Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Andover Forest Post Acute Care Center during CMS and state inspections, most recent first.
Four residents did not receive care in accordance with professional standards: one resident used a cervical collar without a physician's order or care plan documentation; two residents received acetaminophen without timely documentation in the eMAR; and another resident with a PICC line did not have required external length or arm circumference measurements documented, with staff unaware of the policy requirements.
Three dependent residents did not receive required assistance with ADLs, including bathing, eating supervision, and denture care. One resident was not bathed as scheduled, another with severe cognitive impairment and dysphagia was left unsupervised during meals despite care plans and therapy recommendations, and a third with dementia did not receive help managing dentures, resulting in lost or unavailable dentures during meals. Staff interviews and documentation revealed a lack of awareness and missing care plan interventions for these needs.
Surveyors found that staff did not consistently date or discard medications with shortened expiration dates, such as insulin pens, inhalers, and eye drops, according to manufacturer guidelines. Medication and treatment carts, as well as the medication room, were left unlocked and unattended, allowing unauthorized access to drugs and biologicals. Staff and the DON confirmed these practices were not in line with facility policy.
A resident with intact cognition and no invoked Health Care Proxy had a MOLST form signed by a Health Care Agent instead of signing it personally, contrary to facility policy and legal requirements. The Social Worker confirmed the resident was alert and oriented, and there was no documentation authorizing the Health Care Agent to sign on the resident's behalf.
A resident with dementia and severe cognitive impairment had a nightstand with a large crack and jagged edge that prevented the drawer from closing and posed a risk of injury. Despite staff awareness of the broken furniture for several months, no maintenance request was made, and the nightstand remained in disrepair and within the resident's reach.
A resident with dementia and intact cognition, whose preferred language is Spanish, did not have a care plan addressing their communication needs. Staff were not fluent in Spanish and could only use basic words, and the care plan lacked instructions for effective communication, despite facility policy requiring documentation of language needs.
A resident with multiple chronic conditions was found using an air mattress without an active physician order, and weekly skin checks ordered by the physician were not documented for over five weeks. Staff confirmed that both the use of the air mattress and the completion of skin checks require proper orders and documentation, but these were not present in the medical record.
A resident with a stage 3 sacral pressure ulcer and spinal cord injury was placed on a low air loss mattress without a physician order, and the mattress was set incorrectly for the resident's weight. Nursing staff and the DON confirmed that an order was required and that mattress settings should match the resident's weight, but these steps were not followed, resulting in inadequate pressure ulcer management.
A resident with severe cognitive impairment and a chronic indwelling urinary catheter did not have physician orders specifying catheter size, bulb size, frequency of changes, or irrigation. Nursing staff performed catheter changes and irrigations without required physician authorization, and no anchoring system was in place to prevent dislodgement. Facility staff confirmed that proper orders were not obtained for the resident's catheter care.
Two residents did not receive necessary behavioral health care and services as required. One resident with a history of alcohol abuse was not offered substance use support services or a care plan until more than two weeks after admission, despite being cognitively intact and motivated for sobriety. Another resident with severe cognitive impairment and on Depakote did not have recommended labs or monitoring completed, even after multiple recommendations from behavioral health and pharmacy staff. Staff interviews confirmed these failures were due to lapses in assessment, care planning, and follow-through on recommendations.
Staff failed to maintain accurate medical records for two residents: one was documented as wearing a fracture boot despite not having it, and another had weekly skin checks marked as completed without supporting documentation in the medical record. Interviews with nursing staff and the DON confirmed the inaccuracies and missing documentation.
A resident with a central line for dialysis and a history of multidrug-resistant organism exposure did not have enhanced barrier precautions implemented as required by facility policy and physician orders. Observations showed no precaution signage or PPE near the room, and staff confirmed that only standard precautions were being used despite the resident's risk factors.
