Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Adviniacare Newburyport during CMS and state inspections, most recent first.
Delayed response to post-fall change in condition and hip fracture. A resident with dementia, repeated falls, and impaired mobility fell and was initially noted to have no pain, but later developed new 8/10 R hip pain, decreased ROM, and guarding. Nursing documented calling the on-call MD overnight without a return call, and the resident was not sent out until STAT x-rays later showed an impacted R femoral neck fracture.
Failure to Follow Up on Significant Weight Changes: The facility did not timely assess or document follow-up for significant weight changes in two residents. One resident with cerebral palsy, anxiety, protein calorie malnutrition, and severe cognitive impairment had multiple significant weight losses and gains, but physician and nutrition notes did not show awareness or assessment of the changes. Another resident with dementia and dysphagia had a significant weight loss, yet the record did not show that the change was addressed or that a comprehensive nutrition assessment was completed after hospice admission. The DON and dietitian stated that notable weight discrepancies should be reported and assessed promptly.
Failure to maintain and monitor a resident’s midline catheter. A resident admitted with sepsis had an undated, lifting catheter dressing with redness at the site, and the insertion site could not be visualized because of a disk. The resident said the dressing had not been changed since the hospital. Records showed the dressing change and external catheter measurement were not consistently documented, and the chart did not show that the physician was notified about possible catheter migration.
Failure to Follow Contact Precautions During Medication Administration: A nurse entered a resident’s room for med pass without donning the required gown and gloves for Contact Precautions for C-diff, then later put on gloves for an injection but still did not wear a gown. Another resident was visiting in the room, left to ask for medication, and returned without PPE or hand hygiene. The nurse and DON both stated they did not believe PPE was needed unless direct care was being provided.
A resident with severe cognitive impairment was left unattended in the dining room, resulting in a fall and nasal fracture. Additionally, surveyors found oxygen cylinders improperly stored in resident rooms, posing safety hazards. Staff interviews confirmed the need for supervision and proper storage, but these measures were not implemented.
The facility failed to maintain adequate staffing levels to meet resident care needs, as evidenced by a review of working schedules showing insufficient staffing for 30 consecutive days. The staffing plan included RNs, LPNs, and CNAs based on daily census and resident preferences, but challenges in recruiting dependable staff led to operating below budgeted hours. The Administrator acknowledged staffing issues, with a budgeted HPPD of 3.58.
The facility failed to follow food safety protocols, with issues such as unlabeled and expired food, improper storage of personal items, and cross-contamination during food handling. Observations included a staff member's water bottle stored with resident food, undated food items, and a cook contaminating ready-to-eat food with unclean gloves and a name badge.
A facility failed to accurately complete the MDS Assessment for a resident, omitting the administration of antipsychotic medication, Abilify, which the resident had been receiving daily. Despite the resident's diagnoses of Major Depressive Disorder and Anxiety Disorder, and documentation in the physician's orders, MAR, and plan of care, the MDS did not reflect the use of the medication. This discrepancy was confirmed by the MDS Nurse upon review.
The facility failed to create comprehensive care plans for two residents with histories of alcohol abuse and suicidal ideation. One resident's care plan did not address their documented history of alcohol abuse or past suicidal thoughts, as staff did not consider it necessary without a current diagnosis. Another resident, admitted with alcohol dependence, initially lacked a personalized substance abuse care plan, which was only developed after a surveyor's review.
A resident with dysphagia and a history of choking incidents was not reassessed by speech therapy after a swallowing incident, and was left unsupervised during meals, contrary to their care plan. Observations showed the resident eating inappropriate food items without staff oversight, despite the need for supervision and specific dietary measures. Interviews revealed a lack of communication and adherence to the care plan among facility staff.
Two residents with severe cognitive impairments and dysphagia were left unsupervised during meals, contrary to their care plans. One resident was observed eating alone in their room, resulting in food spills, while the other experienced a choking incident in the dining room. Despite care plans requiring supervision and adaptive devices, these were not consistently provided, highlighting a significant deficiency in care.
