F
36/100The Mansion at Brigham Inspection Report, Violations & Safety Grade (NEWBURYPORT, Massachusetts)
77 HIGH STREET, NEWBURYPORT, Massachusetts 01950
Phone: 9784624221
CMS Overall:1/5
Overview & Bed Count
Certified Beds
64
Avg Residents/Day
39.3
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Essex
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing2/5
Quality1/5
Nurse Staffing Check
| Metric | This Facility | Massachusetts Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.62 | 0.66 | -0.03 |
| Total Nurse Hours per Resident per Day | 3.64 | 3.94 | -0.30 |
| CMS Staffing Rating | 2/5 | 3.1/5 | - |
| Nursing Staff Turnover | N/A | 37.6% | - |
Health Citation History
66 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-09-17 | Administration Deficiencies | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | F – Moderate Harm Potential |
| 2025-09-17 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | E – Moderate Harm Potential |
| 2025-09-17 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E – Moderate Harm Potential |
| 2025-09-17 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2025-09-17 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2025-09-17 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2025-09-17 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2025-09-17 | Nursing and Physician Services Deficiencies | Observe each nurse aide's job performance and give regular training. | D – Moderate Harm Potential |
| 2025-09-17 | Environmental Deficiencies | Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | D – Moderate Harm Potential |
| 2024-11-05 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2024-11-05 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2024-09-12 | Administration Deficiencies | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | F – Moderate Harm Potential |
| 2024-09-12 | Resident Rights Deficiencies | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | E – Moderate Harm Potential |
| 2024-09-12 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
| 2024-09-12 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | E – Moderate Harm Potential |
| 2024-09-12 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E – Moderate Harm Potential |
| 2024-09-12 | Quality of Life and Care Deficiencies | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | E – Moderate Harm Potential |
| 2024-09-12 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E – Moderate Harm Potential |
| 2024-09-12 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-09-12 | Administration Deficiencies | Provide timely, quality laboratory services/tests to meet the needs of residents. | E – Moderate Harm Potential |
| 2024-09-12 | Nutrition and Dietary Deficiencies | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | E – Moderate Harm Potential |
| 2024-09-12 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | E – Moderate Harm Potential |
| 2024-09-12 | Nutrition and Dietary Deficiencies | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | E – Moderate Harm Potential |
| 2024-09-12 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2024-09-12 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E – Moderate Harm Potential |
| 2024-09-12 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2024-09-12 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D – Moderate Harm Potential |
| 2024-09-12 | Resident Rights Deficiencies | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | D – Moderate Harm Potential |
| 2024-09-12 | Resident Assessment and Care Planning Deficiencies | PASARR screening for Mental disorders or Intellectual Disabilities | D – Moderate Harm Potential |
| 2024-09-12 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D – Moderate Harm Potential |
| 2024-09-12 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2024-09-12 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2024-09-12 | Quality of Life and Care Deficiencies | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D – Moderate Harm Potential |
| 2024-09-12 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2024-09-12 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2024-09-12 | Quality of Life and Care Deficiencies | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | D – Moderate Harm Potential |
| 2024-09-12 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-09-12 | Quality of Life and Care Deficiencies | Provide care or services that was trauma informed and/or culturally competent. | D – Moderate Harm Potential |
| 2024-09-12 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-09-12 | Nutrition and Dietary Deficiencies | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | D – Moderate Harm Potential |
| 2024-09-12 | Nutrition and Dietary Deficiencies | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | D – Moderate Harm Potential |
| 2024-09-12 | Administration Deficiencies | Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. | C – Minimal Harm Potential |
| 2024-09-12 | Resident Rights Deficiencies | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | B – Minimal Harm Potential |
| 2024-09-12 | Resident Assessment and Care Planning Deficiencies | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | B – Minimal Harm Potential |
| 2024-09-12 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | B – Minimal Harm Potential |
| 2024-09-12 | Nursing and Physician Services Deficiencies | Post nurse staffing information every day. | B – Minimal Harm Potential |
| 2024-09-03 | Nutrition and Dietary Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-09-03 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2024-09-03 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2024-07-17 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
Showing 50 of 66 citations.