A resident with Alzheimer's disease and dysphagia, requiring supervision during meals, experienced a choking incident when served whole meatballs instead of the prescribed chopped meat. The resident's care plan and physician's orders specified a regular diet with chopped meat, but meal trays were not checked to ensure compliance. The incident highlighted the importance of adhering to dietary requirements and proper meal preparation protocols in LTC facilities.
The facility failed to assess for eligibility and offer pneumococcal vaccinations per CDC recommendations and facility policy for two residents. Both residents had no documentation indicating they were educated about the benefits and potential side effects of the immunization, nor records showing they received or refused the vaccine.
The facility failed to ensure that essential mechanical equipment was in safe, operating condition. Two elevators were not in safe operating condition since December 2023, affecting residents' ability to attend activities and receive timely food delivery. Additionally, the heat in the main dining room was not operational since December 2023, preventing residents from eating their meals there. The Maintenance Director acknowledged ongoing issues with the servicing companies for both the elevator and the heating system.
The facility failed to accurately complete an MDS assessment for a resident, incorrectly coding a resolved pressure ulcer as still present. The MDS Nurse used outdated information and did not conduct a current assessment or interview direct care staff, leading to the deficiency.
The facility failed to provide necessary supervision for a resident with severe cognitive impairment during meals and did not update the care plan for another resident after an incident of assaultive behavior and revocation of smoking privileges. Observations and staff interviews revealed inconsistencies and lack of documentation in the care plans.
The facility failed to review and revise a resident's care plan with the IDT after each MDS assessment. Despite the resident's pressure ulcer being resolved, the care plan was not updated, and interventions were not revised accordingly. Staff confirmed the resident had not used protective boots or received treatment for a long time.
A resident with Alzheimer's disease and full incontinence did not receive timely incontinence care, resulting in a heavily soiled brief. Observations over two days showed the resident was not checked or changed for extended periods, and staff interviews confirmed the lack of care.
A resident with macular degeneration and legal blindness did not receive follow-up vision services as recommended by an optometrist. Despite expressing a desire to see their community eye doctor and having a physician's order for vision evaluation, the facility staff failed to schedule the necessary appointment.
The facility failed to provide weekly cleanings of an oxygen concentrator filter for a resident with COPD and emphysema. The filter had not been checked for cleanliness in 35 days, and staff were unaware of the maintenance requirements.
The facility failed to develop a trauma-informed care plan for a resident with PTSD, despite the resident being cognitively intact and having difficulty adjusting to the facility. The social worker was unaware of the PTSD diagnosis, indicating a lack of communication and proper care planning.
The facility failed to ensure pharmaceutical services met the needs of a resident by not having the prescribed medication, spironolactone, available for administration on two consecutive days. The nurse did not notify the pharmacy or the physician about the unavailability, contrary to the facility's policy.
The facility failed to secure medications for a resident, as observed by a surveyor who found a bottle of Naproxen, saline nose spray, and eye drops on the resident's nightstand. The resident's clinical record did not indicate any assessment or physician's order for self-administration of these medications. Staff were unaware of the resident keeping medications at bedside, indicating non-compliance with the facility's medication storage policy.
A resident admitted with multiple diagnoses, including legal blindness and chronic pain syndrome, did not receive necessary dental services for denture replacement despite multiple requests and recommendations. The facility staff acknowledged the oversight but failed to follow up on the denture fabrication request.
A facility failed to follow a prescribed therapeutic diet and fluid restriction for a resident with a history of kidney transplant and end-stage renal disease. The facility did not ensure proper fluid distribution between dietary and nursing staff, leading to inconsistencies in fluid amounts provided. Nursing staff and the unit manager were unaware of the specific fluid amounts allowed, and the resident's fluid intake was not adequately tracked.
The facility failed to store food in a clean, sanitary, and safe manner. Observations revealed unlabeled and undated salads, loosely wrapped sandwiches, and improperly sealed hard-boiled eggs in the walk-in refrigerator. The Food Service Director confirmed the expectation for proper labeling, dating, and sealing of all foods.
