Nim Henson Geriatric Center

F-F609)

The findings include:

Review of the facility's policy, titled Abuse Prevention Program, undated, revealed all incidents would be documented, whether abuse occurred, was alleged or suspected. Furthermore, any incident or allegation involving abuse or mistreatment would result in an abuse investigation. Review of the facility's policy titled Abuse Reporting, revealed the Administrator was the Abuse Coordinator.

Review of Resident 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 Resident 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 Resident R2, she stated on 12/24/2024, CNA2 was rough while providing care. Resident R2 further stated CNA2 continued to provide care, and Resident R2 told CNA2 that if she continued to be rough during care, she would report her. Resident R2 stated CNA2 replied, if you report me, I will beat your ass. Resident R2 stated she reported this to CNA6. Additionally, Resident 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 Resident R2's room on 12/24/2024,

the resident was crying. CNA6 stated when Resident R2 was questioned, she stated CNA2 had said she would smack

the fire out of her if she (Resident R2) reported the rough care CNA2 had provided. CNA6 stated this was her recollection of what was stated to her by Resident 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 15 185112 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 In an interview on 02/04/2025 at 3:06 PM, CNA2 stated she had not been in Resident R2's room on 12/24/2024. CNA2 stated she had not been in Resident R2's room in more than a month prior to the allegation being made on Level of Harm - Actual harm 12/24/2024. The CNA stated she could not remember why she had been told not to go into Resident R2's room the month prior to the allegation, but the Director of Nursing (DON) may have been the person who instructed Residents Affected - Few her not to go into Resident R2's room. CNA2 stated on 12/24/2024, she was instructed by RN1 to go to the breakroom and was then informed of Resident R2's allegation that she (CNA2) had threatened to hit the resident.

In continued interview with CNA2, she stated she had spoken on the phone with the Administrator on the evening of 12/24/2024. She stated she was instructed to continue working her shift, but to stay on the front hall away from Resident R2's room. CNA2 stated she was not asked to write a statement and continued to work as scheduled.

In an interview with RN1, on 02/05/2025 at 11:45 AM, she stated on 12/24/2024 around 5:00 PM, CNA6 reported to her an allegation made by Resident R2. RN1 stated CNA6 reported she was informed by Resident R2, that CNA2 told Resident R2 if she didn't quiet down, CNA2 would slap the shit out of her. RN1 stated this was her recollection of what was stated to her by Resident R2, as she did not document this nor was she asked to write a statement. RN1 stated she went to Resident R2's room and noted the resident had her blanket pulled up to her chin and stated she was afraid of CNA2.

In interview with RN1, on 02/05/2025 at 11:45 AM, she stated she instructed CNA1 and CNA2 to remain in

the break room while she contacted the Administrator by phone. RN 1 stated she informed the Administrator of the allegation of verbal abuse and the allegation of rough care provided to Resident R2 by CNA2. RN1 stated the Administrator had her to take the phone to Resident R2 and the Administrator spoke with Resident R2 on the phone for approximately 20 minutes while CNA1 and CNA2 remained in the breakroom. RN1 stated the Administrator then spoke with CNA1 and CNA2 via phone. She stated that after the Administrator spoke with her, CNA1, and CNA2 she informed her that she was going to end the investigation because she did not suspect any abuse. She stated the Administrator instructed her to have CNA2 to go to the front hall and continue working and to ensure CNA2 did not go back down the hall where the resident resided. RN1 stated the Administrator did not instruct her to complete any documentation, investigation, or monitoring regarding the allegation other than to ensure CNA2 did not go back down the hall where Resident R1 resided. During the interview with RN1she stated she did not document any monitoring of CNA2 to ensure CNA2 did not got to Resident R2's hallway.

