs and biologicals were labeled and stored properly, with expired medications and unlabeled syringes found in medication carts.
F 0812: The facility failed to prepare and serve food under sanitary conditions as the kitchen hand washing sink was clogged and not draining during staff hand washing.
F 0842: The facility failed to ensure accuracy of medical records for Resident #37 by not updating the care plan to reflect the physician's order for oxygen at 4 liters per minute.
F 0880: The facility failed to implement an infection prevention and control program by not ensuring staff performed proper hand hygiene during incontinence care for Resident #321.
Report Facts
Medication expiration count: 50
Medication expiration count: 100
Medication expiration count: 5
Medication expiration count: 32
Medication expiration count: 120
Resident sample size: 31
Viewing
Loading inspection reports...