A nurse in an LTC facility administered incorrect doses of Simethicone and Cranberry to a resident with severe cognitive impairment, resulting in a medication error rate of 8%. The errors were confirmed by reviewing the resident's physician's orders and medication bottles.
A resident with severe cognitive impairment had a physician order to avoid blood pressure readings on the left arm due to a past mastectomy. Despite this, nursing staff documented readings from the left arm on multiple occasions. A nurse later admitted to documenting in error, stating the right arm was used. The DON expected accurate documentation.
Delayed response to post-fall change in condition and hip fracture
Penalty
Summary
The facility failed to provide timely treatment and care according to orders and professional standards of practice for a resident who had a fall and later developed a fractured femur. The resident had diagnoses including a displaced midcervical fracture of the right femur, repeated falls, and dementia, and the most recent MDS showed moderately impaired cognition and need for partial to moderate assistance with ADLs. The falls care plan identified the resident as being at risk for falls due to decreased mobility, poor safety awareness, impaired balance, use of assistive devices, and legal blindness. After an unwitnessed fall, the resident was initially assessed as having no pain and no change in range of motion from baseline. Several hours later, the resident reported new 8/10 right hip pain, showed a change in ROM, and was guarding the right hip. Nursing documentation stated that the on-call MD was called after 2:00 A.M. with no return call, and later that morning the on-call service was called again. The NP was then notified, assessed the resident, and ordered STAT x-rays after the resident continued to have right hip pain. The x-ray showed a right femoral neck fracture with impaction without displacement, and the resident was sent to the hospital due to the STAT x-ray results. During interviews, the NP stated the on-call system was active overnight and that a call placed at 2:00 A.M. should normally receive a response within the hour. The nurse stated she called the on-call physician because the resident had increased pain and a change in condition, but never received a call back. The DON stated that when a resident has a change of status several hours after a fall, including new 8/10 pain, change in ROM, and guarding the hip, and the nurse cannot reach the on-call provider at 2:00 A.M., the resident should be sent to the ER and the provider notified as soon as possible.
Failure to Follow Up on Significant Weight Changes
Penalty
Summary
The facility failed to follow up on significant weight changes for two residents, and the record showed that the required weight assessments and notifications were not completed in a timely manner. The facility policy titled Weight Assessment and Interventions required monthly weights, retaking any 5 lb. monthly or 3 lb. weekly change within 72 hours for confirmation, notification of the dietitian by nursing, and dietitian response within 72 hours. The policy also identified significant weight loss thresholds of 5% in 1 month, 7.5% in 3 months, and 10% in 6 months. One resident had diagnoses including cerebral palsy, anxiety, and protein calorie malnutrition, and the MDS showed severe cognitive impairment. The weight record showed a loss from 147.0 lbs. to 127.7 lbs. over about three months, a 13.1% significant weight loss, and later a gain of 11.0 lbs. in one month, a 7.9% significant weight gain, followed by another 12.3 lb. loss in one month, an 8.6% significant weight loss. Physician progress notes and nutrition progress notes did not show that staff were made aware of or addressed these significant changes. Quarterly nutrition assessments were completed after the changes, but they documented gradual weight loss and no additional nutrition intervention. A second resident had diagnoses including dementia and dysphagia and was severely impaired. The weight record showed a loss of 13 lbs. in one month, a 7.4% significant weight loss, and the record did not show that physician or nutrition progress notes addressed the change. The resident was later admitted to hospice, but the medical record did not show a comprehensive nutrition assessment after the significant weight change or after hospice admission. During interviews, the dietitian and DON stated that notable weight discrepancies should be reported and assessed promptly, and that interventions should occur within 72 hours to a week after the change is identified.
