A list of the most recent deficiencies for Breakwater Commons. 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? |
---|---|---|---|---|
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 | 2023-10-31 | 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 | 2023-10-31 | 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 | 2023-10-31 | 2023-12-15 | N |
Establish policies and procedures for sheltering. | Fire Safety | 2023-10-31 | 2023-12-15 | N |
Establish methods for sharing information. | Fire Safety | 2023-10-31 | 2023-12-15 | N |
Establish emergency prep training and testing. | Fire Safety | 2023-10-31 | 2023-12-15 | N |
Establish staff and initial training requirements. | Fire Safety | 2023-10-31 | 2023-12-15 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-31 | 2023-12-15 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2023-10-31 | 2023-12-15 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-31 | 2023-12-15 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-31 | 2023-12-15 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-31 | 2023-12-15 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-31 | 2023-12-15 | N |
Have restrictions on the use of flammable curtains. | Fire Safety | 2023-10-31 | 2023-12-15 | N |
Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-10-31 | 2023-12-15 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-31 | 2023-12-15 | N |
Meet requirements for the use of electrical equipment. | Fire Safety | 2023-10-31 | 2023-12-15 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-31 | 2023-12-15 | N |
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 |
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 |
Post nurse staffing information every day. | 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 |
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 |
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 |
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 |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-05 | 2022-02-19 | N |
Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-01-03 | 2022-01-21 | N |
Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-01-03 | 2022-01-21 | N |
Establish policies and procedures for medical documentation. | Fire Safety | 2022-01-03 | 2022-01-21 | N |
Provide family notifications of emergency plan. | Fire Safety | 2022-01-03 | 2022-01-21 | N |
Establish staff and initial training requirements. | Fire Safety | 2022-01-03 | 2022-01-21 | N |
Conduct testing and exercise requirements. | Fire Safety | 2022-01-03 | 2022-01-21 | N |
Implement emergency and standby power systems. | Fire Safety | 2022-01-03 | 2022-01-21 | N |
Meet other general requirements. | Fire Safety | 2022-01-03 | 2022-01-21 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-03 | 2022-01-21 | 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 | 2022-01-03 | 2022-01-21 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2022-01-03 | 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 | 2022-01-03 | 2022-01-21 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2022-01-03 | 2022-01-21 | N |
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-01-03 | 2022-01-21 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-03 | 2022-01-21 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-03 | 2022-01-21 | N |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-15 | 2021-08-29 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-15 | 2021-08-29 | Y |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-15 | 2021-08-29 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-15 | 2021-08-29 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-07-15 | 2021-08-29 | Y |
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-07-15 | 2021-08-29 | Y |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-08-15 | 2019-09-16 | N |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-08-15 | 2019-09-16 | 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 | 2019-08-15 | 2019-09-16 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-15 | 2019-09-16 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-15 | 2019-09-16 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-15 | 2019-09-16 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-15 | 2019-09-16 | N |