Breckinridge Place

In the surveyor’s words

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

• Actual harm, isolatedF656Apr 15, 2022

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Care Plan was implemented for one (1) of four (4) sampled residents (Resident #17). The facility care planned Resident #17 to require extensive assistance of two (2) staff for turning, repositioning, and bed mobility. However, on 02/21/2022, Certified Nursing Assistant (CNA) #1 provided incontinent care for Resident #17 alone, and without the care planned assistance of two (2) staff members. During the provision of incontinent care by only CNA #1, Resident #17 rolled off the bed and was observed as bleeding from his/her face. […]

• Actual harm, isolatedF689Apr 15, 2022

  Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents received adequate supervision and assistive devices to prevent accidents (Resident #17). The facility assessed and care planned Resident #17 to be at risk for falls and to require the assistance of two (2) staff for bed mobility and incontinent care. However, on 02/21/2022 Certified Nursing Assistant (CNA) #1 provided incontinent care to the resident without the assistance of another staff member as per the care plan. As a result, Resident #17 rolled off the side of the bed during the incontinent care provided by CNA #1. […]

• No harm, potential for more than minimal, widespreadF812Apr 15, 2022

  Based on observation, interview, and facility policy review, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation revealed opened food items in the facility's reach in refrigerator and dry storage area which were not dated. The findings include: Review of the facility policy titled, Dietary Services Food Handling and Preparation, Dry Storage, dated 08/01/2015, revealed all foods were to be labeled as to content and dated. Observation on 04/12/2022 at 9:03 AM, of the facility's kitchen area revealed the reach in refrigerator had an opened container of beef base flavoring that was approximately half full; however, was not labeled or dated. […]

• No harm, potential for more than minimal, isolatedF760Jul 20, 2023

  Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents were free of significant medication errors for one (1) of three (3) residents sampled for medication administration in a total sample of twenty-four (24) residents (Resident #16). Observation of medication administration on 07/19/2023 at 9:18 AM, revealed Certified Medication Aide (CMA) #1 dropped a white tablet onto Resident #16's left leg. He proceeded to obtain another tablet from the medication cart and he placed a pink tablet in the medicine cup. […]