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Deficiency Records for Breakwater Commons
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.
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 | 2023-10-31 | 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 |
| 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 |
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