A list of the most recent deficiencies for Breakwater Village. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-01 | 2023-03-20 | N |
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-02-01 | 2023-03-20 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-01 | 2023-03-20 | N |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-01 | 2023-03-20 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-01 | 2023-03-20 | N |
Provide activities to meet all resident's needs. | Health | 2023-02-01 | 2023-03-20 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-01 | 2023-03-20 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-01 | 2023-03-20 | N |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-02-01 | 2023-03-20 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-10 | 2023-02-22 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-10 | 2023-02-22 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-25 | 2020-04-24 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-02-25 | 2020-04-24 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-25 | 2020-04-24 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-18 | 2020-04-22 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-18 | 2020-04-22 | N |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-02-18 | 2020-04-22 | N |
Provide activities to meet all resident's needs. | Health | 2020-02-18 | 2020-04-22 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-18 | 2020-04-22 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-02-18 | 2020-04-22 | N |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-02-18 | 2020-04-22 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-18 | 2020-04-22 | N |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-02-18 | 2020-04-22 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-02-18 | 2020-04-22 | N |
Provide or obtain dental services for each resident. | Health | 2020-02-18 | 2020-04-22 | N |
Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2020-02-18 | 2020-04-22 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-18 | 2020-04-22 | N |
Provide and implement an infection prevention and control program. | Health | 2020-02-18 | 2020-04-22 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-04 | 2019-02-25 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2019-02-04 | 2019-02-25 | N |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-02-04 | 2019-02-25 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-04 | 2019-02-25 | N |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-02-04 | 2019-02-25 | N |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-02-04 | 2019-02-25 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-02-04 | 2019-02-25 | N |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-02-04 | 2019-02-25 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-04 | 2019-02-25 | N |
Post nurse staffing information every day. | Health | 2019-02-04 | 2019-02-25 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-04 | 2019-02-25 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-04 | 2019-02-25 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-02-04 | 2019-02-25 | N |