Breakwater Commons

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.

Rule F0578. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 8, 2026.

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.

Rule F0584. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 8, 2026.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Rule F0609. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 8, 2026.

Provide the required documentation or notification related to the resident’s needs, appeal rights, or bed-hold policies.

Rule F0628. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 8, 2026.

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Rule F0636. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 8, 2026.

Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted

Rule F0655. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 8, 2026.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 8, 2026.

Provide care or services that was trauma informed and/or culturally competent.

Rule F0699. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 8, 2026.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Rule F0755. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 8, 2026.

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.

Rule F0761. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 8, 2026.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Rule F0812. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 8, 2026.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Rule F0842. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 8, 2026.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Rule F0657. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 8, 2026.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Rule F0690. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jul 10, 2025.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Rule F0842. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 1, 2025.

Have a plan that describes the process for conducting QAPI and QAA activities.

Rule F0865. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Aug 1, 2025.

Provide and implement an infection prevention and control program.

Rule F0880. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jul 10, 2025.

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Rule F0940. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jul 10, 2025.

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.

Rule F0578. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Rule F0657. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Rule F0684. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

Provide safe and appropriate respiratory care for a resident when needed.

Rule F0695. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

Observe each nurse aide’s job performance and give regular training.

Rule F0730. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

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.

Rule F0761. E: no actual harm, potential for more than minimal harm.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Rule F0812. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Rule F0868. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

Provide and implement an infection prevention and control program.

Rule F0880. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Rule F0883. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

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.

Rule F0887. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Rule F0947. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Mar 4, 2025.

Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Rule F0580. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 4, 2025.

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.

Rule F0584. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 4, 2025.

Assess the resident when there is a significant change in condition

Rule F0637. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 4, 2025.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 4, 2025.

Honor the resident’s right to be treated with respect and dignity and to retain and use personal possessions.

Rule F0557. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Dec 9, 2024.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Rule F0812. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Dec 9, 2024.

Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted

Rule F0655. B: no actual harm, potential for minimal harm. From a complaint.

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.

Rule F0584. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 8, 2024.

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.

Rule F0585. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 8, 2024.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 8, 2024.

Respond appropriately to all alleged violations.

Rule F0610. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 8, 2024.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. E: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 8, 2024.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Rule F0842. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 8, 2024.

Reasonably accommodate the needs and preferences of each resident.

Rule F0558. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 30, 2024.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 30, 2024.

Respond appropriately to all alleged violations.

Rule F0610. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 30, 2024.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: May 30, 2024.

Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Rule F0580. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Apr 12, 2024.