The facility failed to maintain accurate medical records for a resident, documenting blood pressure readings from the left arm when they were actually taken from the right arm, despite explicit instructions to avoid the left arm due to a dialysis AV fistula.
A nurse failed to perform hand hygiene after handling a resident's draining leg and removing gloves, potentially contaminating medication cards and the medication cart. The nurse admitted to not washing or sanitizing his hands, despite knowing the requirement for hand hygiene.
The facility failed to post nurse staffing information daily, as required by federal regulations. The survey team was unable to locate the postings on multiple days, and both the Scheduler and the DON confirmed the information was not posted as required.
Failure to Follow Professional Standards in Physician Orders, Medication Documentation, and PICC Line Monitoring
Penalty
Summary
The facility failed to ensure that four residents received care in accordance with professional standards of practice. For one resident with a C4 spinal cord injury, there was no physician's order for the use of a cervical collar, despite hospital discharge instructions and physician notes indicating the need for continuous use of the collar. The resident's care plan and Kardex also lacked any mention or instructions regarding the cervical collar, and staff were unaware of the requirement, leading to inconsistent use and lack of documentation when the resident was noncompliant. Two other residents did not have timely documentation of acetaminophen administration. In both cases, nurses administered acetaminophen as needed for pain or fever but failed to document the administration in the electronic medication administration record (eMAR) at the time of administration. Both nurses acknowledged forgetting to document the medication, and there were no emergent situations that would have justified the delay. The facility's policy requires immediate documentation of medication administration, which was not followed in these instances. For another resident with a peripherally inserted central catheter (PICC line), the facility did not obtain or document the required external measurements of the PICC line or the resident's arm circumference upon admission or during dressing changes, as required by facility policy and physician orders. The hospital discharge paperwork also lacked these measurements, and staff did not contact the hospital to obtain them. The resident's care plans, nurse progress notes, and practitioner notes did not include any documentation of these measurements, and staff were uncertain about the policy and whether the required monitoring had been completed.
Failure to Provide Required ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three dependent residents, resulting in deficiencies in bathing, eating supervision, and denture care. One resident with an amputation and diabetes, who was cognitively intact and required substantial assistance with bathing, was not provided with any bathing or washing assistance over a weekend, as confirmed by both the resident and documentation. The care plan specified the need for extensive staff assistance with bathing and personal hygiene, but this was not carried out as required. Another resident with severe cognitive impairment, dysphagia, and a history of stroke required supervision or touching assistance while eating, as indicated by the care plan, physician orders, and speech therapy recommendations. Despite this, the resident was repeatedly observed eating alone in their room with the privacy curtain drawn, making them unobservable from the hallway. Staff did not check in during meals, and documentation showed that supervision was not provided for the vast majority of meal opportunities in the previous month. Interviews with staff revealed a lack of awareness regarding the resident's need for supervision during meals. A third resident with dementia and moderate cognitive impairment required partial assistance with oral hygiene and denture management. Observations showed the resident's dentures were left on the floor and not available during meals, and the resident reported frequent loss and lack of staff assistance with denture care. The care plan, physician orders, and Kardex did not include any interventions for denture management, despite repeated incidents of lost or broken dentures and staff acknowledging the resident's need for assistance. Interviews confirmed that staff were unclear about their responsibilities for denture care due to missing information in the care documentation.
Failure to Properly Store and Secure Medications
Penalty
Summary
Facility staff failed to store drugs and biologicals in accordance with state and federal laws, as well as facility policy. Surveyors observed that medications with shortened expiration dates, such as insulin pens, inhalers, and eye drops, were not consistently dated when opened and were not discarded according to manufacturer guidelines. For example, insulin pens were found in medication carts well past their recommended use period after opening, and some medications were opened but undated. Staff interviews confirmed that these medications should have been dated and discarded per policy, but this was not done. Additionally, the medication room was found unlocked and unattended, allowing unauthorized access to medications. Treatment carts containing ointments and biologicals were also left unlocked and unattended on multiple occasions, making their contents accessible to anyone passing by. Staff and the DON acknowledged that medication rooms and treatment carts should always be locked when unattended, but this practice was not consistently followed.