Failure to Maintain and Monitor Midline Catheter Dressing
Penalty
Summary
The facility failed to provide care and maintenance of a resident’s midline catheter and failed to monitor for catheter-related complications. Resident #109 was admitted with diagnoses including other gram-negative sepsis and had intact cognition with a BIMS score of 15 out of 15. The facility policy for midline dressing changes required transparent dressings to be changed every 7 days or sooner if compromised, with assessment for erythema, drainage, swelling, induration, skin temperature, or tenderness, and the dressing to be labeled with the date, time, and initials of the person performing the change. On observation, the resident’s right arm catheter dressing was undated, the lower portion was lifting with hanging tape, and the insertion site was not visible because of a disk and surrounding redness. The resident stated the dressing had not been changed since the hospital. The physician orders required midline dressing changes and external catheter length measurements, and the care plan directed monitoring of the site every shift and dressing changes every 7 days and as needed. The MAR showed the dressing was changed once and the external catheter measured 8 cm, while hospital discharge paperwork showed the external catheter measured 0 cm. The record did not show that the physician was notified about possible midline migration. Staff interviews confirmed weekly dressing changes and monitoring expectations, and the DON reviewed the photograph and stated that if the dressing was not changed, that would be falsifying documentation.
Failure to Follow Contact Precautions During Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The deficiency involved a resident on Contact Precautions for C-diff, with a sign posted at the room entrance directing staff and visitors to clean hands and for providers and staff to wear gloves and a gown before room entry and discard them before leaving the room. On 9/17/25 at 8:50 A.M., a nurse entered the resident’s room to administer medications without putting on gloves or a gown. After giving oral medications, the nurse needed to administer an injection and then put on gloves, but still did not put on a gown. A drawer stocked with gowns and gloves was located outside the room. At the time, another resident was visiting in the room, left the room in a wheelchair to ask the nurse for medication, and then returned to continue visiting; that resident was not wearing PPE and did not wash or sanitize hands. During interviews, the nurse stated that residents with C-diff require Contact Precautions but said she did not think a gown and gloves were needed just to give medications and did not know what precautions were necessary for another resident visiting a resident on Contact Precautions. The DON later stated that residents with C-diff require Contact Precautions but did not think PPE was required unless someone entering the room was providing direct care.
Inadequate Supervision and Unsafe Oxygen Cylinder Storage
Penalty
Summary
The facility failed to provide adequate supervision for a resident with severe cognitive impairment, resulting in a fall and injury. The resident, who was dependent on staff for mobility and had a history of falls, was left unattended in the dining room. This lack of supervision led to the resident falling from their wheelchair, sustaining a nasal fracture and other injuries. Despite the care plan indicating the need for supervision and the resident's high risk for falls, staff left the resident alone while collecting breakfast trays. Additionally, the facility did not ensure the safe storage of oxygen cylinders in resident rooms. On multiple occasions, surveyors observed oxygen cylinders freestanding without proper support, posing a potential hazard. Staff interviews confirmed that oxygen cylinders should be stored in carriers or carts to prevent accidents, yet this protocol was not followed, leaving the cylinders unsecured on the floor. The Director of Nursing acknowledged the deficiencies, noting that the resident should not have been left unattended and that oxygen cylinders must be properly stored. Despite the facility's policies and staff awareness of the risks, these safety measures were not implemented, leading to the identified deficiencies.