In an interview on 02/04/2025 at 11:40 AM, with the Social Services Director (SSD), she stated on 12/24/2024 the Administrator notified her by phone that Resident R2 had made a complaint stating that CNA2 had provided rough care. The SSD stated this was discussed in the morning standup meeting on Monday morning following the incident. The SSD stated the Director of Nursing (DON), Assistant Director of Nursing (ADON), and she monitored Resident R2 for three (3) days with no issues noted. However, the SSD stated she could not locate any documentation for the follow-up or monitoring of Resident R2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 15 185112 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 In an interview with the ADON, on 02/04/2025 at 3:35 PM, she stated she was informed by the Administrator of the allegation by Resident R2, and was told CNA2 had provided rough care. The ADON stated she assisted with Level of Harm - Actual harm monitoring of Resident R2 for three (3) days following the allegation and Resident R2 did not mention anything regarding the incident. However, the ADON was unable to submit documented evidence of the three (3) day monitoring. Residents Affected - Few During the interview, the ADON stated if abuse was alleged or suspected, the alleged perpetrator should be removed from the building and an investigation should be completed. However, she stated CNA2 was not sent home after the allegation because Resident R2 only stated CNA2 provided rough care. The ADON stated she did not complete any interviews related to the allegation as she was not instructed to do so by the Administrator, who was responsible for the investigation.

In an interview on 02/04/2025 with the DON, she stated she assisted with monitoring of Resident R2 for two to three (2-3) days after the 12/24/2024 allegation was made. The DON stated the resident did not appear in any distress nor did she have any complaints. However, the DON was unable to submit documented evidence of

the monitoring. During further interview, the DON stated she did not recall why CNA2 was instructed prior to

the 12/242024 allegation, not to be in Resident R2's room, but it was over some type of conflict. The DON stated she did not conduct any interviews related to the allegation, as the Administrator did not instruct her to do so.

Review of a handwritten document, dated 12/24/2024, signed by the Administrator, revealed the Administrator was contacted around 7:00 PM by RN1. Per the document, RN1 reported Resident R2 had stated CNA2 was rough with her while providing care. However, the the Administrator was unable to submit further investigation related to the allegation.

In an interview with the Administrator, on 02/04/2025 at 11:27 AM, she stated she was contacted on 12/24/2024 by RN1 and informed of the allegation made by Resident R2. She stated she had a 20-minute conversation with Resident R2 and throughout the call, Resident R2 could not explain what she meant by the CNA being rough.

The Administrator stated after speaking with Resident R2, CNA1, and CNA2 she thought this was only a concern as

she was only informed Resident R2 had stated CNA2 was rough while providing care. She stated she did not think there needed to be an abuse investigation nor did she think CNA2 needed to be removed from resident care. However, during continued interview with the Administrator, she stated she was not made aware that CNA2 had told Resident R2 she would beat the shit out of her.

In an interview, on 02/06/2025 at 5:08 PM, with the Medical Director, he verified the Administrator made him aware of an allegation made by Resident R2 on 12/24/2024. He stated Resident R2 alleged CNA2 had been abusive or rough while providing care. He stated the DON and the ADON had conducted interviews and concluded there was no physical or verbal abuse. The Medical Director stated he would expect the facility to conduct a thorough investigation and CNA2 be removed from the facility while an investigation was completed.

52131

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 15 185112 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51174

Residents Affected - Many Based on observation, interview, and review of the facility's policies, the facility failed to store, prepare, distribute, and serve food in a sanitary manner.

Dietary staff failed to check six (6) of 12 food temperatures on the steam table during the dinner meal on [DATE REDACTED].

Additionally, dietary staff failed to discard eight (8) expired food items.

The findings include:

1. Review of the facility's policy titled, Food & Beverage Temperature Control, undated, revealed food and beverage temperatures were checked and recorded prior to meal service. Further review revealed all staff would ensure residents received safe food served at acceptable temperatures.

Observation on [DATE REDACTED] at 5:07 PM, revealed Cook1 failed to check the food temperatures for the mashed potatoes, beef goulash, pureed green beans, pureed rice, pureed bread, and pureed beef goulash on the steam table prior to serving the dinner meal.

