Breckinridge Memorial Nursing Facility

In the surveyor’s words

From the most serious findings on record at Breckinridge Memorial Nursing Facility, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Jan 3, 2025

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and/or implement a Comprehensive Care Plan (CCP) to ensure it met the residents' medical, nursing, mental, and psychosocial needs as identified on his/her comprehensive assessment and other assessments for one (1) of eighteen (18) sampled residents (Resident (R)1). On 04/27/2024, R1 exhibited exit seeking behaviors, however, staff failed to care plan the resident for these behaviors. On 04/28/2024, R1 eloped from the skilled nursing facility (SNF) unit, located in a hospital, via the elevator without staff's knowledge and was found in the lobby trying to exit through the doors. […]

• Immediate jeopardy, isolatedF689Jan 3, 2025

  Based on interview, record review, and review of the facility's investigation documentation and policies, the facility failed to have an effective system in place to ensure resident safety for 1 of 18 sampled residents, (Resident (R)1). On 04/27/2024, R1 exhibited exit-seeking behaviors, however, the facility failed to ensure the resident was provided increased supervision. On 04/28/2024, R1 eloped from the facility (a skilled nursing facility [SNF] unit) without staff knowledge and was found on the first-floor lobby (of the acute care hospital the facility was located in) trying to exit the building [facility]. […]

• Immediate jeopardy, isolatedF656Jan 29, 2021

  Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to follow the care plan for two (2) of ten (10) sampled residents (Resident #6 and Resident #1). Staff failed to follow the care plan for Resident #6 related to elopement; and, for Resident #1 related to falls. Resident #6 stated multiple times he/she wanted to leave the facility prior to the elopement, and the facility placed a Wanderguard (WG) on the resident. On 08/08/2020, Resident #6 exited three (3) doors utilized only by staff and not equipped with Wanderguard (WG) alarms to exit the second floor facility. Respiratory staff discovered Resident #6 at the bottom of the stairwell, without his/her walker, and near an exit door. […]

• Immediate jeopardy, isolatedF689Jan 29, 2021

  Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide an environment that was free from accident hazards as possible for six (6) of ten (10) sampled residents (Residents #1, #2, #3, #4, #5 and #6). Resident #6 was at risk for elopement and Residents #1, #2, #3, #4, and #5 related to falls. Resident #6 had a history of wandering and telling staff he/she was going to leave the facility. The facility obtained a Physician's Order to apply a Wanderguard (device to monitor the resident's whereabouts) device to the resident's person. However, the facility failed to increase the resident's supervision. […]

• No harm, potential for more than minimal, widespreadF812Mar 5, 2026

  Based on observation, interview, and policy review, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for contamination during meal service. These failures had the potential to affect 18 of 18 residents who received meals from the dietary department.Review of the facility policy, Nutritional Services Infection Prevention and Control, revised 08/29/2022, revealed food handlers were required to perform hand hygiene prior to contact with or preparation of food items and beverages. […]