Jackson, KY

Breathitt Health & Rehabilitation

2-star overall rating with 2-star inspections with abuse icon flag with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

420 Jett Drive, Jackson, KY

(606) 666-2456

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

70

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Lyon Healthcare

Operator or chain grouping

Approved since

1972-07-19

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

14 facilities

Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.87

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.53

Licensed practical nurse staffing · state 0.81 · national 0.87

Aide hours / resident day

1.65

Nurse aide staffing · state 2.43 · national 2.35

Total nurse hours

3.06

All reported nurse hours · state 4.01 · national 3.89

Licensed hours

1.40

RN + LPN hours · state 1.58 · national 1.54

Weekend hours

2.45

Weekend nurse staffing · state 3.50 · national 3.43

Weekend RN hours

0.49

Weekend registered nurse coverage · state 0.52 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.62

CMS adjusted RN staffing hours

Adjusted total hours

2.16

CMS adjusted total nurse staffing hours

Case-mix index

1.93

Higher values indicate more complex resident acuity

RN turnover

22%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

25%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,467

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

23.59

Composite VBP score used to determine payment impact.

Payment multiplier

0.9832

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.52

Performance 20.26% · Measure score 2.52 · Achievement 2.52 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

0

Performance 11.61% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

6.91

Performance 35.42% · Measure score 6.91 · Achievement 6.91 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

0

Baseline 4.35 hours · Performance 2.59 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.07%	10.72% 0.3 pts worse	No Different than the National Rate · Eligible stays 57 · Observed rate 14.04% · Lower 95% interval 8.08%
Discharge to community	46.31%	50.57% 4.3 pts worse	No Different than the National Rate · Eligible stays 41 · Observed rate 36.59% · Lower 95% interval 31.2%
Medicare spending per beneficiary	1.52	1.02 0.5 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 37 · Denominator 37
Falls with major injury	2.7%	0.77% 1.9 pts worse	Numerator 1 · Denominator 37
Discharge self-care score	9.09%	53.69% 44.6 pts worse	Numerator 2 · Denominator 22
Discharge mobility score	9.09%	50.94% 41.8 pts worse	Numerator 2 · Denominator 22
Pressure ulcers or injuries, new or worsened	2.7%	2.29% 0.4 pts worse	Numerator 1 · Denominator 37 · Adjusted rate 1.62%
Healthcare-associated infections requiring hospitalization	11.61%	7.12% 4.5 pts worse	No Different than the National Rate · Eligible stays 45 · Observed rate 24.44% · Lower 95% interval 6.12%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 49
Staff flu vaccination coverage	39.39%	42% 2.6 pts worse	Numerator 26 · Denominator 66
Discharge function score	4.55%	56.45% 51.9 pts worse	Numerator 1 · Denominator 22
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 19 · 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	2.6	1.9 0.7 pts worse	1.9 0.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.6 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	4.6	2.2 2.4 pts worse	1.8 2.8 pts worse	Long Stay · 20240701-20250630 · Adjusted 4.6 · Observed 4.6 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	94.3% 5.7 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	96.2% 3.8 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	3.8%	3.8% About the same	3.3% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.0% · Q3 6.1% · Q4 5.5% · 4Q avg 3.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	68.1%	15.2% 52.9 pts worse	11.4% 56.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 77.1% · Q2 68.2% · Q3 54.8% · Q4 70.8% · 4Q avg 68.1%
Percentage of long-stay residents who lose too much weight	14.3%	6.7% 7.6 pts worse	5.4% 8.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 21.4% · Q3 6.5% · Q4 11.5% · 4Q avg 14.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	49.3%	29.6% 19.7 pts worse	19.6% 29.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 54.9% · Q2 53.1% · Q3 47.9% · Q4 41.5% · 4Q avg 49.3%
Percentage of long-stay residents who received an antipsychotic medication	9.2%	17.6% 8.4 pts better	16.7% 7.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 6.7% · Q3 6.2% · Q4 12.5% · 4Q avg 9.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	11.0%	17.3% 6.3 pts better	16.3% 5.3 pts better	Long Stay · 2024Q4-2025Q3 · Q3 14.8% · Q4 13.7% · 4Q avg 11.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	9.7%	15.6% 5.9 pts better	14.9% 5.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.0% · Q3 12.5% · Q4 17.1% · 4Q avg 9.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.0%	0.7% 0.3 pts worse	1.0% About the same	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.7% 1.7 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	16.5%	19.8% 3.3 pts better	19.8% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 14.0% · Q3 19.5% · Q4 17.9% · 4Q avg 16.5%
Percentage of long-stay residents with pressure ulcers	2.7%	5.5% 2.8 pts better	5.1% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.4% · Q3 1.3% · Q4 5.3% · 4Q avg 2.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	92.1%	83.8% 8.3 pts better	81.7% 10.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 91.3% · Q3 94.7% · Q4 91.1% · 4Q avg 92.1%
Percentage of short-stay residents who had an outpatient emergency department visit	17.0%	13.9% 3.1 pts worse	12.0% 5 pts worse	Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 19.4% · Expected 12.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.8% 1.8 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	91.7%	83.6% 8.1 pts better	79.7% 12 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	13.2%	24.5% 11.3 pts better	23.9% 10.7 pts better	Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 16.1% · Expected 29.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-07 · Fire 2025-02-07

6 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2019-08-29 · Fire 2019-08-29

0 health deficiencies

No concentrated health issue counts in this cycle.

5 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2018-06-07 · Fire 2018-06-07

8 health deficiencies

Top issue: Resident Rights (3 deficiencies)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-07

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-02-27

E · Potential for more than minimal harm 2025-02-07

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-02-27

E · Potential for more than minimal harm 2025-02-07

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-02-07

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-02-07

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-02-07

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-02-07

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-02-07

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-02-27

F · Potential for more than minimal harm 2019-08-29

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2019-09-19

E · Potential for more than minimal harm 2019-08-29

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-09-19

E · Potential for more than minimal harm 2019-08-29

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2019-09-19

D · Potential for more than minimal harm 2019-08-29

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2019-09-19

D · Potential for more than minimal harm 2019-08-29

K500 · Services Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2019-09-19

E · Potential for more than minimal harm 2018-06-07

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2018-06-28

Inspection history

Recent health citations

G · Actual harm 2025-02-07

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-03-09

G · Actual harm 2025-02-07

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-03-09

G · Actual harm 2025-02-07

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-03-09

F · Potential for more than minimal harm 2025-02-07

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-03-09

D · Potential for more than minimal harm 2025-02-07

F576 · Resident Rights Deficiencies

Health

Ensure residents have reasonable access to and privacy in their use of communication methods.

Corrected 2025-03-09

D · Potential for more than minimal harm 2025-02-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-09

E · Potential for more than minimal harm 2018-06-07

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2018-06-28

D · Potential for more than minimal harm 2018-06-07

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2018-06-28

D · Potential for more than minimal harm 2018-06-07

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2018-06-28

D · Potential for more than minimal harm 2018-06-07

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2018-06-28

D · Potential for more than minimal harm 2018-06-07

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2018-06-28

D · Potential for more than minimal harm 2018-06-07

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2018-06-28

D · Potential for more than minimal harm 2018-06-07

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2018-06-28

D · Potential for more than minimal harm 2018-06-07