During an interview with Cook1, on [DATE REDACTED] at 5:07 PM, she stated she only checked the temperature of the foods on the main steam table, not the pureed foods.

2. Review of the facility's policy titled,Food Safety, undated, revealed food or beverage items that had exceeded the manufacturer's expiration date would be discarded.

Observation on [DATE REDACTED] at 2:02 PM, revealed seven (7) expired food items in the walk-in refrigerator and one (1) expired food item in the pantry. The expired food items in the walk-in refrigerator included Dill Pickle Chips with an expiration date of [DATE REDACTED]; Less Sodium Soy Sauce with an expiration date of [DATE REDACTED]; another Less Sodium Soy Sauce with no lid with an expiration date of ,d+[DATE REDACTED]; Wishbone Zesty [NAME] Italian Dressing with an expiration date of [DATE REDACTED]; Worcestershire Sauce with an expiration date of [DATE REDACTED]; and two (2) bottles of Lemon Juice with expiration dates of [DATE REDACTED] and [DATE REDACTED]. Observation of the pantry revealed one (1) pack of flour tortillas in saran wrap that was hardened with a date of [DATE REDACTED] and [DATE REDACTED] handwritten

on the saran wrap.

During interview with the Dietary Manager, on [DATE REDACTED] at 1:07 PM, she stated all food served to residents should have a temperature check prior to serving. The Dietary Manager further stated if the food was not the correct temperature it could cause the residents to become sick. Continued interview revealed it was all dietary staff's responsibility to check the pantry, freezers, and refrigerators for expired food.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 15 185112 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During an interview with the Administrator, on [DATE REDACTED] at 2:32 PM, she stated checking the temperature of all foods prior to serving should be part of the dietary staff's routine. She further stated it was important to check Level of Harm - Minimal harm or food temperatures at the steam table prior to serving because if the food temperatures were not the correct potential for actual harm temperatures, this could lead to foodborne illnesses for the residents. The Administrator stated there should not be any expired food in the kitchen as expired food could possibly cause residents to become sick. Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 185112 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49360 potential for actual harm Based on observation, interview, record review, and review of the facility's policies, the facility failed to Residents Affected - Few maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (3) of 19 sampled residents (Resident (R)7, Resident R28, and Resident R50).

1. Observation on 02/02/2025 at 6:00 PM, revealed Certified Nursing Assistant (CNA)7 failed to don (put on) Personal Protective Equipment (PPE) prior to providing care for Resident R7 who was on Enhanced Barrier Precautions (EBP). Additionally, CNA7 failed to wash or sanitize hands upon exiting Resident R7's room after providing care.

2. Observations on 02/02/2025; 02/03/2025; 02/05/2025; and 02/06/2025, revealed Resident R28's urinal was not labeled with the resident's name, nor was it dated or covered. Resident R28's urinal was either lying on the floor or hanging from the rail in the bathroom.

3. Observation on 02/03/2025 at 9:47 AM, revealed Resident R50's bathroom had two (2) unlabeled, undated, uncovered urinals on the back of the commode, and an uncovered bedpan.

The findings include:

Review of the facility's policy, titled Enhanced Barrier Precautions (EBP), dated 03/08/2024, revealed the EBP policy was implemented to reduce the transmission of multidrug-resistant organisms (MDROs) within

the facility. EBP would be utilized in conjunction with standard precautions to provide targeted gown and glove use during high-contact resident care activities. Further review revealed high contact care activities included assisting with providing hands on care.

1. Review of Resident R7's Face Sheet in the Electronic Medical Record (EMR), under the clinical information tab, revealed the facility admitted the resident on 09/12/2024 with diagnoses including lack of coordination and failure to thrive.

Review of Resident R7's Physician's Orders dated 10/10/2024, revealed orders for Enhanced Barrier Precautions (EBP- infection control intervention designed to reduce transmission of multidrug-resistant organisms) related to a history of Methicillin-resistant Staphylococcus aureus (MRSA) found in the wound. EBP included wearing the appropriate Personal Protective Equipment (PPE) which included a disposable gown and gloves.

