Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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 389 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) |
|---|---|---|---|---|
| Port Rehabilitation And Healthcare Center | 0.6 mi | — | 0 | 0 |
| Brigham Health And Rehabilitation Center | 1.5 mi | — | 41 | 0 |
| Maplewood Center | 2.9 mi | — | 0 | 0 |
| Mill Town Health And Rehabilitation | 3.6 mi | — | 4 | 0 |
| Lakeview House Skld Nrsg And Residential Care Fac | 8 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Adviniacare Newburyport.
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 August 2026) and official state health department websites.