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Health Inspection

Breathitt Health & Rehabilitation

February 7, 2025 · Jackson, KY · 420 Jett Drive
Citations 2
CMS Rating 2/5
Beds 120
Provider ID 185112
Healthcare Facility
Breathitt Health & Rehabilitation
Jackson, KY  ·  View full profile →
Inspection Summary

Breathitt Health & Rehabilitation in Jackson, KY — inspection on February 7, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF609
Actual harm allegation being made on 12/24/2024. CNA2 stated she could not recall why she had been instructed not to Few been the person who instructed her not to go into R2's room. In further interview, CNA2 stated that on affected

Review of the facility's policy titled Abuse Reporting, revealed the Administrator was the Abuse Coordinator.

Review of R2's electronic medical record (EMR), under the Face Sheet revealed the facility admitted the resident on 08/01/2024 with diagnoses that included Multiple Sclerosis, Anxiety and Depression.

Review of R2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/16/2024, located in the EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition.

Additional review of the MDS, revealed the facility assessed the resident as having no behaviors, as totally dependent on staff for transfers, and as ambulation not occurring.

In an interview on 02/02/2024 at 1:58 PM, with R2, she stated on 12/24/2024, CNA2 was rough while providing care. R2 further stated CNA2 continued to provide care, and R2 told CNA2 that if she continued to be rough during care, she would report her. R2 stated CNA2 replied, if you report me, I will beat your ass. R2 stated she reported this to CNA6.

Additionally, R2 stated CNA1 was in the room at the time of the incident assisting with pulling her up in the bed.

In an interview on 02/05/2025 at 9:54 AM, with CNA6, she stated upon entering R2's room on 12/24/2024, the resident was crying. CNA6 stated when R2 was questioned, she stated CNA2 had said she would smack the fire out of her if she (R2) reported the rough care CNA2 had provided. CNA6 stated this was her recollection of what was stated to her by R2, as she did not document the allegation nor was she asked to write a statement. CNA6 stated she immediately reported the allegation to Registered Nurse (RN)1.

In an interview on 02/05/2025 at 10:39 AM, CNA1 stated she could not remember if CNA2 was in R2's room on 12/24/2024. CNA1 stated the Administrator interviewed her over the phone related to the allegation, but she was not asked to write a statement.

185112

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 185112 B.

Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Breathitt Health & Rehabilitation 420 Jett Drive Jackson, KY 41339

Review of R2's electronic medical record under the Face Sheet revealed the facility admitted the resident on 08/01/2024 with diagnoses which included Multiple Sclerosis, Anxiety and Depression.

Review of R2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of

11/16/2024, located under the MDS tab, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition.

Additional review of the MDS, revealed the facility assessed the resident as having no behaviors, as totally dependent on staff for transfers, and as ambulation not occurring.

During an interview on 02/02/2025 at 1:58 PM, with R2, she stated on 12/24/2024, CNA2 was rough while providing care. R2 stated CNA2 continued to provide rough care and she told CNA2, if she continued to be rough during care, she would report her. R2 stated CNA2 then responded, if you report me, I will beat your ass. R2 stated she reported this to CNA6; however, she was unaware of the time of the occurrence or the time she reported it to CNA6.

Further, R2 stated CNA1 was in the room assisting to pull R2 up in bed during this incident. R2 stated RN1 brought the phone in her room and R2 spoke with the Administrator. R2 stated she informed the Administrator of CNA2's statement that she would beat her ass if R2 reported her for being so rough while providing care.

During an interview on 02/05/2025 at 9:54 AM, with CNA6, she stated upon entering R2's room just after supper, the resident was crying. CNA6 stated R2 alleged CNA2 told her, she would smack the fire out of her if R2 reported her being rough with her care. CNA6 stated this was what she remembered related to the conversation.

However, she was not asked to write a statement related to the allegation. CNA6 stated she immediately reported the allegation to Registered Nurse (RN)1.

During an interview on 02/05/2025 at 10:39 AM, with CNA1, she stated she could not remember if CNA2 was in R2's room on 12/24/2024.

185112

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 185112 B.

Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Breathitt Health & Rehabilitation 420 Jett Drive Jackson, KY 41339

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Jackson, KY, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Breathitt Health & Rehabilitation or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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