Observation on 02/02/2025 at 6:00 PM, revealed an orange dot at Resident R7's door which meant the resident was

on EBP. Additionally, there was a sign on the door that stated Enhanced Barrier Precautions. Further

observation revealed there was a cart at the door which contained boxes of gloves and disposable gowns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 185112 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During observation of dinner meal pass on 02/02/2025 at 6:00 PM, Certified Nursing Assistant (CNA)7 failed to don Personal Protective Equipment (PPE) prior to entering Resident R7's room with a meal tray. CNA7 proceeded Level of Harm - Minimal harm or to lower the head of the bed and assist the resident up higher in the bed by holding the resident under her potential for actual harm shoulder while the resident bent her knees and pushed herself up. After assisting Resident R7 up higher in the bed, CNA7 failed to wash or sanitize her hands upon exiting the room. CNA7 then proceeded to the beverage cart Residents Affected - Few outside of Resident R7's room in the hallway to obtain water and orange juice for Resident R7. CNA7 was observed going back into Resident R7's room without donning PPE and proceeded to assist the resident with her dinner tray.

During an interview with CNA7, on 02/05/2025 at 9:22 AM, she stated if PPE was not donned appropriately for Enhanced Barrier Precautions (EBP), it placed the resident, other residents and staff at risk for spread of infection. CNA 7 stated all residents on EBP should not be touched by staff unless staff was wearing gloves and a disposable gown. CNA7 stated, she always tried to don appropriate PPE prior to entering Resident R7's room and she knew she should wash or sanitize her hands upon exiting the room. She stated, I must have been in

a hurry. I would never put any of my residents at risk for getting an infection or bacteria.

During interview with Registered Nurse (RN) 1, on 02/02/2025 at 6:18 PM, she stated all staff had been educated on infection control policies and an orange dot on the resident's room number indicated the resident was on EBP. RN 1 stated all staff should be aware they were to don the appropriate PPE before providing any type of care for residents on EBP. RN1 stated she monitored as she was going down the halls and if staff was identified not wearing appropriate PPE, she would immediately educate them. The RN stated

the Director of Nursing (DON) completed daily rounds for infection control measures as well.

During an interview, on 02/05/2025 at 1:46 PM, the Director of Nursing/Infection Preventionist (DON/IP), stated she expected nursing staff to follow the facility's policies regarding PPE and EBP. The DON/IP stated if she ever saw any staff not following proper infection control procedures, she would immediately provide them education on what they did wrong and the corrective actions needed. The DON/IP stated following infection control policies and procedures for a resident on EBP was important in order to prevent other residents or staff from being exposed. Further, she stated it was important to use good hand hygiene after providing care, and upon exiting a resident's room. The DON/IP further stated she had been the DON and IP for almost five (5) years. She stated she tried to make daily rounds and educate staff regarding infection control procedures as needed.

2. Review of the facility's policy, titled Bedpan/Urinal, Offering/Removing, undated, revealed per the general guidelines, bedpans and/or urinals were required to be labeled with the resident's name and would be stored

in a clean and dignified manner. Continued review revealed bedpans or urinals would not be left in the bathroom or on the floor.

During the initial tour of the facility, on 02/02/2025 at 2:40 PM, there was a urinal which was not labeled with Resident R28's name, was not dated, and was uncovered. The urinal was sitting on the floor next to Resident R28's bed, which was out of reach for the resident.

Interview with Resident R28 on 02/02/2025 at 2:40 PM, revealed staff assisted him with using the urinal so he would not have placed the urinal on the floor. Further interview revealed the resident required staff to check his brief as he was sometimes incontinent.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 185112 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of Resident R28's Quarterly Minimum Data Set (MDS), dated [DATE REDACTED], located in the electronic medical record, revealed the facility assessed the resident as having a Brief Interview for Mental Status score of 15 out of 15, Level of Harm - Minimal harm or which indicated intact cognition. Continued review revealed the facility assessed Resident R28 as being frequently potential for actual harm incontinent of bladder.