Failure to Ensure Proper Execution of MOLST Form
Penalty
Summary
The facility failed to ensure that a resident's Medical Orders for Life Sustaining Treatment (MOLST) form was executed in accordance with its own policy and standards of practice. Specifically, the MOLST for a resident with diagnoses including hemiplegia, type 2 diabetes mellitus, and end stage renal disease was signed by an individual identified as a Health Care Agent, despite the fact that the resident was assessed as having intact cognition and there was no documentation that the Health Care Proxy had been invoked. The facility's policy requires that a MOLST form must be signed by the resident or a legally recognized representative only if the resident lacks capacity and the Health Care Proxy has been invoked. Record review showed that the resident scored a perfect 15 out of 15 on the Brief Interview for Mental Status exam, indicating full cognitive capacity, and there was no evidence in the medical record that the Health Care Proxy had been invoked. The MOLST form was completed and signed by someone other than the resident, with the box for Health Care Agent checked, and later signed by a Physician Assistant. During interview, the Social Worker confirmed the resident was alert, oriented, and that the Health Care Proxy was not invoked, and was unsure who had signed the MOLST. This failure resulted in the MOLST not being properly executed according to facility policy and legal requirements.
Failure to Maintain Safe and Functional Resident Furniture
Penalty
Summary
The facility failed to ensure a safe and homelike environment for a resident with dementia and severe cognitive impairment by not maintaining the resident's nightstand in a functional and safe condition. The nightstand, located within the resident's reach, had a large crack with a jagged edge on the drawer, preventing it from closing and posing a risk of injury. The exterior of the nightstand was also in poor condition, with scratches and peeling paint. The resident's personal belongings, including a telephone, purse, and nebulizer mask, were stored in the damaged drawer. Despite the nightstand being broken since at least December, staff did not report the issue to maintenance as required by facility policy. Both a CNA and the unit manager were aware of the damage but did not initiate a maintenance request. The maintenance director confirmed that no report had been made in the facility's electronic maintenance system, and the director of nursing stated that staff are expected to promptly report such issues. The deficiency was identified through observations, interviews, and record review.
Failure to Develop Communication Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to document and develop a care plan addressing the communication needs of a resident whose preferred language is Spanish. Despite the facility's policy requiring documentation of language and communication needs in the electronic medical record and the provision of language services at no charge, the resident's care plan did not include any information about their preferred language or instructions for staff on how to communicate effectively. The Minimum Data Set (MDS) indicated the resident had intact cognition and specifically requested an interpreter for communication with healthcare staff, but this was not reflected in the care plan. Interviews with the resident and staff confirmed that the resident speaks only Spanish and does not speak English. Nursing staff administering medication to the resident were not fluent in Spanish and could only communicate using a few basic words. Both the Assistant Director of Nurses and the Social Worker acknowledged that a person-centered communication care plan identifying the resident's preferred language should have been in place to guide staff interactions and ensure the resident's needs were met.
Failure to Obtain Physician Order for Air Mattress and Complete Weekly Skin Checks
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for one resident. Specifically, the resident, who had diagnoses including bipolar disorder, type 2 diabetes, and dementia, was observed using an air mattress on multiple occasions. However, there was no active physician's order or care plan documentation authorizing the use of the air mattress, despite staff acknowledging that such an order is required. The air mattress was set to a weight significantly higher than the resident's actual weight, and staff interviews confirmed that the resident had been transferred with the air mattress but lacked the necessary physician's order. Additionally, the facility did not ensure that weekly skin checks were performed and documented as ordered by the physician. The resident's medical record showed that the last completed skin check was over five weeks prior to the survey, despite an active order for weekly checks. Staff interviews revealed that the resident was not resistive to care, and both nursing staff and the DON confirmed that skin checks should be documented regardless of findings. The lack of documentation indicated that the required skin checks were not completed or recorded as ordered.
