Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Port Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Food storage and tray line hygiene deficiencies were observed in the kitchen and nourishment area. Prepared foods in the walk-in refrigerator were found past use-by dates or without visible dates, a loaf of bread remained stored beyond its use-by date, and during meal prep a dietary staff member had uncovered facial hair and touched tray-line items after contacting his face with gloved hands, while another staff member placed used gloves on the tray line shelf.
A resident with dementia and a care plan for bruising, bleeding, and skin tears related to ASA therapy had yellow fading areas and a scrape-like red area on the lower right shin, later noted as a pea-sized scab. The resident’s skin checks were not properly documented in the assessment record, progress notes did not reflect the discoloration, and staff interviews showed inconsistent awareness of the skin findings.
A resident with an indwelling Foley catheter, severe cognitive impairment, and a history of obstructive uropathy had the catheter drainage bag repeatedly observed touching the floor while he/she remained in bed. The resident’s care plan required the privacy bag to stay off the floor, and staff interviews confirmed the bag should never touch the floor. The resident’s HCP expressed concern because of frequent UTIs, and records showed the resident was being treated for a UTI with a positive urine culture.
Delayed Response to Severe Weight Loss: A resident with dementia and other chronic conditions had an 11.22% weight loss documented, but the weight was not rechecked the next day and the RD did not complete a timely nutritional assessment. The record showed no confirmed reweigh after the loss was identified, despite facility policy requiring prompt confirmation of any 5% weight change. Staff later noted the resident had reduced intake, and the RD stated the delay affected timely assessment and intervention.
A resident with a PICC line had a dressing that remained dated and visibly peeling/lifting on repeated observations, despite orders for weekly dressing and connector changes and measurement of the external catheter length. The TAR and progress notes did not document external length measurements, and nursing staff stated the dressing should have been changed when it was peeling and that catheter length should have been documented to confirm placement.
A resident with acute respiratory failure and other diagnoses was observed receiving oxygen via nasal cannula at 2 LPM, but the active chart lacked a physician order for oxygen. The MDS indicated continuous O2 therapy, and facility staff, including the Charge Nurse, UM, and DON, acknowledged that oxygen administration requires a physician order and that the resident did not have one until the issue was brought to the facility’s attention.
A resident with CKD stage 5 and dependence on HD had a right chest dialysis access site, but nursing documentation did not show ongoing assessment or pre- and post-dialysis monitoring, and the resident said staff had not assessed the site after dialysis. Surveyors also found no emergency clamps or pressure dressings in the room, and the DON stated the room kit contained gauze but was unaware a clamp should be included for a resident with a tunneled HD catheter.
Failure to implement EBP for a resident with a central dialysis catheter. The resident had CKD stage 5, was dependent on renal dialysis, and required extensive assistance with care. The facility’s EBP policy stated that residents with indwelling medical devices such as central lines require targeted gown and glove use during high-contact care, but no EBP sign was posted outside the room, the record lacked documentation of EBP use, and staff reported caring for the resident without using EBP.
A resident alleged being slapped by a CNA, but the incident was not reported immediately to the Administrator or DON as required by the facility's abuse policy. The resident, with intact cognitive functioning, reported the incident to a nurse, who informed the Charge Nurse, but the report was delayed until the Unit Manager discovered it days later. Additionally, the facility failed to conduct a required NAR check for the CNA before employment.
A resident with a stage 3 pressure ulcer did not have a comprehensive care plan addressing the existing skin breakdown, and the facility failed to implement required bed and chair alarms as per the falls care plan. Despite physician orders and care plan requirements, the alarms were not in place, and the care plan was not updated upon the resident's readmission. Interviews with staff confirmed these deficiencies, indicating a lapse in executing and updating care plans as per facility policy.
A resident with diabetes and other conditions developed a new wound on the left buttock, but the LTC facility delayed treatment for two days. The facility's policy requires immediate intervention for new skin areas, but the resident's medical record lacked documentation of the wound's condition and care plan. The DON acknowledged the need for immediate action but could not provide specific details about the wound.