Fire Safety Citation History
42 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-09-17 | Emergency Preparedness Deficiencies | Address subsistence needs for staff and patients. | F – Moderate Harm Potential |
| 2025-09-17 | Emergency Preparedness Deficiencies | Establish staff and initial training requirements. | F – Moderate Harm Potential |
| 2025-09-17 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2025-09-17 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | F – Moderate Harm Potential |
| 2025-09-17 | Construction Deficiencies | Use approved construction type or materials. | F – Moderate Harm Potential |
| 2025-09-17 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | F – Moderate Harm Potential |
| 2025-09-17 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | F – Moderate Harm Potential |
| 2025-09-17 | Egress Deficiencies | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | F – Moderate Harm Potential |
| 2025-09-17 | Egress Deficiencies | Provide hallway or ground-level exits in all residents' rooms. | F – Moderate Harm Potential |
| 2025-09-17 | Smoke Deficiencies | Have an enclosure around a vertical opening shaft. | F – Moderate Harm Potential |
| 2025-09-17 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2025-09-17 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-09-17 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F – Moderate Harm Potential |
| 2025-09-17 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2025-09-17 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2025-09-17 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2024-09-12 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | F – Moderate Harm Potential |
| 2024-09-12 | Emergency Preparedness Deficiencies | Address subsistence needs for staff and patients. | F – Moderate Harm Potential |
| 2024-09-12 | Emergency Preparedness Deficiencies | Establish procedures for tracking staff and patients during an emergency. | F – Moderate Harm Potential |
| 2024-09-12 | Emergency Preparedness Deficiencies | Establish policies and procedures including evacuation. | F – Moderate Harm Potential |
| 2024-09-12 | Emergency Preparedness Deficiencies | Create arrangements with other facilities to receive patients. | F – Moderate Harm Potential |
| 2024-09-12 | Emergency Preparedness Deficiencies | Establish methods for sharing information. | F – Moderate Harm Potential |
| 2024-09-12 | Emergency Preparedness Deficiencies | Establish emergency prep training and testing. | F – Moderate Harm Potential |
| 2024-09-12 | Emergency Preparedness Deficiencies | Establish staff and initial training requirements. | F – Moderate Harm Potential |
| 2024-09-12 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2024-09-12 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | F – Moderate Harm Potential |
| 2024-09-12 | Construction Deficiencies | Use approved construction type or materials. | F – Moderate Harm Potential |
| 2024-09-12 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | F – Moderate Harm Potential |
| 2024-09-12 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | F – Moderate Harm Potential |
| 2024-09-12 | Egress Deficiencies | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | F – Moderate Harm Potential |
| 2024-09-12 | Egress Deficiencies | Provide hallway or ground-level exits in all residents' rooms. | F – Moderate Harm Potential |
| 2024-09-12 | Smoke Deficiencies | Have an enclosure around a vertical opening shaft. | F – Moderate Harm Potential |
| 2024-09-12 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2024-09-12 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | F – Moderate Harm Potential |
| 2024-09-12 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2024-09-12 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2023-09-05 | Construction Deficiencies | Use approved construction type or materials. | F – Moderate Harm Potential |
| 2023-09-05 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | F – Moderate Harm Potential |
| 2023-09-05 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | F – Moderate Harm Potential |
| 2023-09-05 | Egress Deficiencies | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | F – Moderate Harm Potential |
| 2023-09-05 | Egress Deficiencies | Provide hallway or ground-level exits in all residents' rooms. | F – Moderate Harm Potential |
| 2023-09-05 | Smoke Deficiencies | Have an enclosure around a vertical opening shaft. | F – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.