All citations for Breakwater Commons

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Breakwater Commons

Last standard health inspection on record

April 9, 2026

Showing 1 to 25 of 36 citations

  1. No harm, with potential for more than minimal harm

    Conduct risk assessment and an All-Hazards approach.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0006, Emergency Preparedness Deficiencies. Inspection of November 1, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  2. No harm, with potential for more than minimal harm

    Establish policies and procedures for sheltering.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0022, Emergency Preparedness Deficiencies. Inspection of November 1, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  3. No harm, with potential for more than minimal harm

    Establish methods for sharing information.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0033, Emergency Preparedness Deficiencies. Inspection of November 1, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  4. No harm, with potential for more than minimal harm

    Establish emergency prep training and testing.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0036, Emergency Preparedness Deficiencies. Inspection of November 1, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  5. No harm, with potential for more than minimal harm

    Establish staff and initial training requirements.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0037, Emergency Preparedness Deficiencies. Inspection of November 1, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  6. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of November 1, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2023).

  7. No harm, with potential for more than minimal harm

    Have generator or other power source capable of supplying service within 10 seconds.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of November 1, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  8. No harm, with potential for more than minimal harm

    Have proper medical gas storage and administration areas.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of November 1, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  9. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of September 26, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (November 8, 2024).

  10. No harm, with potential for more than minimal harm

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

    Pattern (more than a few residents). CMS level E.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of September 26, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (November 8, 2024).

  11. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of November 1, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 19, 2023).

  12. No harm, with 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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of November 1, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 1, 2023).

  13. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0585, Resident Rights Deficiencies. Inspection of September 26, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (November 8, 2024).

  14. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0609, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of September 26, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (November 8, 2024).

  15. No harm, with potential for more than minimal harm

    Respond appropriately to all alleged violations.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0610, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of September 26, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (November 8, 2024).

  16. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0842, Resident Assessment and Care Planning Deficiencies. Inspection of September 26, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (November 8, 2024).

  17. No harm, with potential for more than minimal harm

    Reasonably accommodate the needs and preferences of each resident.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0558, Resident Rights Deficiencies. Inspection of April 10, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (May 30, 2024).

  18. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0609, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of April 10, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (May 30, 2024).

  19. No harm, with potential for more than minimal harm

    Respond appropriately to all alleged violations.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0610, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of April 10, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (May 30, 2024).

  20. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of April 10, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (May 30, 2024).

  21. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0580, Resident Rights Deficiencies. Inspection of March 13, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (April 12, 2024).

  22. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of November 1, 2023. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (December 1, 2023).

  23. No harm, with potential for more than minimal harm

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0867, Administration Deficiencies. Inspection of November 1, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 19, 2023).

  24. No harm, with potential for more than minimal harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0211, Egress Deficiencies. Inspection of November 1, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  25. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0222, Egress Deficiencies. Inspection of November 1, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 22, 2023).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.