The facility failed to label insulin pens with resident names, open dates, and expiration dates, as required by professional principles. During an observation, two Lantus insulin pens were found in a medication cart without proper labeling, making it impossible to identify the intended residents. Interviews with nursing staff confirmed the deficiency, acknowledging the need for proper labeling to ensure medication viability.
Food Storage and Tray Line Hygiene Deficiencies
Penalty
Summary
Food was stored and distributed in a manner that did not follow professional food safety standards. In the main kitchen walk-in refrigerator, surveyors observed multiple prepared foods that were covered, labeled, and dated inconsistently, including fruit cups dated 8/21/25, 8/22/25, and 8/23/25; cooked burgers dated 8/23/25; cooked pasta noodles dated 8/21/25; an opened package of turkey deli meat dated 8/10/25; peas dated 8/19/25; and nine cups of milk with no visible date. The Food Service Director stated that stored food should be labeled with a use-by date, used within three days, and that items dated 8/19/25 through 8/22/25 should have been discarded. The director also stated the turkey deli meat dated 8/10/25 should have been labeled with a use-by date and should not have remained in the refrigerator. In a nourishment kitchen, a loaf of white bread was observed with a use-by date of 8/26/25 while it was still stored on 8/27/25. During meal service preparation, Dietary Staff #1 was observed with facial hair not contained by a beard cover while standing in the food distribution area. He rested his gloved hands on his facial hair and nose, then touched plate warmer pallets and placed them on multiple meal trays. Dietary Staff #2 removed used gloves and placed them directly onto the tray line shelf. The Food Service Director stated that facial hair should be covered in food preparation areas and during food distribution, that Dietary Staff #1 should not have touched the plate pallets after contacting his facial hair and nose, and that used gloves should not have been placed on a clean area.
Failure to Document and Report Skin Discoloration on a Resident at Risk for Bruising
Penalty
Summary
The facility failed to ensure treatment and care were provided in accordance with standards of quality of care for one resident with a known risk and care plan for bruising, bleeding, and skin tears related to ASA therapy. Resident #12 was admitted in May 2024 with diagnoses including unspecified dementia, bipolar disorder, delusional disorders, and heart disease. The most recent MDS indicated severe cognitive impairment, substantial/maximal assistance with showering and bathing, and dependence for lower body dressing. During observations, the resident’s lower right leg showed yellow fading areas down the shin and a scrape-like red area on the shin, and later a pea-sized red area consistent with a scab on the right shin was observed. The resident’s active care plan directed staff to inspect the skin daily during care for bruising, unusual bleeding, and petechiae. However, progress notes from 8/18/25 through 8/26/25 did not document any discoloration or alteration to the lower right leg, and the weekly skin check was documented as skin intact on 8/18/25 with no further weekly skin check assessments found. The TAR showed the weekly skin check for 8/25/25 as completed, but there was no progress note indicating the resident refused the skin check. During interviews, CNA #4 stated the bruises on the lower right leg had been there and that nurses knew about them, Nurse #1 observed discoloration of the right leg, Charge Nurse #2 and the Unit Manager said they were not aware of any skin issues on the lower right leg, Nurse #6 said she signed off on the weekly skin check but did not document it under the assessment and had not been informed of any skin issues, and the DON stated weekly skin checks are to be documented on the weekly skin assessment.
Improper Foley Catheter Bag Placement
Penalty
Summary
The facility failed to maintain professional standards in managing and caring for a urinary catheter for one resident with an indwelling Foley catheter. The resident was admitted with obstructive uropathy and dementia, had severe cognitive impairment with a BIMS score of 4 out of 15, and had a physician’s order for Foley catheter care every shift. The resident’s care plan also directed staff to provide a catheter privacy bag and ensure the bag was not touching the floor. During multiple surveyor observations, the resident’s urinary catheter drainage bag, attached to the bed frame by a privacy bag, was seen with part of the bag directly touching the floor while the resident remained in bed. The same condition was observed several times throughout the day. The resident’s HCP stated concern about catheter care because the resident had frequent UTIs. Staff interviews confirmed the bag and privacy bag should never touch the floor, and the Unit Manager stated the resident was currently being treated for a UTI. Review of records showed a urine culture with greater than 100,000 pseudomonas aeruginosa and provider documentation of a UTI.
