Deficiency Records for Breakwater Village
Updated as of August 01, 2024
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Deficiency Records for Breakwater Village
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.
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 each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-03-20 | 2024-05-03 | 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 | 2024-03-20 | 2024-05-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-03-20 | 2024-05-03 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-03-20 | 2024-05-03 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-03-20 | 2024-05-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-20 | 2024-05-03 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-03-20 | 2024-05-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-20 | 2024-05-03 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2024-03-20 | 2024-05-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-20 | 2024-05-03 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-04-04 | 2024-04-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-04 | 2024-04-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-04-04 | 2024-04-30 | N |
| 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 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-10 | 2022-10-14 | 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 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 |
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