Residents Affected - Few Observations on 02/02/2025 at 5:16 PM; 02/03/2025 at 10:15 AM; 02/05/2025 at 2:43 PM; and 02/06/2025 at 9:23 AM, revealed Resident R28's urinal was unlabeled with the resident's name, undated, and uncovered on the floor or hanging from the rail in the bathroom.

During interview with CNA5, on 02/02/2025 at 2:58 PM, she stated Resident R28 was totally dependent on staff for toileting and was not able to place the urinal on the floor. CNA5 stated she was not sure who placed the urinal on the floor, but it had to be a staff member. CNA5 stated she had been trained on bedpans and urinals and both were to be labeled with the resident's name, dated and stored in a bag to prevent the spread of bacteria. The CNA stated urinals were not to be placed on the floor per the facility's policy.

During interview with Registered Nurse (RN)1, on 02/02/2025 at 3:14 PM, she stated urinals were to be labeled with the resident's name, dated and placed in a bag and kept in the bathroom unless the resident had a preference of keeping it on a bedside table for easier reach. However, RN1 stated Resident R28 was totally dependent for urinary needs and would not be able to use the urinal independently. She stated it was an infection control issue if the urinals weren't labeled with the resident's name, dated and bagged as it could spread bacteria to not only that resident but to another resident.

3. During observation on 02/03/2025 at 9:47 AM, Resident R50's bathroom had two (2) urinals which were unlabeled with the resident's name, undated, and uncovered sitting on the back of the commode. Additionally, there was an uncovered bedpan on the back of the commode.

During an interview on 02/05/2025 at 1:46 PM with the Director of Nursing/Infection Preventionist (DON/IP),

she stated the urinals should be labeled with resident's name, dated, bagged, and stored per facility policy.

She stated the urinals should be stored per the resident's preference. The DON/IP stated she made daily rounds. However, she did not go into residents' bathrooms during those rounds. She stated it was an infection control issue if urinals and bed pans were not labeled, dated and bagged as it could potentially cause the spread of bacteria which could lead to urinary tract infections. She stated all nursing staff was responsible for making sure the policy was followed.

During an interview, on 02/06/2025 at 2:32 PM, with the Administrator, she stated general hand washing was number one, and donning PPE as indicated was expected of all staff. She stated she left it to her clinical management to make rounds to ensure there were no infection control concerns. She stated she expected all staff to follow the facility's infection control policies.

52131

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 185112

F-F610.

The findings include:

Review of the facility's policy, titled Abuse Reporting, undated, revealed the Administrator or person in charge, would notify immediately, the state licensing and certification agency, the resident's representative,

the attending physician, and law enforcement officials when the facility received an allegation of abuse.

Review of Resident 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 Resident 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 Resident R2, she stated on 12/24/2024, CNA2 was rough while providing care. Resident R2 stated CNA2 continued to provide rough care and she told CNA2, if she continued to be rough during care, she would report her. Resident R2 stated CNA2 then responded, if you report me, I will beat your ass. Resident 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, Resident R2 stated CNA1 was in the room assisting to pull Resident R2 up in bed during

this incident. Resident R2 stated RN1 brought the phone in her room and Resident R2 spoke with the Administrator. Resident R2 stated

she informed the Administrator of CNA2's statement that she would beat her ass if Resident 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 Resident R2's room just after supper, the resident was crying. CNA6 stated Resident R2 alleged CNA2 told her, she would smack the fire out of her if Resident 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 Resident R2's room on 12/24/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 15 185112 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 During an interview on 02/04/2025 at 3:06 PM, with CNA2, she denied being in Resident R2's room on 12/24/2024. CNA2 stated on 12/24/2024 she was instructed by RN1 to go to the breakroom and was then informed that Level of Harm - Actual harm Resident R2 had accused her (CNA2) of saying she was going to hit her.