Delayed Response to Severe Weight Loss
Penalty
Summary
The facility failed to address a severe weight loss for a resident with unspecified dementia, bipolar disorder, delusional disorders, and heart disease. The resident’s documented weight decreased from 126.2 pounds on 6/3/25 to 112.4 pounds on 7/2/25, a loss of 11.22 percent that met the facility’s criteria for severe weight loss. The clinical record did not show that the weight was retaken to confirm the loss, and the Registered Dietitian did not complete a nutritional assessment until 7/16/25, 14 days after the severe weight loss was documented. The facility policy titled Weight Assessment and Interventions stated that any weight change of 5 percent or more should be retaken the next day for confirmation and, if verified, nursing should immediately notify the dietician in writing. The policy also defined severe weight loss thresholds, including greater than 5 percent in 1 month and greater than 10 percent in 6 months. The resident’s record showed no documented reweight after the 7/2/25 weight, and the next recorded weight was 117.8 pounds on 7/17/25, followed by additional lower weights in late July and early August. The resident’s MDS dated 7/16/25 indicated severe cognitive impairment, set-up/cleanup assistance for eating, a height of 63 inches, a weight of 112 pounds, and a loss of 5 percent or more in the last month or 10 percent in the last 6 months. The care plan identified the resident as at risk for malnutrition, but the revision to the care plan occurred on 8/7/25, after the severe weight loss had already been documented. The physician’s orders included a regular diet, fortified foods, and yogurt twice daily, but there was no order to obtain weights. An IDT note dated 7/8/25 documented that a 13-pound weight loss was discussed and a re-weigh was considered, yet the next recorded weight was not until 7/17/25. Interviews with nursing and management staff confirmed that a reweigh should have been obtained within 24 to 48 hours and that the resident’s weight loss was significant, while the RD stated the delay in confirming the weight loss impacted timely nutritional assessment and intervention.
PICC Line Dressing and External Length Not Properly Monitored
Penalty
Summary
The facility failed to provide care and maintenance of a PICC line for one resident with diagnoses including presence of a left artificial knee joint, encephalopathy, and muscle weakness. The resident had intact cognition on the most recent MDS assessment and had a PICC line in the right upper arm. On multiple survey observations, the PICC dressing was dated 8/20/25 and was peeling and lifting at the corners; on one observation, tape was seen along one edge holding the dressing down. The resident’s care plan directed weekly changes of the dressing, injection caps, and extension tubing, with monitoring every shift and reporting abnormalities. Physician orders required the PICC dressing and needleless connector(s) to be changed and the external catheter length to be measured every Wednesday and every night shift. The August 2025 TAR showed dressing changes documented on 8/13, 8/20, and 8/27, but the surveyor observed the dressing still dated 8/20 on 8/28. The TAR and progress notes did not document measurement of the external catheter length on 8/20 or 8/27. During interviews, nursing staff stated that PICC dressing changes should be completed as ordered, that a peeling or lifting dressing should have been changed as needed, and that external catheter length should be documented to confirm the line had not migrated.
Missing Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure that respiratory care and services were provided in accordance with professional standards of practice for one resident. Resident #26 was admitted with diagnoses including gastrointestinal hemorrhage, acute respiratory failure, muscle weakness, and a stage 3 pressure ulcer. The most recent MDS, dated 8/12/25, showed a BIMS score of 13 out of 15 and indicated the resident was receiving continuous oxygen therapy. On 8/26/25 and again on 8/27/25, the surveyor observed Resident #26 awake in bed receiving oxygen via nasal cannula at 2 liters per minute. Review of the resident’s active physician orders did not show an order for oxygen administration, even though the electronic record documented oxygen use beginning 8/12/25. Facility policy required verification of a physician’s order for oxygen administration. During interviews, the Charge Nurse, Unit Manager #2, and the DON each stated that oxygen administration requires a physician’s order, and they acknowledged that Resident #26 did not have one until the issue was brought to the facility’s attention.