Failure to Obtain Physician Order and Properly Set Air Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent new pressure ulcers for a resident with a stage three sacral pressure ulcer and spinal cord injury. The resident was dependent on staff for bed mobility and had a documented recommendation from a wound consultant for a low air loss mattress. Despite this, there was no physician order for the use of an air mattress, and the resident's care plan did not include the use of such a device. The resident was observed on multiple occasions using a Medline Supra APL air mattress, but the mattress was set to 240 pounds, which did not correspond to the resident's actual weight, which ranged from 152 to 166 pounds during the relevant period. Interviews with nursing staff and the DON confirmed that a physician order is required for air mattress use and that mattress settings should be based on the resident's weight according to manufacturer guidelines. Staff acknowledged that the air mattress should have been set according to the resident's weight and that the absence of a physician order was an oversight. The facility did not have a written policy for air mattresses but expected staff to follow manufacturer guidelines. These failures resulted in the resident not receiving appropriate pressure ulcer management as recommended.
Lack of Physician Orders for Indwelling Urinary Catheter Care
Penalty
Summary
The facility failed to follow professional standards of practice for the care of an indwelling urinary catheter for one resident. The resident, who had severe cognitive impairment and a chronic indwelling urinary catheter due to benign prostatic hyperplasia, did not have appropriate physician orders for the use and care of the catheter. Specifically, there were no orders specifying the catheter size, bulb size, frequency of catheter or catheter bag changes, or instructions for irrigation. Despite this, nursing staff changed the catheter and irrigated it on multiple occasions without obtaining the required physician orders. Observations confirmed the resident had an indwelling urinary catheter in place, and there was no anchoring system to prevent accidental dislodgement. Interviews with facility staff, including the Unit Manager and DON, confirmed that physician orders are required for all aspects of catheter care, and acknowledged that such orders were not obtained for this resident. Documentation also showed that catheter care activities, such as changes and irrigation, were performed without the necessary physician authorization.
Failure to Provide Timely Behavioral Health Services and Implement Recommendations
Penalty
Summary
The facility failed to provide timely and appropriate behavioral health care and services to two residents, as required by their own policies and comprehensive care plans. One resident was admitted with a history of alcohol abuse and withdrawal, including a recent episode of seizures related to withdrawal. Despite being cognitively intact and expressing motivation for sobriety, the resident was not offered behavioral health or substance use support services upon admission. The care plan addressing substance use was not implemented until 17 days after admission, and only after the resident was found with alcohol in the facility. Interviews with staff confirmed that the resident should have been assessed and offered support services within the first week, but this did not occur. Another resident, admitted with diagnoses including cerebral infarction, dysphagia, and muscle weakness, exhibited severe cognitive impairment and behavioral symptoms. The resident was prescribed Depakote for depression, and a behavioral health nurse practitioner recommended obtaining a Depakote level, lipid profile, and EKG. The facility's pharmacist also noted that the Depakote drug level was overdue and recommended ordering the necessary labs. However, a review of the medical record showed that these recommended labs were never obtained, and the facility was unable to provide evidence of completed labs when requested by the surveyor. Interviews with facility staff revealed that recommendations from behavioral health services were uploaded to the electronic medical record and sent to the unit manager, but the unit where the resident resided did not have a unit manager at the time, resulting in a lack of follow-through. The DON acknowledged that the recommended labs should have been obtained shortly after they were recommended, but this did not occur, indicating a breakdown in the process for implementing behavioral health recommendations.