Staffing Deficiency in Meeting Resident Care Needs
Penalty
Summary
The facility failed to maintain sufficient staffing levels to meet the personal care needs of its residents. The facility assessment outlined a staffing plan that included a Director of Nurses (DON), an Assistant Director of Nurses (ADON), and a combination of Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) for each shift, along with Certified Nursing Assistants (CNAs). However, the actual working schedules reviewed for the past 30 days revealed that the facility did not meet the appropriate staffing levels on any of those days. The facility's staffing plan was based on the daily census and individual resident needs, including preferences for schedules and specific care requirements, such as those needing 1:1 attention or assistance with transfers. Interviews conducted during the survey highlighted the facility's challenges in maintaining adequate staffing. The Scheduler acknowledged difficulties in finding dependable staff and noted that the facility was operating below the budgeted hours. The Administrator confirmed that staffing was an ongoing issue and stated that the budgeted hours per patient per day (HPPD) for the facility census was 3.58. Despite the expectation to staff according to regulations, the facility struggled with recruitment, impacting their ability to provide sufficient care to residents.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food storage and handling, as observed during a survey. In the main kitchen, an open water bottle belonging to a staff member was stored with resident food, which is against the facility's policy. Additionally, in the third-floor kitchenette, several food items were found unlabeled and undated, including a container of prepared soup and an open container of soy milk. A yogurt was found with an expired date, and a lunch bag belonging to a nurse was improperly stored next to resident food in the second-floor kitchenette. On the first floor, a pizza box with undated and unlabeled slices was observed. During a breakfast tray line observation, several food safety violations were noted. An open bag of hard-boiled eggs was found undated in the refrigerator. The container used for storing serving utensils had visible debris, indicating poor sanitation practices. The cook was observed contaminating his gloves by touching various surfaces and then handling ready-to-eat food without changing gloves. Additionally, the cook's name badge came into contact with scrambled eggs, further risking contamination. The Food Service Director confirmed that staff are expected to check kitchenette refrigerators three times daily to ensure proper labeling and expiration dates. The director also stated that staff should not store personal food with resident food and that contaminated gloves should not be used to handle ready-to-eat food. These observations indicate a failure to follow established food safety protocols, potentially compromising resident safety.
Inaccurate MDS Assessment for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessments were accurately completed for a resident, leading to a deficiency. Specifically, the MDS for a resident with diagnoses of Major Depressive Disorder and Anxiety Disorder did not document the administration of antipsychotic medication, Abilify, which the resident had been receiving daily since July. The resident's MDS, dated August 16, 2024, indicated moderate cognitive impairment but omitted the antipsychotic medication. This oversight was confirmed during an interview with the MDS Nurse, who acknowledged the incorrect coding after reviewing the resident's medical record. The resident's physician's orders, Medication Administration Record (MAR), and plan of care all indicated the use of Abilify for mood depression and behavior management, highlighting the discrepancy in the MDS documentation.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents with histories of alcohol abuse and suicidal ideation. For one resident, the facility did not create a care plan addressing their history of alcohol abuse, despite documentation in their social history evaluation and behavioral health group therapy notes indicating such a history. The resident denied having a history of alcohol abuse, and the social worker and regional director of clinical did not believe a care plan was necessary due to the lack of a documented diagnosis. Additionally, the facility did not develop a care plan for this resident's history of suicidal ideation, even though hospital discharge paperwork indicated past suicidal thoughts. The social worker and regional director of clinical did not consider a care plan necessary as the resident denied current suicidal ideation. Another resident was admitted with diagnoses including alcohol dependence with withdrawal delirium. The facility did not initially develop a personalized substance abuse care plan for this resident. It was only after a surveyor's review that a care plan was initiated. The social worker acknowledged the absence of a personalized care plan and subsequently developed one. These deficiencies highlight the facility's failure to adhere to its policy of creating comprehensive care plans that address residents' physical, psychosocial, and functional needs.
