The University of Kentucky
Since its inception The Breckinridge has drawn on the resources of The Sanders-Brown Center on Aging at The University of Kentucky to create a facility that is state-of-the-art in Alzheimer’s care. The Breckenridge maintains an affiliation with the The University of Kentucky for the purpose of furthering Alzheimer’s research and education and providing clinical care for residents and their families.
AGING AND ENVIRONMENT
A critical look at an aging environment, The Breckinridge, specific to the context of dementia and Alzheimer’s Disease.
— Pamela Desin
The Breckinridge, located on Cornerstone Drive in Lexington, Kentucky, is an early Alzheimer’s and related dementia care facility that was built in November 1998. It is off the beaten path, and a visitor must be vigilant to see the long driveway graced by two brick pillars, one that says The Breckinridge and one that lists the address One of the features that set it apart was that it was the first and only dementia facility at the time; there was nothing else available except nursing homes. The main front door has a doorbell that has to be rung to gain access, and a staff member will come through a locked door to a small vestibule and open the outside door. The facility also employs a pull cord pager system instead of bell ringing. Upon entering the facility, there are no smells except for food around meal time or a baking activity. There are no odors of any kind, no personal smells, and no cleaning supply smells. It is remarkably quiet for the number of people there. Other noticeable environmental cues are the peaceful, welcoming common areas full of engaged residents. The serenity is necessary with the population who live here. People with different types of dementia respond to the stimuli around them. The staff keeps the facility as quiet as possible to avoid over stimulating their residents.
The Breckinridge is licensed to house twenty-six occupants, but typically maintains a population of twenty-four. They currently have twenty-three, with a new admission scheduled in January 2014. It is a private pay establishment, not certified for participation in Medicare or Medicaid. There is an up-front Assessment fee that is refunded if the person is deemed ineligible for admission. If the criteria is met and a room is available, the fee is non-refundable. The monthly resident fee includes meals, personal care, laundry, housekeeping, activities, and cable television. The monthly fee does not include any activity outside the on-site care. Escorts to appointments, medications, long-distance calls, beauty/barber services, and purchase of personal supplies are some things not covered. Resident and personal fee payments are due monthly. Respite care is also available at Breckinridge when space is available, and fees are charged daily, payable in advance, but with no Assessment fee. All long and short term residents must meet the same eligibility criteria: have an irreversible and progressive dementia diagnosis; not have a communicable disease; be able to communicate enough to be understood; not have combative or dangerous behaviors; be able to pay; and be independent in mobility and personal care. Six years ago, these criteria were easily met. Now, there are instances of several residents needing assistance with toileting and personal care, and at least one current resident exhibits word salad in verbal communication.
Ellen Fidler, was there the day ground was broken for the facility, and she still oversees the activities as the Director at the Breckinridge. Ellen list the largest expenditure as the pay roll. At inception, caregivers made around $9.00 per hour. Today, they start at $13.00 per hour. Some other staff members are Donna Townsend, the Activities Director who has been there fourteen years and is the social leader of the facility, and my tour guide, Janel, who has been assisting with many aspects of care for about thirty years but has only been at the Breckinridge for about six years. She is hands-on when it comes to patient care, and instrumental in the flow of activities and keeping the mood upbeat. Her gentle but bubbly personality speaks to the residents respectfully and honestly as she communicates and interacts with them.
The building consists of an inviting, open floor plan with two living/social areas displaying couches, chairs, tables and coffee tables, televisions, bookshelves, and a fireplace. Furniture in the common areas and throughout the facility is plentiful, with suitable walking paths between pieces, but none so far apart that there is nothing to grab onto in case of falls. Between these two living areas is a central kitchen and dining area. There is one analog clock in this area. One wall of the dining area consists of large windows, and doors leading to a large garden area that the residents can go out to at any time. According to Ellen, any door that looks like a door, the residents can go through without any alarms being triggered. Staff are notified the door has been opened by a vibrating pager, and they can check to be sure the person is dressed appropriately for being out-of-doors. The garden area includes a walking trail that has been updated with rubber bricks for a softer landing, in case of falls. There are tables and chairs, and it is a well-decorated area. Smoking is allowed outside only, and there is currently only one resident who smokes.
