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Inspection visit

Inspection

ADVINIACARE NEWBURYPORTCMS #22533253 citations on this visit
53 citations recorded

Citations

53 citations recorded*CMS

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.

  • 0658GeneralS&S Dpotential for harm

    F658 - Comprehensive Care Plans

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0677SeriousS&S Hactual harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0686GeneralS&S Dpotential for harm

    F686 - Skin Integrity

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0689SeriousS&S Kimmediate jeopardy

    F689 - Accidents

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

  • 0690GeneralS&S Dpotential for harm

    F690 - Incontinence

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  • 0692GeneralS&S Epotential for harm

    F692 - Assisted nutrition and hydration

    Provide enough food/fluids to maintain a resident's health.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0712GeneralS&S Dpotential for harm

    F712 - Frequency of physician visits

    Ensure that the resident and his/her doctor meet face-to-face at all required visits.

  • 0725GeneralS&S Epotential for harm

    F725 - Nursing Services

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0726GeneralS&S Epotential for harm

    F726 - Nursing Services

    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

  • 0732GeneralS&S Cno actual harm

    F732 - Nurse Staffing Information

    Post nurse staffing information every day.

  • 0740GeneralS&S Dpotential for harm

    F740 - Behavioral health services

    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  • 0741GeneralS&S Dpotential for harm

    F741 - The facility must have sufficient staff who provide direct services to

    Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

  • 0745GeneralS&S Dpotential for harm

    F745 - The facility must provide medically-related social services to attain or

    Provide medically-related social services to help each resident achieve the highest possible quality of life.

  • 0756GeneralS&S Dpotential for harm

    F756 - Drug Regimen Review

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0757GeneralS&S Dpotential for harm

    F757 - Unnecessary Drugs—General

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • 0758GeneralS&S Dpotential for harm

    F758 - Medication Errors

    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  • 0759GeneralS&S Epotential for harm

    F759 - Medication Errors

    Ensure medication error rates are not 5 percent or greater.

  • 0041GeneralS&S Fpotential for harm

    Implement emergency and standby power systems.

  • 0353GeneralS&S Fpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0918GeneralS&S Fpotential for harm

    F918 - Bathroom Facilities

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

  • 0657GeneralS&S Dpotential for harm

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0550GeneralS&S Epotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0552GeneralS&S Dpotential for harm

    F552 - Planning and Implementing Care

    Ensure that residents are fully informed and understand their health status, care and treatments.

  • 0561GeneralS&S Dpotential for harm

    F561 - Self-determination

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  • 0580GeneralS&S Dpotential for harm

    F580 - Notification of Changes

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

  • 0585GeneralS&S Dpotential for harm

    F585 - Grievances

    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.

  • 0600SeriousS&S Gactual harm

    F600 - Freedom from Abuse, Neglect, and Exploitation

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0609GeneralS&S Dpotential for harm

    F609 - The facility must develop and implement written policies and procedures that:

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

  • 0610GeneralS&S Epotential for harm

    F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the

    Respond appropriately to all alleged violations.

  • 0626GeneralS&S Dpotential for harm

    F626 - Transfer and discharge-

    Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

  • 0656GeneralS&S Epotential for harm

    F656 - Comprehensive Care Plans

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

  • 0761GeneralS&S Fpotential for harm

    F761 - Labeling of Drugs and Biologicals

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  • 0791GeneralS&S Dpotential for harm

    F791 - Dental Services

    Provide or obtain dental services for each resident.

  • 0801GeneralS&S Fpotential for harm

    F801 - Staffing

    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

  • 0803SeriousS&S Jimmediate jeopardy

    F803 - Menus and nutritional adequacy

    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

  • 0835SeriousS&S Jimmediate jeopardy

    F835 - Administration

    Administer the facility in a manner that enables it to use its resources effectively and efficiently.

  • 0837SeriousS&S Jimmediate jeopardy

    F837 - Governing body

    Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

  • 0842GeneralS&S Dpotential for harm

    F842 - Resident-identifiable information

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

  • 0865GeneralS&S Fpotential for harm

    F865 - Quality assurance and performance improvement (QAPI) program

    Have a plan that describes the process for conducting QAPI and QAA activities.

  • 0867GeneralS&S Fpotential for harm

    F867 - Program feedback, data systems and monitoring

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

  • 0880GeneralS&S Fpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0881GeneralS&S Fpotential for harm

    F881 - Infection prevention and control program

    Implement a program that monitors antibiotic use.

  • 0882GeneralS&S Fpotential for harm

    F882 - Infection preventionist

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

  • 0940SeriousS&S Kimmediate jeopardy

    F940 - Training Requirements

    Develop, implement, and/or maintain an effective training program for all new and existing staff members.

  • 0941GeneralS&S Fpotential for harm

    F941 - Training Requirements

    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

  • 0942GeneralS&S Fpotential for harm

    F942 - Training Requirements

    Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

  • 0943GeneralS&S Fpotential for harm

    F943 - Abuse, neglect, and exploitation

    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

  • 0944GeneralS&S Fpotential for harm

    F944 - Quality assurance and performance improvement

    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

  • 0945GeneralS&S Fpotential for harm

    F945 - Infection control

    Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

  • 0946GeneralS&S Fpotential for harm

    F946 - Compliance and ethics

    Provide training in compliance and ethics.

  • 0949GeneralS&S Fpotential for harm

    F949 - Training Requirements

    Provide behavior health training consistent with the requirements and as determined by a facility assessment.

FAQ · About this visit

Common questions about this visit

What happened during the November 7, 2023 survey of ADVINIACARE NEWBURYPORT?

This was a inspection survey of ADVINIACARE NEWBURYPORT on November 7, 2023. The surveyor cited 53 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at ADVINIACARE NEWBURYPORT on November 7, 2023?

Yes, 53 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure services provided by the nursing facility meet professional standards of quality."

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.

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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.