Deficiency Records for Breakwater Village
Updated as of February 01, 2021
This is not the most recent data for Breakwater Village. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2020-08-28 | 2020-08-28 | Y |
| 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 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 |
| 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 |
| 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 | Y |
| 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 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-21 | 2019-12-30 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-11-21 | 2019-12-30 | Y |
| 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 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-04 | 2018-05-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-04-04 | 2018-05-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-04-04 | 2018-05-09 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-04-04 | 2018-05-09 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-04-04 | 2018-05-09 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-04-04 | 2018-05-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-04-04 | 2018-05-09 | 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 | 2018-04-04 | 2018-05-09 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-04-04 | 2018-05-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-04 | 2018-05-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-04 | 2018-05-09 | 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 | 2018-04-04 | 2018-05-09 | N |
| Provide activities to meet all resident's needs. | Health | 2018-04-04 | 2018-05-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-04-04 | 2018-05-09 | 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 | 2018-04-04 | 2018-05-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-04-04 | 2018-05-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-04-04 | 2018-05-09 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2018-04-04 | 2018-05-09 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2018-04-04 | 2018-05-09 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-04-04 | 2018-05-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-04-04 | 2018-05-09 | 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 | 2018-04-04 | 2018-05-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-04 | 2018-05-09 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-03-29 | 2018-04-30 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2018-03-29 | 2018-04-30 | N |