Failure to Monitor Dialysis Access and Keep Emergency Supplies Available
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care and services for a resident with chronic kidney disease stage 5 and dependence on renal dialysis. Resident #41 was cognitively intact and received hemodialysis. The resident had a right chest dialysis access site, but the physician’s order did not include directions to monitor or assess for complications and to document those assessments. The care plan included monitoring for infection, bleeding, hemorrhage, bacteremia, septic shock, and vital signs and weight per protocol, but the nursing progress notes from 8/2/25 through 8/26/25 did not show observation or care of the hemodialysis catheter or pre- and post-dialysis condition. On 8/27/25 at 7:30 A.M., the surveyor observed the dialysis access site to the right upper chest covered with undated bordered gauze, and the resident stated that nursing staff had not provided care to assess the site upon return from dialysis. The resident’s TAR and MAR for 8/26/25 did not indicate orders to monitor or assess the right chest port for complications. During interviews, nursing staff and the DON stated that dialysis residents should have site assessments, documentation, and communication with the dialysis center, and that complications could include bleeding, infection, dislodgement, inflammation, or redness. The DON also stated that the resident should have an emergency kit in the room and that gauze would be used for pressure if bleeding occurred. The facility also failed to ensure an emergency kit with clamps was kept with the resident for an emergency related to the tunneled hemodialysis catheter. On 8/26/25 and again on 8/27/25, the surveyor did not observe emergency clamps or pressure dressings in the resident’s room. The DON later observed an emergency kit in the resident’s top drawer containing gauze, but was unaware that a clamp should be included for a resident with a hemodialysis catheter. The facility policy stated that if there is major bleeding from the post-dialysis site, pressure should be applied, emergency services and the dialysis center contacted, and the clamps on the lumens verified as closed.
Failure to Implement Enhanced Barrier Precautions for Resident with Central Dialysis Catheter
Penalty
Summary
The facility failed to establish and 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 Resident #41, who was admitted in August 2025 with chronic kidney disease stage 5 and dependence on renal dialysis. The most recent MDS, dated 8/9/25, indicated the resident was cognitively intact with a BIMS score of 13 out of 15, received hemodialysis, required assistance with all personal care and mobility, and had incontinence. Review of the facility’s Enhanced Barrier Precautions policy, dated December 2024, stated that EBPs apply when a resident has an indwelling medical device such as a central line and that gown and glove use is required during high-contact care activities. On 8/26/25, the surveyor observed no sign posted outside Resident #41’s room indicating EBPs were required. Review of the resident’s medical record failed to show an order or documentation for EBPs. Staff interviews on 8/27/25 showed CNA #2 had cared for the resident without using EBPs, Nurse #5 said the resident should have had an EBP sign posted but she had not used EBPs, Unit Manager #2 said the resident should have EBPs for care related to the central line but had not used them, and the ADON and DON both stated that a resident with a port should have EBPs because it is an open line.
Failure to Report Abuse Allegation and Conduct NAR Check
Penalty
Summary
The facility failed to adhere to its abuse policy regarding the immediate reporting of abuse allegations. On a specific date, a resident alleged that a Certified Nurse Aide (CNA) slapped them on the forearm during care. Although the resident reported the incident to a nurse, and the nurse subsequently informed the Charge Nurse, neither of them reported the allegation to the Administrator or Director of Nursing (DON) immediately, as required by the facility's policy. Instead, the written statements were placed in the Unit Manager's mailbox, delaying the report until the following Monday when the Unit Manager discovered the statements and informed the DON. The resident involved in the incident had a history of a fracture and anxiety, and their cognitive functioning was intact, as indicated by a perfect score on a mental status assessment. The resident was able to communicate effectively and reported the incident promptly. Despite this, the staff failed to follow the mandated reporting procedures, resulting in a delay in addressing the allegation of abuse. Additionally, the facility did not conduct a required Nurse Aide Registry (NAR) check for the CNA involved in the incident before their employment. The CNA was an agency-contracted employee, and the responsibility for the NAR check was assumed to be with the agency. However, it was later discovered that the check had not been completed, which was a violation of the facility's screening protocol for new employees.
