Facility profile · CCN 205124
Breakwater Commons
49 federal citations on record , and 2 federal enforcement actions totaling $11,998.
Record summary
Federal record · Q1 202649
Total citations
44
Last 3 years
1
Actual harm+
2
Federal penalties
$11,998
Total fines
1
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
49 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| May 28, 2025 | F940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. | D | Complaint |
| May 28, 2025 | F880 | Provide and implement an infection prevention and control program. | E | Complaint |
| May 28, 2025 | F865 | Have a plan that describes the process for conducting QAPI and QAA activities. | D | Complaint |
| May 28, 2025 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Complaint |
| May 28, 2025 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Complaint |
| Jan 23, 2025 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | Complaint |
| Jan 23, 2025 | F637 | Assess the resident when there is a significant change in condition | D | Complaint |
| Jan 23, 2025 | F584 | 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. | E | Complaint |
| Jan 23, 2025 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint |
| Jan 23, 2025 | F947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | E | Standard |
| Jan 23, 2025 | F887 | 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. | D | Standard |
| Jan 23, 2025 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Standard |
| Jan 23, 2025 | F880 | Provide and implement an infection prevention and control program. | D | Standard |
| Jan 23, 2025 | F868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | D | Standard |
| Jan 23, 2025 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard |
| Jan 23, 2025 | F761 | 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. | E | Standard |
| Jan 23, 2025 | F730 | Observe each nurse aide's job performance and give regular training. | D | Standard |
| Jan 23, 2025 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | E | Standard |
| Jan 23, 2025 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E | Standard |
| Jan 23, 2025 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E | Standard |
| Jan 23, 2025 | F578 | 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. | E | Standard |
| Nov 12, 2024 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D | Complaint |
| Nov 12, 2024 | F557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | E | Complaint |
| Oct 30, 2024 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | B | Complaint |
| Sep 26, 2024 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Complaint |
| Sep 26, 2024 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | Complaint |
| Sep 26, 2024 | F610 | Respond appropriately to all alleged violations. | D | Complaint |
| Sep 26, 2024 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Sep 26, 2024 | F585 | 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. | D | Complaint |
| Sep 26, 2024 | F584 | 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. | E | Complaint |
| Apr 10, 2024 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Complaint |
| Apr 10, 2024 | F610 | Respond appropriately to all alleged violations. | D | Complaint |
| Apr 10, 2024 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Apr 10, 2024 | F558 | Reasonably accommodate the needs and preferences of each resident. | D | Complaint |
| Mar 13, 2024 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint |
| Nov 1, 2023 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint |
| Nov 1, 2023 | F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | D | Standard |
| Nov 1, 2023 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard |
| Nov 1, 2023 | F732 | Post nurse staffing information every day. | B | Standard |
| Nov 1, 2023 | F625 | 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. | B | Standard |
| Nov 1, 2023 | F623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | B | Standard |
| Nov 1, 2023 | F584 | 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. | E | Standard |
| Sep 26, 2023 | F761 | 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. | D | Complaint |
| Sep 26, 2023 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Complaint |
| Jan 5, 2022 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Standard |
| Jan 5, 2022 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D | Standard |
| Jan 5, 2022 | F761 | 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. | D | Standard |
| Jan 5, 2022 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Standard |
| Jan 5, 2022 | F637 | Assess the resident when there is a significant change in condition | D | Standard |
Federal enforcement history
Federal regulators have imposed 2 enforcement actions against this facility, including 2 civil money penalties totaling $11,998 .
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| Aug 28, 2023 | Fine | $3,529 | — |
| Aug 7, 2023 | Fine | $8,469 | — |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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