Breakwater Commons

In the surveyor’s words

From the most serious findings on record at Breakwater Commons, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 5, 2022

  Based on record review and interviews, the facility failed to provide accessible call bell assistance devices necessary to prevent an avoidable accident from occurring for 1 of 3 sampled residents who experienced a fall (Resident #21) . Finding: Resident #21 was admitted to the facility from an acute hospital early in February of 2020, with a diagnosis of lack of coordination, unsteadiness on feet, history of falling and abnormalities of gait and mobility. A review of the care plan, initiated on 2/4/20, noted that the resident was a Moderate risk for falls r/t (related to) deconditioning and included the intervention to Be sure call light is within reach and encourage use for assistance as needed. On 10/10/21 Resident #21 had an unwitnessed fall resulting in lower back pain. […]

• No harm, potential for more than minimal, patternF584Apr 9, 2026

  Based 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)Findings:1. East UnitOn 4/6/26 at 9:10 a.m., a surveyor observed a sit-to-stand patient lift by the central sitting area and a sit-to-stand patient lift by the nurse's station near resident room [ROOM NUMBER], that had food particles and debris in the foot base areas. […]

• No harm, potential for more than minimal, patternF609Apr 9, 2026

  Based 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.Findings:Resident #61 was admitted 3/26 and has diagnoses to include Alzheimer's and Dementia.Review of Resident #61's clinical record revealed progress notes stating the following:3/11/26: 22:09 Resident was aggressive towards resident in room [ROOM NUMBER]B as [he/she] went up to [him/her] and slapped [him/her] in [his/her] face.3/11/26:26 14:07 Resident was aggressive with CNA's this… […]

• No harm, potential for more than minimal, patternF628Apr 9, 2026

  Based 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).Findings: 1. Documentation in Resident 1's clinical record indicated that he/she was transferred to an acute hospital on 1/7/26 and 1/24/26. Further review of the clinical record revealed an incomplete Transfer and Discharge Notice. […]

• No harm, potential for more than minimal, patternF655Apr 9, 2026

  Based 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).Findings:Review of Resident #61's clinical record revealed progress notes stating the following:3/4/26: CNA reported that resident took off the toilet tank cover and attempted to hit CNA with it. […]