Cycle 1
Health 2025-01-23 · Fire 2025-01-23
21 health deficiencies
Top issue: Infection Control (4 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Rockland, ME
Breakwater Commons
1-star overall rating with 1-star inspections with $11,998 in total fines with 21 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
100 Commons Drive, Rockland, ME
(207) 301-6810
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.84
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.47 · national 0.87
Aide hours / resident day
3.16
Nurse aide staffing · state 2.86 · national 2.35
Total nurse hours
4.80
All reported nurse hours · state 4.35 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
4.42
Weekend nurse staffing · state 3.91 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.73 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.85
CMS adjusted RN staffing hours
Adjusted total hours
4.86
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
74%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
75%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
227
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
77.03
Composite VBP score used to determine payment impact.
Payment multiplier
1.0251
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.36
Performance 18.02% · Measure score 7.36 · Achievement 7.36 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
8.07
Performance 5.42% · Measure score 8.07 · Achievement 8.07 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
7.68
Baseline 4.59 hours · Performance 5.26 hours · Measure score 7.68 · Achievement 7.68 · Improvement 5.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.32% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 87 · Observed rate 4.6% · Lower 95% interval 6.16% |
| Discharge to community | 60.63% |
50.57%
10.1 pts better
|
Better than the National Rate · Eligible stays 71 · Observed rate 60.56% · Lower 95% interval 50.95% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 97.98% |
95.27%
2.7 pts better
|
Numerator 97 · Denominator 99 |
| Falls with major injury | 1.01% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 99 |
| Discharge self-care score | 59.3% |
53.69%
5.6 pts better
|
Numerator 51 · Denominator 86 |
| Discharge mobility score | 60.47% |
50.94%
9.5 pts better
|
Numerator 52 · Denominator 86 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 99 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.42% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 1.16% · Lower 95% interval 3.17% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 48 |
| Staff flu vaccination coverage | 76.19% |
42%
34.2 pts better
|
Numerator 112 · Denominator 147 |
| Discharge function score | 67.44% |
56.45%
11 pts better
|
Numerator 58 · Denominator 86 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 86.96% |
96.28%
9.3 pts worse
|
Numerator 60 · Denominator 69 |
| Resident COVID-19 vaccinations up to date | 38.46% |
25.2%
13.3 pts better
|
Numerator 20 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.4
0.6 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.4 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
90.7%
5 pts better
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 87.8% · Q2 100.0% · Q3 97.5% · Q4 97.5% · 4Q avg 95.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.1% |
95.5%
1.4 pts worse
|
95.5%
1.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
4.3%
1.8 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.5% · Q3 1.2% · Q4 1.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.3% |
10.7%
0.6 pts worse
|
11.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 13.1% · Q3 13.5% · Q4 7.6% · 4Q avg 11.3% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
5.5%
1.3 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.3% · Q3 3.4% · Q4 8.3% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.5% |
17.0%
3.5 pts worse
|
19.6%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 17.2% · Q3 18.6% · Q4 20.0% · 4Q avg 20.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.1% |
21.0%
0.1 pts worse
|
16.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 24.0% · Q3 25.0% · Q4 16.3% · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 39.3% |
29.6%
9.7 pts worse
|
16.3%
23 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.5% · Q2 44.5% · Q3 35.0% · Q4 33.2% · 4Q avg 39.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 41.2% |
25.7%
15.5 pts worse
|
14.9%
26.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 32.7% · Q3 52.8% · Q4 46.7% · 4Q avg 41.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.3%
0.8 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.7%
0.5 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 0.0% · Q3 1.2% · Q4 1.3% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.7% |
29.8%
1.1 pts better
|
19.8%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 27.2% · Q3 25.8% · Q4 34.4% · 4Q avg 28.7% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.4%
1.5 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.4% · Q3 3.5% · Q4 2.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.4% |
71.2%
15.2 pts better
|
81.7%
4.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.4% · Q2 86.2% · Q3 84.9% · Q4 88.2% · 4Q avg 86.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.3% |
15.6%
5.7 pts worse
|
12.0%
9.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 18.1% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.4%
1.1 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.1% · Q3 0.0% · Q4 3.8% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.7% |
74.5%
4.8 pts worse
|
79.7%
10 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.2% |
20.5%
5.7 pts worse
|
23.9%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.2% · Observed 19.0% · Expected 17.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-01 · Fire 2023-11-01
21 health deficiencies
Top issue: Resident Rights (8 deficiencies)
18 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2022-01-05 · Fire 2022-01-05
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
16 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-01-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-23
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-01-22
D · Potential for more than minimal harm
2025-01-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-06
