A list of the most recent deficiencies for Adviniacare Newburyport. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-31 | 2024-03-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-31 | 2024-03-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-31 | 2024-03-08 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2024-01-31 | 2024-03-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-07 | 2024-01-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-07 | 2024-01-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-07 | 2024-01-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-07 | 2023-12-19 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-11-07 | 2023-12-19 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-07 | 2023-12-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-07 | 2023-12-19 | N |
| 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. | Health | 2023-11-07 | 2023-12-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-07 | 2023-12-19 | N |
| Respond appropriately to all alleged violations. | Health | 2023-11-07 | 2023-12-19 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-11-07 | 2023-12-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-07 | 2023-12-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-07 | 2023-12-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-07 | 2023-12-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-07 | 2023-12-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-07 | 2023-12-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-07 | 2023-12-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-07 | 2023-12-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-07 | 2023-12-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-07 | 2023-12-19 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-11-07 | 2023-12-19 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-11-07 | 2023-12-19 | N |
| 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. | Health | 2023-11-07 | 2023-12-19 | N |
| Post nurse staffing information every day. | Health | 2023-11-07 | 2023-12-19 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-11-07 | 2023-12-19 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-11-07 | 2023-12-19 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-11-07 | 2023-12-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-11-07 | 2023-12-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-07 | 2023-12-19 | N |
| 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. | Health | 2023-11-07 | 2023-12-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-07 | 2023-12-19 | N |
| 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. | Health | 2023-11-07 | 2023-12-19 | N |
| Provide or obtain dental services for each resident. | Health | 2023-11-07 | 2023-12-19 | N |
| 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. | Health | 2023-11-07 | 2023-12-19 | N |
| 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. | Health | 2023-11-07 | 2023-12-19 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-11-07 | 2023-12-19 | N |
| 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. | Health | 2023-11-07 | 2023-12-19 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-11-07 | 2023-12-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-07 | 2023-12-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-07 | 2023-12-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-11-07 | 2023-12-19 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-11-07 | 2023-12-19 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-11-07 | 2023-12-19 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-11-07 | 2023-12-19 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2023-11-07 | 2023-12-19 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-11-07 | 2023-12-19 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-11-07 | 2023-12-19 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2023-11-07 | 2023-12-19 | N |
| Provide training in compliance and ethics. | Health | 2023-11-07 | 2023-12-19 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-11-07 | 2023-12-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-14 | 2023-11-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-14 | 2023-11-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-14 | 2023-11-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-14 | 2023-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-09 | 2023-09-28 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-09 | 2023-09-28 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-08-09 | 2023-09-28 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-08-09 | 2023-09-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-09 | 2023-09-28 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-30 | 2022-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-30 | 2022-10-03 | N |
| 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. | Health | 2022-08-25 | 2022-08-30 | N |
| Respond appropriately to all alleged violations. | Health | 2022-08-25 | 2022-08-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-25 | 2022-08-30 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-08-25 | 2022-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-25 | 2022-08-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-11-21 | 2019-12-13 | N |
| 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. | Health | 2019-11-21 | 2019-12-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-21 | 2019-12-13 | N |
