Inspection visit
Fire Safety inspection
Citations
18 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0022GeneralS&S Fpotential for harm
Establish policies and procedures for sheltering.
- 0033GeneralS&S Fpotential for harm
Establish methods for sharing information.
- 0511GeneralS&S Dpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0211GeneralS&S Dpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0222GeneralS&S Dpotential for 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.
- 0321GeneralS&S Fpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0351GeneralS&S Dpotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Cno actual harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
- 0751GeneralS&S Dpotential for harm
Have restrictions on the use of flammable curtains.
- 0753GeneralS&S Dpotential for harm
Have restrictions on the use of highly flammable decorations.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0919GeneralS&S Dpotential for harm
Meet requirements for the use of electrical equipment.
- 0923GeneralS&S Fpotential for harm
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the November 1, 2023 survey of BREAKWATER COMMONS?
This was a inspection survey of BREAKWATER COMMONS on November 1, 2023. The surveyor cited 18 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BREAKWATER COMMONS on November 1, 2023?
Yes, 18 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Establish policies and procedures for sheltering."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.