D · Potential for more than minimal harm
2025-01-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-21
F · Potential for more than minimal harm
2023-11-01
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-01
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-01
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-01
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-01
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-12-22
F · Potential for more than minimal harm
2023-11-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-01
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-01
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-01
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-01
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-01
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-12-15
C · Minimal harm
2023-11-01
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-15
F · Potential for more than minimal harm
2022-01-05
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2022-01-21
F · Potential for more than minimal harm
2022-01-05
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2022-01-21
F · Potential for more than minimal harm
2022-01-05
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2022-01-21
F · Potential for more than minimal harm
2022-01-05
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-01-21
F · Potential for more than minimal harm
2022-01-05
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-01-21
F · Potential for more than minimal harm
2022-01-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-01-21
F · Potential for more than minimal harm
2022-01-05
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-01-21
F · Potential for more than minimal harm
2022-01-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-01-21
F · Potential for more than minimal harm
2022-01-05
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-01-21
D · Potential for more than minimal harm
2022-01-05
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-01-21
D · Potential for more than minimal harm
2022-01-05
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2022-01-21
D · Potential for more than minimal harm
2022-01-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-01-21
D · Potential for more than minimal harm
2022-01-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-01-21
D · Potential for more than minimal harm
2022-01-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-01-21
D · Potential for more than minimal harm
2022-01-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-01-21
D · Potential for more than minimal harm
2022-01-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-01-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-05-28
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-05-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-05-28
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-05-28
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-01-23
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-01-23
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-01-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-01-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-01-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-01-23
F761 · Pharmacy Service Deficiencies
Health
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.
Not marked corrected
E · Potential for more than minimal harm
2025-01-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-01-23
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F887 · Infection Control Deficiencies
Health
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.
Corrected 2025-03-04
E · Potential for more than minimal harm
2024-11-12
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-09
B · Minimal harm
2024-10-30
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Not marked corrected
E · Potential for more than minimal harm
2024-09-26
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-09-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-26
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-04-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-04-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-04-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-04-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-03-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-04-12
E · Potential for more than minimal harm
2023-11-01
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-11-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-11-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-11-01
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-12-19
B · Minimal harm
2023-11-01
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-12-01
B · Minimal harm
2023-11-01
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2023-12-01
B · Minimal harm
2023-11-01
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-09-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-09-26
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-11-15
G · Actual harm
2022-01-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-02-19
D · Potential for more than minimal harm
2022-01-05
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2022-02-19
D · Potential for more than minimal harm
2022-01-05
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-02-19
D · Potential for more than minimal harm
2022-01-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-02-19
D · Potential for more than minimal harm
2022-01-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-02-19
Penalties and ownership
What sits behind the stars
$3,529
2023-08-28
Fine
Fine · fine $3,529
Fine
$8,469
2023-08-07
Fine
Fine · fine $8,469
Fine
Ownership
Breakwater Commons Operations, LLC
5% Or Greater Direct Ownership Interest · Organization
Breshnahan, Richard
5% Or Greater Security Interest · Individual
Chadwick, Carl
W-2 Managing Employee · Individual
Cross, Royce
5% Or Greater Security Interest · Individual
Cyr, Glen
Corporate Director · Individual
Harstad, Paul
5% Or Greater Security Interest · Individual
Orestis, John
Corporate Director · Individual
Richards, Mary
Corporate Director · Individual
Tyler, Michael
Corporate Director · Individual
Ury, William
Corporate Director · Individual
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