CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Breakwater Commons
View the most recent health deficiencies and inspection results for Breakwater Commons. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Breakwater Commons. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-05-28 | 2025-08-01 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2025-05-28 | 2025-08-01 | 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 | 2025-05-28 | 2025-07-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-05-28 | 2025-07-10 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2025-05-28 | 2025-07-10 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2025-01-23 | 2025-03-04 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2025-01-23 | 2025-03-04 | 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 | 2025-01-23 | 2025-03-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-01-23 | 2025-03-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-01-23 | 2025-03-04 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2025-01-23 | 2025-03-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-01-23 | 2025-03-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-01-23 | 2025-03-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-01-23 | 2025-03-04 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2025-01-23 | 2025-03-04 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2025-01-23 | 2025-03-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-01-23 | 2025-03-04 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2025-01-23 | 2025-03-04 | Y |
| Assess the resident when there is a significant change in condition | Health | 2025-01-23 | 2025-03-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-01-23 | 2025-03-04 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2025-01-23 | 2025-02-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-01-23 | 2025-02-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2025-01-23 | 2025-02-06 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2025-01-23 | 2025-01-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-01-23 | 2025-01-21 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-11-12 | 2024-12-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-11-12 | 2024-12-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-09-26 | 2024-11-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-09-26 | 2024-11-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-09-26 | 2024-11-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-26 | 2024-11-08 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-09-26 | 2024-11-08 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-09-26 | 2024-11-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-10 | 2024-05-30 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-10 | 2024-05-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-10 | 2024-05-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-04-10 | 2024-05-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-13 | 2024-04-12 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-11-01 | 2023-12-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-01 | 2023-12-22 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-11-01 | 2023-12-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-01 | 2023-12-19 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Establish methods for sharing information. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Post nurse staffing information every day. | Health | 2023-11-01 | 2023-12-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-01 | 2023-12-01 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-01 | 2023-12-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-01 | 2023-12-01 | 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 | 2023-11-01 | 2023-12-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-26 | 2023-11-15 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-26 | 2023-11-15 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-05 | 2022-02-19 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-01-05 | 2022-02-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-05 | 2022-02-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-01-05 | 2022-02-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-05 | 2022-02-19 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Meet other general requirements. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-01-05 | 2022-01-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-10-30 | Not Fixed | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2025-01-23 | Not Fixed | N |