Breakwater Commons

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 units (East, [NAME] and South Units) and the laundry room for 3 of 3 facility tours/observations. (4/6/26, 4/7/26 and 4/9/26)

Inspectors wroteBased on record review and interviews, the facility failed to report, allegations of Abuse to the Division of Licensing and Certification (DLC) (State Survey Agency) 5 incidents of resident-to-resident abuse, 4 incidents of resident-to-staff abuse, 3 incidents of resident-to-staff abuse and 1 incident of resident-to-visitor abuse for 1 of 21 residents reviewed during an annual recertification survey.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide written notice of transfer/discharge to resident/representatives, in addition the facility failed to provide written notice of bed hold to include cost of care and appeal rights to resident/representatives for 8 of 8 residents reviewed for hospitalization (Residents #1, #3, #7, #11, #54, #64, & #78).

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 10 residents reviewed for new admissions (Resident #61).

Inspectors wroteBased on record reviews and interviews, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 14 of 21 residents reviewed for care planning (Residents #1, #3, #7, #9, #11, #15, #54, #64, #65, #68, #74, #78, #105, #108).

Inspectors wroteBased on record review, observations, and interviews, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and ensure that two people who are authorized to administer medications signed the Shift Count page of the Controlled Substances Book [a logbook used to record controlled medications], indicating that they counted all controlled substances at the change of shift for multiple shifts, for 3 of 3 units observed (West Unit, South Unit, and East Unit).

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a food slicer, a food mixer, a food disposal unit, fans, chemicals, a hood system, a stove, floors and kitchenette refrigerators/freezers; and failed to ensure foods in food bins, a reach-in freezer, a walk-in refrigerator and a walk-in freezer were dated, labeled and/or sealed; and failed to ensure that kitchen staff members with facial hair wore facial hair protection for 3 of 3 kitchen/kitchenettes tours. (4/6/26)

Inspectors wroteBased on record reviews, interviews, and policy review, the facility failed to ensure that clinical records were complete and contained accurate information for 2 of 2 residents reviewed for neurological assessments (Resident #78 and #105) and 1 of 1 resident reviewed for pressure ulcers (Resident #9).

Inspectors wroteBased on facility policy review, record reviews, and interview, the facility failed to ensure that the resident and/or resident representative was provided with written information, concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate, was completed for 2 of 4 residents reviewed for advanced directives. (Resident #15 and #78).

Inspectors wroteBased on record review and interview the facility failed to complete a Minimum Data Set (MDS) upon a residents death (Resident #97). Review of Resident 97's clinical record revealed he/she died in mid January of 2026. Review of Resident 97's Minimum Data Set (MDS) lacked evidence that a MDS was completed upon his/her death. During an interview on [DATE] at 2:15 p.m., the Director of Nursing reviewed Resident #97's clinical record and confirmed an MDS was not completed after resident died.

Inspectors wroteBased on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage chemicals being properly secured for 2 of 2 observations for 1 of 4 days of survey. (4/6/26)

Inspectors wroteBased on record review, facility policy, and interview, the facility failed to identify a resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 1 of 3 sampled resident reviewed with a current diagnosis of PTSD. (Resident #74)

Inspectors wroteBased on observations and interviews, the facility failed to adequately store controlled substances in a permanently affixed compartment for 2 of 3 medication refrigerators observed (West Unit medication refrigerator, South Unit medication refrigerator). Additionally, the facility failed to ensure medications were stored properly in medication storage refrigerators on 3 of 3 units ( East Unit, [NAME] Unit, and South Unit).

Inspectors wrote2 Review of Center for Disease Control: Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) updated July 12, 2022 states Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Make PPE, including gowns and gloves, available immediately outside of the resident room. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. [...]

Inspectors wroteBased on record review and interview, the facility failed to obtain a physician order to change an indwelling urinary catheter (Foley catheter) for 1 of 3 residents reviewed for indwelling urinary catheters (Resident #1).

Inspectors wroteBased on record review and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for indwelling urinary catheters (Resident #1).

Inspectors wroteBased on record review and interview, the facility failed to implement its Quality Assurance and Performance Improvement (QAPI) program to ensure compliance with its Plan of Correction (POC) for F-842, related to intake and output (I & O) documentation resulting in inaccurate and incomplete documentation. During the revisit survey on 7/16/25, F-842 was recited related to incomplete intake and output (I & O) documentation. The facility POC indicated a date of correction date of 7/10/25 that included the following corrective actions: A house audit was performed by the unit managers of resident charts for residents with an order for I & O tracking. Educate nurse managers on documenting the facility order protocol inclusive of entering verbal provider orders into the clinical chart. Nurse managers/designee will conduct weekly audits for 60 days. Audit results will be reviewed in QAPI. [...]

Inspectors wroteBased on record review and interviews, the facility failed to implement and maintain an effective training program for nursing staff in the areas of urinary catheter care, as part of the facility's follow-up to their facility reported incident dated 5/12/25. Additionally, the facility failed to implement and maintain an effective training program for nursing staff contracted through a staffing agency, in the areas of urinary catheter care and infection prevention, for 2 of 2 staff reviewed during an investigation of a facility-reported incident (Licensed Practical Nurse [LPN] #2, #3).