The lighting throughout the facility is low, most of it recessed in tray ceilings and covered drop lights. Window treatments are sparse around the few windows in the common areas of the building, allowing natural light to flow in. Bedroom areas have window-length curtains, allowing for privacy and preferences of open or closed. There was no glare from any floor, as most are dark wood in the common areas, or soft, inviting green carpeting in the sleeping and living areas. There are very few tiled areas, and these have patterns, are in low-light areas, and not noticeably waxed to a shine. There are very distinctive breaks between the floors and walls, making them clearly delineated for sight-impaired persons. The hallways are free of clutter or unnecessary items, and wooden benches are installed in case of a needed rest or instability while walking. There are comfortable, smooth wooden handrails along all the walls throughout the common areas of the facility, except for the bathrooms and shower areas, which have metal grab bars. Each resident gets a shower two to three times per week, so it is important those safety bars are functional and available. Doors to the residents’ bedrooms are split or half doors, hinged so both the bottoms and tops of the doors can open independently. The door handles are levered, making them easier to open. Residents’ rooms are spacious, decorated with all their own furniture, knick-knacks, and pictures. Necessary accommodations are made as needed, such as low mattresses for fall-risks, and modifications to toilet areas for ease of use.
Daily routines and schedules do not vary much, as Alzheimer patients need a structured environment. Residents are awakened and helped to get ready for the day, and eat breakfast between 8:00 am and 10:30 am. They usually eat together in the dining room while watching television, but some may prefer to dine alone in their room. At noon, they prepare for lunch, serving a home-cooked meal from scratch at 12:30 pm. Twenty-nine to thirty-five people eat at this time, as the staff and residents dine together. Usually there are 5-10 staff eating lunch with the residents. Quiet time is 1; 30 pm to 3:30 pm and those not sleeping play trivia games, sing, have gospel, or do other quiet activities. Around 3:30 is tea time, when a snack is served. Then more robust activities, such as balloon volleyball, occur. At 6:00 pm a light dinner is served, including a sandwich and potato chips, or a casserole and rolls. After dinner is a wind-down period before getting ready for bed between 7:00 pm and 9:30 pm. There are no formal weekly church services, but a local deacon conducts a Bible Devotion for fifteen minutes or so every Thursday for anyone who wants to attend. Other local churches bring in groups that sing, put on plays or perform other activities throughout the year, and especially at Christmas.
Ellen proudly notes that over 70% of the employees have been there five years or longer; 40% have been there over ten years. She feels this translates into excellent care. Longevity of staff members and a low turnover rate also translates into satisfied employees, who give the facility its stability, continuity, and sustainability. Ellen feels that Breckinridge is the epitome of a successful aging environment. She said “Many have come along since, but none do it any better” (E. Fidler, personal communication, December 12, 2013). There is pride and caring evident in all the staff. Besides the cook, activity people, and caregivers, there is a full-time laundry person to wash personal clothing and linens, and housekeeping is there five days per week. The person who works in the salon is there once a week for styling and trims. There is a large activity calendar in the dining area listing events for the month. Some activities are making things for holidays such as gingerbread houses for Christmas, celebrating birthdays, Thanksgiving and Christmas dinners, playing the piano or a guitar, singing, trivia and other games, and watching television. They are trying to plan a trip to see the Southern Lights.
The daily caregiving staff at the facility consist of nurses who generally work twelve hours, beginning around seven or eight in the morning. An activity person is usually there twelve hours a day also during the week, as are caregivers who work twelve hour shifts, either 7:00 am to 7:00 pm or 7:00 pm to 7:00 am. The lowest staff to resident ratio during the day is on the weekends, when there are five caregivers on duty. After 9:00 pm, there are two staff members present. There is a separate staff room that is multipurpose, functioning as a conference room, break room, and care plan development area. This room is peach colored with large cabinets for personal items.