Failure to Implement Comprehensive Care Plan and Safety Measures
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was admitted with a stage 3 pressure ulcer. Despite the presence of a wound on the sacrum, the resident's care plan did not include a specific plan for addressing the actual skin breakdown. The resident's initial wound consult form and subsequent wound consultant notes confirmed the presence of the stage 3 pressure ulcer, yet the care plan only addressed potential skin breakdown, not the existing condition. Interviews with the charge nurse and the Director of Nurses revealed that the care plan should have been updated upon the resident's readmission from the hospital to include the stage 3 pressure injury. Additionally, the facility failed to implement bed and chair alarms for the resident as indicated in the falls plan of care. Observations over several days showed that the resident did not have bed or chair alarms in place, despite physician orders and the active falls care plan requiring them. The resident confirmed the absence of alarms since admission, and the September Treatment Administration Record inaccurately documented that alarms were applied every shift. Interviews with the CNA and charge nurse indicated that the alarms had not been used since mid-August, and the plan of care and physician's orders were not followed or updated. The facility's policy on interdisciplinary care planning emphasizes the need for ongoing execution and modification of care plans to meet residents' needs. However, in this case, the care plan was not updated to reflect the resident's current condition, and the required interventions for fall prevention were not implemented. This oversight highlights a failure in the facility's processes for ensuring that care plans are comprehensive and executed as intended.
Delayed Wound Treatment for Resident
Penalty
Summary
The facility delayed the implementation of a wound treatment for a resident who developed a new wound. The resident, who was admitted with diagnoses including diabetes, osteoarthritis, and muscle weakness, was found to have an open area on the left buttock. Despite the resident being cognitively intact and reporting the wound, the facility did not apply any treatment for the first couple of days after the wound was discovered. The Treatment Administration Record indicated that the wound treatment was initiated two days after the wound was first noted. The facility's policy on pressure injury prevention and treatment requires immediate investigation, reporting to the physician, and implementation of new interventions for any new skin areas. However, the medical record for the resident failed to document further notes describing the new open area, and the care plans did not indicate an actual skin breakdown care plan had been initiated. The Director of Nursing acknowledged that new skin areas should be addressed immediately and that residents with wounds should have measurements documented, but was unable to provide specific details regarding the resident's wounds.
Improper Labeling of Insulin Pens
Penalty
Summary
The facility failed to ensure that drugs and biologicals, specifically insulin pens, were labeled in accordance with currently accepted professional principles. During an observation, it was noted that two Lantus insulin pens in a medication cart on the [NAME] unit were not labeled with the required open and expiration dates. Additionally, the resident names on the pens were illegible, making it impossible to determine which resident each pen was intended for. This oversight was confirmed during interviews with nursing staff, who acknowledged the requirement for insulin pens to be labeled with the resident's name, open date, and expiration date, as they are only viable for 28 days after opening. The facility's policy on medication storage, revised in December 2019, mandates that certain medications, including multi-dose injectable vials, must have an expiration date shorter than the manufacturer's expiration date once opened. Despite this policy, the insulin pens observed did not comply with these labeling requirements. Interviews with Nurse #1, Charge Nurse #2, and the Director of Nurses confirmed the deficiency, as they all recognized the necessity for proper labeling to ensure medication purity and potency. The failure to label the insulin pens appropriately represents a deviation from the facility's established procedures and professional standards.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 594 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Newburyport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adviniacare Newburyport | 0.6 mi | ★★★★★ | 9 | 0 |
| The Mansion At Brigham | 1.1 mi | ★★★★★ | 41 | 0 |
| Maplewood Center | 3.4 mi | ★★★★★ | 0 | 0 |
| Mill Town Health And Rehabilitation | 4.2 mi | ★★★★★ | 7 | 0 |
| Lakeview House Skld Nrsg And Residential Care Fac | 8.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Port Rehabilitation And Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.