Inspectors wrote3. Resident #16 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 4. Resident #84 was admitted on [DATE]. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 5. Resident #17 was admitted on [DATE]. [...]

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 2 of 3 units (East and South) for 3 of 3 days of survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that a care plan was developed in the area of cardiac pacemaker (Resident #86, #83), hospice services (#243), respiratory needs (#54, #16) and psychoactive medications (#71) for 6 of 26 sampled residents reviewed for comprehensive care plans.

Inspectors wrote8. Resident #71's medical record, surveyor noted two MDS Significant change assessments, dated 2/15/24 and 5/1/24 and two MDS Quarterly assessments dated 7/1/24 and 9/4/24. The clinical record lacked evidence that a care plan meeting was held by the IDT for the 2/15/24, 5/1/24, 7/1/24 and 9/4/24 assessments. On 1/23/25 at 1:41 p.m., the above finding was confirmed with the [NAME] President of Quality Improvement and Nursing Services 3. On 1/21/25 at 9:07 a.m., during an interview, Resident #90 stated he/she was not sure if he/she had an IDT meeting. Resident #90 was admitted on [DATE] and had an admission MDS completed on 1/1/25. The medical record lacks evidence that an IDT meeting, which included the participation of the resident and resident's representative, was held within 7 days of this assessment. [...]

Inspectors wroteBased on observations, interviews, record reviews, facility policy, and manufacturer directions, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice in the area of nutrition for 1 of 2 residents reviewed (Resident #60) and in the area of falls for 2 of 3 residents reviewed (Residents #79, #37). Additionally, the facility failed to obtain physician orders for medications located at a resident's bedside, for 2 of 2 sampled residents (Residents #40, #70).

Inspectors wrote3. On 1/21/25 at 9:15 a.m., 1/22/25 at 8:41 a.m., and on 1/23/25 at 8:21 a.m., observations of Resident #17's oxygen nasal cannula tubing dated 1/13 and an undated nebulizer pipe stored on the back of the nebulizer machine and the bedside dresser. Review of resident #17's medical record had providers orders dated 1/9/25 to Change Tubing 1 Time Weekly, Clean/Store oxygen tubing not in use 1 Time Weekly and provider orders dated 1/4/25 for ipratropium 0.5 mg (milligram)-albuterol 3 mg (2.5 mg base)/3 mL (milliliter) nebulization solution .Inhalation Three Times Daily. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure expired medications were removed from the supply available for use and failed to ensure that medications were stored properly as per manufacturers' recommendations for 3 of 5 medication/treatment carts reviewed for medication storage.

Inspectors wroteBased on observations, interviews, and policy review the facility failed to ensure foods were dated and labeled in, stand up freezer, dry storage room and the walk in freezer. In addition, the facility failed to discard obvious freezer burned food on 1 of 3 survey days. Additionally, the facility failed to ensure a sanitary environment during 1of 2 dining observations of meal service on 1 of 3 units.

Inspectors wroteBased on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training for 5 of 5 randomly selected CNAs employed greater than 1 year (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5). Findings On 1/22/25, a surveyor reviewed the following employee education files: 1. CNA #1 was hired 12/5/1994. Review of CNA #1 Employee In-service/attendance Records lacked evidence that she completed the 12 hours of required continuing education for the year of 2024. 2. CNA #2 was hired 8/31/2020. Review of CNA #2 Employee In-service/attendance Records lacked evidence that she completed the 12 hours of required continuing education for the year of 2024. 3. CNA #3 was hired 3/18/2013. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that a medical provider and the resident's representative were notified of a significant change in medical condition for 1 of 2 residents reviewed for death (Resident #243).

Inspectors wroteBased on record review and interview, the facility failed to ensure that a Minimum Data Set, Version 3.0 (MDS) Significant Change in Status Assessment was completed within 14 days from the effective date of the Hospice election, for 1 of 2 sampled residents reviewed for hospice (Resident#243).

Inspectors wroteBased on the review of annual evaluations and interviews, the facility failed to complete a annual performance evaluation for Certified Nursing Assistants (CNA) at least every 12 months, for 1 of 5 CNA's reviewed with employment greater than 1 year. (CNA#4)

Inspectors wroteBased on an interview and review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan, meeting attendance sheet and Power Points provided, the facility failed to present evidence that the required members attended 3 of 4 quarters provided.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an Infection Control Program designed to help prevent the development of infections related to Subcutaneous injected medication for 1 of 1 resident observed for subcutaneous medication administration (Resident #60).

Inspectors wroteBased on immunization record review, review of the facility's immunization policy and interview, the facility failed to implement their Influenza, Pneumococcal, COVID policy for 1 of 5 residents whose immunization records were reviewed (#16)

Inspectors wroteBased on immunization record review, review of the facility's immunization policy and interview, the facility failed to implement their Influenza, Pneumococcal, COVID policy for 1 of 5 residents whose immunization records were reviewed (#16)

Inspectors wroteBased on interviews and review of the facility internal investigation reports, the facility failed to ensure that 2 of 5 residents reviewed were treated with dignity and respect (#1, #4) .