Failure to Supervise and Assess Resident with Dysphagia
Penalty
Summary
The facility failed to meet professional standards of quality for Resident #52, who had a history of dysphagia and required a mechanical soft diet with supervision during meals. Despite these requirements, the facility did not reassess the resident's diet texture after a swallowing incident in August 2024, as documented by the Nurse Practitioner. The resident had previously experienced choking incidents in July 2022 and July 2023, which necessitated medical intervention, yet there was no follow-up assessment by speech therapy after the August 2024 incident. Observations by the surveyor revealed multiple instances where Resident #52 was left unsupervised during meals, contrary to the care plan that required supervision and cueing to prevent choking. On October 8, 2024, the resident was observed choking on French toast without staff supervision, and on subsequent days, the resident was seen eating inappropriate food items such as whole bread rolls and cheese curls without proper oversight. The facility's staff, including the Director of Nursing, acknowledged the need for supervision and the use of sippy cups with lids, yet these measures were not consistently implemented. Interviews with facility staff, including the DON, Speech Therapist, and Dietician, highlighted a lack of communication and adherence to the resident's care plan. The DON admitted that the care plan was not updated following the resident's hospital admission for pneumonia and that the resident should have been evaluated by speech therapy after the August incident. The Speech Therapist and Dietician were unaware of the resident's history of choking and the specific dietary restrictions, indicating a breakdown in the facility's internal communication and care coordination processes.
Failure to Supervise Residents During Meals
Penalty
Summary
The facility failed to provide adequate supervision during meals for two residents, both of whom have severely impaired cognition and require assistance with eating. Resident #34, who has a history of dysphagia, was observed multiple times attempting to eat meals alone in their room without staff supervision. Despite the care plan indicating the need for supervision and adaptive devices, the resident was left unsupervised, resulting in food being spilled on their clothing and floor. Interviews with staff confirmed that Resident #34 requires supervision and cueing during meals, yet this was not provided. Resident #52, diagnosed with dysphagia and a history of choking incidents, was also left unsupervised during meals. The resident was observed eating large pieces of food and drinking from cups without lids, which led to a choking incident. Despite the care plan specifying the need for a mechanical soft diet, sippy cups with lids, and supervision, these measures were not consistently implemented. Staff interviews corroborated the need for supervision and cueing to prevent choking, but these precautions were not followed. The facility's failure to adhere to the care plans and provide necessary supervision during meals for these residents represents a significant deficiency. Both residents have documented needs for assistance and supervision due to their medical conditions, yet the facility did not ensure these needs were met, leading to unsafe eating conditions and potential health risks.
Medication Error Rate Exceeds 5% Due to Incorrect Dosing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as observed during a medication pass. One nurse made two errors out of 25 opportunities, resulting in an 8% error rate. These errors affected one resident, who was administered incorrect doses of medications. Specifically, the nurse administered two 125 mg tablets of Simethicone and one 450 mg capsule of Cranberry, contrary to the physician's orders, which specified two 80 mg tablets of Simethicone and one 300 mg Cranberry tablet. The resident involved had severe cognitive impairment, as indicated by a BIMS score of 3 out of 15, and was admitted with diagnoses including metabolic encephalopathy and altered mental status. The errors were identified during a review of the resident's physician's orders and the medication bottles by the surveyor and the Director of Nurses, who confirmed the incorrect doses were administered.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident with severe cognitive impairment, who was admitted with a diagnosis of dementia. The resident had a physician order specifying no blood pressure readings should be taken from the left arm due to a past mastectomy. Despite this order, nursing staff documented that blood pressure readings were taken from the resident's left arm on multiple occasions over several months. During interviews, a nurse admitted to documenting the use of the left arm in error, stating that the blood pressure was actually taken from the right arm. The Director of Nursing expressed that the expectation was for nurses to accurately document which arm was used for blood pressure readings. This discrepancy in documentation indicates a failure to adhere to the facility's policy on accurate charting and documentation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Newburyport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Port Rehabilitation And Healthcare Center | 0.6 mi | ★★★★★ | 20 | 0 |
| The Mansion At Brigham | 1.5 mi | ★★★★★ | 41 | 0 |
| Maplewood Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Mill Town Health And Rehabilitation | 3.6 mi | ★★★★★ | 7 | 0 |
| Lakeview House Skld Nrsg And Residential Care Fac | 8 mi | ★★★★★ | 0 | 0 |
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