Residents Affected - Few During an interview, on 02/05/2025 at 11:45 AM, with RN1, she stated on 12/24/2024 around 5:00 PM, CNA6 reported an allegation. RN1 stated per her recollection, Resident R2 told CNA6, that CNA2 told her if she did not quiet down, she would slap the shit out of her. RN1 stated she then went immediately to Resident R2's room and spoke with her. The RN stated during her conversation with Resident R2, the resident told her she was afraid of CNA2. RN1 stated she did not document this allegation, but had CNA1 and CNA2 stay in the break room while she contacted the Administrator. RN1 stated the Administrator spoke with Resident R2 on the phone while CNA1 and CNA2 remained in the breakroom, and then the Administrator spoke with CNA1 and CNA2 by phone.

During an interview on 02/03/2025 at 2:14 PM with Resident R2's sister, she stated that on 12/24/2024 between 7:30-8:00 PM, upon entering the facility she was informed by RN1 that Resident R2 had alleged rough care by CNA2 and reported CNA2 had told her she would beat the shit out of her if she reported her. The sister stated RN1 had also informed her that Resident R2 had been crying and maybe she could help calm her down. Upon entering the room, Resident R2 appeared to have been crying and stated her feelings were hurt. Resident R2 then repeated to the sister the same allegation as RN1 had informed her of.

During interview with RN1, on 02/05/2025 at 11:45 AM, she stated after the Administrator spoke with Resident R2, CNA1, and CNA2 by phone, which was just after 5:00 PM, the Administrator told her to have CNA2 to go to

the front hall and continue working as she did not suspect any abuse. In further interview with RN1, she stated the Administrator instructed her to not allow CNA2 to go back down the hallway where Resident R2 resided.

RN 1 stated she informed the Administrator of the allegation of verbal abuse as well as the allegation of rough care provided to Resident R2 by CNA2.

During an interview on 02/04/2025 at 11:27 AM, with the Administrator, she stated on 12/24/2024 around 5:00 PM, RN1 informed her of an allegation of CNA2 providing rough care made by Resident R2. The Administrator stated she then had a 20 minute conversation with Resident R2 via phone, and during this call Resident R2 was unable to explain what she meant by the CNA being rough. The Administrator stated she then spoke with CNA1, and CNA2. She stated after the phone interviews with Resident R2, CNA1 and CNA2, she did not feel this was an allegation of abuse, but only a concern and therefore she did not report the allegation to State Agencies or local law enforcement. However, she stated she was not made aware Resident R2 had alleged that CNA2 told her she would beat the shit out of her. The Administrator stated she was only informed Resident R2 had stated CNA2 was rough while providing care.

During an interview on 02/06/2025 at 5:08 PM, with the Medical Director, he stated he was made aware of

an allegation made by Resident R2 on 12/24/2024 by the Administrator. The Medical Director stated he was told Resident R2 alleged an aide had been abusive or rough while providing care. He stated he was further informed the allegation had been worked out and although Resident R2 did not like CNA2, there had not been any type of abuse. In further interview, the Medical Director stated he would expect the facility to report any allegations of abuse to

the appropriate state entities.

52131

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 15 185112 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations.

Level of Harm - Actual harm 44974

Residents Affected - Few Based on interview, record review and review of the facility's policy, the facility failed to conduct a thorough investigation in response to an alleged violation of abuse, for 1 of 19 sampled residents (Resident (R)2).

Resident R2 reported Certified Nursing Assistant (CNA)2 was rough while providing care on 12/24/2024. Resident R2 reported CNA2 told her, if you report me, I will beat your ass. However, the facility failed to conduct a thorough investigation related to the allegation of abuse. CNA2 was allowed to continue working on 12/24/2024 unsupervised, allowing for the potential of further abuse. (Refer to