Inspectors wroteBased on observation and interviews, the facility failed to serve food in accordance with professional standards for food service safety by not delivering food in a sanitary manner for 1 of 1 units observed during the noon meal service. (East unit)

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 3 residents reviewed during a complaint investigation (Resident #3).

Inspectors wroteBased on interviews, the facility failed to maintain a comfortable homelike environment for 1 of 2 units reviewed during a complaint investigation (Memory).

Inspectors wroteBased on record review, interviews, observations, and facility policy, the facility failed to update and include goals and interventions on the resident's current comprehensive care plan for the areas of falls for 1 of 3 residents reviewed (Resident #2), incontinent care for 1 of 3 residents (Resident #3), and psychotropic medication use for 3 of 3 residents reviewed during a complaint investigation.

Inspectors wroteBased on policy review, record reviews, and interviews the facility failed to establish/implement their own grievance policy reviewed for 1 of 4 records reviewed during a complaint investigation (Resident #3).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that an injury of unknown origin was reported to the State Agency after a resident was found on the floor and bleeding from a head laceration for 1 of 4 complaint investigations reviewed (Resident #1).

Inspectors wroteBased on record reviews and interviews, the facility failed to investigate an injury of unknown origin after a resident was found on the floor, bleeding from a head laceration for 1 of 4 complaint investigations reviewed (Resident #1).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 sampled residents reviewed for incontinent care (Resident #1).

Inspectors wroteBased on observations and interviews, the facility failed to ensure that a call bell was accessible to 1 of 3 sampled residents observed for accommodation of needs. (Resident #3).

Inspectors wroteBased on interview, record review, the facility failed to notify the State Agency after two (2) falls that resulted in head injury. (Resident 1, and Resident 2.)

Inspectors wroteBased on interviews and record review and facility policy, the facility failed to thoroughly investigate two falls with head injury (Resident 1 and Resident 2).

Inspectors wroteBased on interviews, record review and policy review the facility failed to update/implement care plans in the area of falls for 2 of 3 residents reviewed for falls (Resident's 1 & 2) and in the area of psychotropic medication use for 1 of 3 residents reviewed for medications (Resident 3).

Inspectors wroteBased on record review and interview, the facility failed to notify the physician and the resident representative of significant changes in the resident's condition in a timely manner for 1 of 1 sampled residents. (1#)

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 2 of 3 units(East Wing-100s and South Wing-200s) for 1 of 1 environmental tour.

Inspectors wroteBased on observations, interview, and the facility's Food Storage and Leftover Food Storage policy, Daily High-Temp Ware Wash checklist Policy, Daily High-Temp Ware Wash checklist Policy, and Refrigerator and Freezer Temperatures checklist Policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a food slicer and ceiling vents; failed to ensure all staff were wearing facial hair protectors; failed to ensure foods were labeled and/or in the dry storage room, reach-in refrigerator, the reach-in freezer, the walk-in refrigerator and the walk-in freezer for 1of 1 kitchen tour on 1 of 3 days of survey. (10/30/23). Additionally, the facility failed to ensure temperatures were monitored for the dish machine and the refrigerators/freezers for dates in August, September and October 2023.

Inspectors wroteBased on observations, interview and review of the Safety Data Sheets, the facility failed to ensure that the resident environment remained free from the potential risk of accidents when they failed to ensure that two chemicals were properly secured during 1 of 3 days of survey (10/30/23).

Inspectors wroteBased on interview and record review, the facility's Quality Assurance Committee failed to ensure that the plan of correction for an identified deficiency from the Annual Long Term Care Recertification survey dated 11/1/23 was followed and effective. The Federal citation F584 was cited again during the re-visit to the annual Long Term Care Recertification Survey, dated 12/7/23.

Inspectors wroteBased on interviews and record reviews, the facility failed to issue a written transfer/discharge notice, which included information regarding appeal rights and the name and address of the Office of the State Long-Term Care Ombudsman, to residents or their representatives for 2 of 3 sampled residents transferred/discharged by the facility to an acute care hospital (Residents #99 and #256).

Inspectors wroteBased on record reviews and interviews, the facility failed to issue a bed hold notice in writing, or within 24 hours, to residents or their legal representatives, for 3 of 3 residents transferred to an acute care facility (#99, #202 and #256).

Inspectors wroteBased on observation and interview, the facility failed to post the current daily nurse staffing information that includes the facility name, and a breakdown of the number of hours of registered and unlicensed nursing staff responsible for direct resident care in a prominent place readily accessible to residents and visitors for 3 of 3 survey days. (10/30/23, 10/31/23 & 11/1/23)

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure that a resident's care plan was implemented, for 1 of 1 sampled resident reviewed for a hearing aids (#1).

Inspectors wroteBased on observation and interview, the facility failed to ensure a treatment cart containing multiple medicated creams, powders, ointments and syringes was locked on 1 of 3 units. (Memory Care Unit)