The residents are varied in their backgrounds, and include a steel worker, teachers, doctors, nurses, the spouse of an ambassador, a distillery worker, FBI person, people who worked in the horse racing industry, a minister, and even a professor at EKU. I met Lawrence, a resident who showed me his room, blanket on his bed, and picture of his beautiful daughters. Another man, Russell was visiting with his daughter, Vickie, and spoke with us about life at Breckinridge. Russell, born in 1930, told me he had moved into the facility about nine months ago. He said he likes it because he can do what he wants, and he takes it upon himself to look out for others. He is considered a hero for saving a woman from falling and being seriously injured when he rushed to her and was in time to ease her fall, before going to get help for her. His daughter likes the facility because she is sure he is getting the best treatment, with proper medications, meals, and socializing only to the extent that he wants it. She likes that he has privacy, and feels secure in his environment, and she is happy knowing he is safe and content. She said all his needs are attended to, leaving him with zero stress. Russell worked for thirty years in a steel mill and two days after he retired and received his pension the company went bankrupt. Those who were retiring mere days behind him lost everything. He feels lucky that he was spared that loss. His daughter visits three to four times a week, and he now spends his time walking in the garden three or four times a day. He likes that the staff tailors things like his food and drink, giving him a larger than usual glass of milk since he drinks more than other residents, and providing food that is “very good”. He found out about Breckinridge through his doctors, who recommended it to the family. They like that he can have his own furniture and personal items with him. They also keep a calendar of all visitors that have come to see him or are pending. This helps to keep him from becoming lonely, because he has something to look forward to. They even have a favorite table in the dining room where they sit for their visit. Many of the residents have a preferred seat they call their own.
Another family I met was Phyllis and her daughter Carla, who were in the beauty salon having a little mother-daughter bonding time over hair coloring. Phyllis was very animated and happy, and had an infectious laugh that made her eyes light up. It was clear she was a happy woman at Breckinridge which, in turn, seemed to please her daughter. These interviews echo what Ellen told me: “We try to keep their routines as much like home as possible – bearing in mind that at home they likely didn’t live with 23 other people. This is our residents’ home and we simply come to work here. We’re mindful of that” (E. Fidler, personal communication, December 12, 2013).
There are no current plans to expand this facility in the future. Their goal is to continue giving the best care possible to people with a dementing illness. Ellen wishes they had also put a fireplace in the dining area when it was built, and she would have allowed for more storage space, as it is at a premium. They do have other facilities in Texas, and are looking at expansion down the road. She describes the typical day for her and Donna, the only two managerial positions. Ellen is on call 24/7, with Donna relieving her every other weekend and when she is on vacation. Ellen is in charge of schedules, dealing with any employee issues that arise, attending meetings, interactions in the community, marketing, meeting new families, evaluating staff members, creating the menus then going grocery shopping, testing of safety equipment, case management of residents (such as behavioral issues), organizing monthly team meetings, and drafting and conducting care plans for every residents at least two times per year. The other staff members are in charge of caregiving, the most important facet of their job. There is nothing more important than care of the residents from the time they get up in the morning until they go to bed at night, and even throughout the night. Resident safety and care is the top priority.
The Breckinridge in Lexington was a one-of-a-kind when it was built and is still a fine institution today. The staff members are kind, caring, and appreciate the special needs of the people they care for. The caregivers seem well taken care of by their employers which translates into successful caregiving that only comes from loving the work. Everything the staff was doing pertained to putting the residents’ needs first, and it created a quiet and serene environment. There was little stress, and everyone seemed content. No one appeared to be overmedicated. Indeed, most seemed fully cognizant, like the woman who asked my husband who I was and he said “My wife” and she answer “Ohhhh… she’s a big one!” We laughed at her lack of filters, but she was stating the truth, and that may have been her personality across her life course. Most everyone conversed freely and easily with me, and I had no ill encounters. One of the nurses shared her knowledge of dementia, giving me an appreciation of the perspective from a different discipline. Everything was tidy, clean, and in pristine condition. It is an obviously well taken care of facility. I was impressed that I could only find one minor thing that I would change, and that is to add more clocks, with large digital readouts, for the staff and those residents who like to keep track of time. Some residents had clocks in their rooms, so being able to see the time outside of their room might be an important consideration to them. Since I was not there on a sunny day, it would be difficult to state there is no glare on the floor but, given the dark color, I doubt there would be any problems. Also, it was difficult to tell because it was raining, but I believe the dining room windows and doors may have been tinted.
My information was gathered from interviews, a pamphlet given to me by Janel, notes from my visit, pictures we took, and the Breckinridge website, www.thebreckinridge.com. All in all, a wonderful experience, pleasant people, and a place I am proud to know exists in Kentucky, specifically in Lexington. It is a place I would be comfortable as a setting for a loved one if there were no other choices. It is not a home. It is their home.