Failure to Maintain Accurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident with a history of dementia and a recent right metatarsal fracture, staff documented in the Treatment Administration Record that the resident was wearing a fracture boot as ordered by the physician, despite the resident discarding the boot upon readmission and not wearing it during the survey period. Multiple staff interviews confirmed that the resident was not wearing the boot, and the Director of Nursing acknowledged that documentation should not have indicated the boot was being worn when it was not. For another resident with bipolar disorder, type 2 diabetes, and dementia, staff documented weekly skin checks as completed in the Treatment Administration Record, but the medical record did not contain documentation of these checks for a five-week period. Review of the resident's record showed the last documented skin check was several weeks prior, and staff could not account for the missing documentation. The Director of Nursing confirmed that skin checks must be documented in the medical record, regardless of findings.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Device
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) in accordance with its own infection control policy for a resident with an indwelling medical device. The resident, who was readmitted with a history of resistance to multiple antimicrobial drugs and dependence on renal dialysis, had a central line (internal jugular catheter) for dialysis access. The care plan included interventions for EBP during personal care, and there was a physician's order for EBP. However, multiple observations revealed that there was no enhanced precaution sign on the resident's door, no personal protective equipment (PPE) available near the room, and no indication that staff were following EBP protocols during high-contact care activities. Interviews with nursing staff and the infection control preventionist confirmed that the resident had an indwelling medical device and that EBP should have been implemented, including signage and PPE availability. Despite this, staff reported that only standard precautions were being used, and the required EBP measures were not in place as per facility policy and physician orders. These findings demonstrate a failure to follow established infection prevention and control procedures for residents with indwelling medical devices.
Dietary Oversight Leads to Choking Incident
Penalty
Summary
The facility failed to ensure that Resident #68 received the proper diet form as ordered by the physician, leading to a choking incident during lunch on 1/22/24. Resident #68, admitted in December 2017 with Alzheimer's disease and diagnosed with dysphagia in July 2019, required supervision for meals as per the MDS assessment. Despite having a care plan specifying the need for assistance and supervision during meals, there was no documentation indicating the level of assistance required for eating. The physician's order from 11/19/19 through 1/22/24 prescribed a regular diet with regular texture and chopped meat for Resident #68. During the incident, Resident #68 was served whole meatballs instead of chopped meat as ordered, resulting in choking and the need for the Heimlich maneuver. Interviews with family members, nurses, and the Speech and Language Pathologists revealed that the meal trays were not checked to ensure the correct diet was delivered. The facility's failure to provide Resident #68's meal in the proper form as ordered by the physician was a critical oversight, especially considering the resident's history of dysphagia and the specific dietary requirements outlined in the care plan and physician's orders. Despite the clear instructions in the therapeutic diet manual and the physician's order for chopped meat, the facility served whole meatballs to Resident #68. The lack of proper oversight by nursing staff, including not checking meal trays and ensuring the correct diet was delivered, contributed to the deficiency. The failure to follow established protocols for residents with specific dietary needs, such as Resident #68, resulted in a serious adverse event that required immediate intervention and highlighted the importance of proper meal preparation and service in long-term care facilities.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to assess for eligibility and offer pneumococcal vaccinations per CDC recommendations and facility policy for two residents. Resident #49, admitted in March 2024 with a diagnosis of diabetes, had no documentation in the medical record indicating that the resident or their representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization. Additionally, there was no record that the resident either received the pneumococcal immunization or did not receive it due to medical contraindication or refusal. The Minimum Data Set (MDS) assessment for Resident #49 indicated that the pneumococcal vaccination was not up to date and had not been offered. Similarly, Resident #87, admitted in March 2021 with diagnoses including dementia and obesity, also had no documentation in the medical record showing that the resident or their representative was educated about the pneumococcal immunization. The MDS assessment for Resident #87 indicated that the pneumococcal vaccination was not up to date and had not been offered. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the facility did not have documentation to support that either resident was educated, offered, or received the pneumococcal immunizations as required by the facility's policy.
Failure to Maintain Essential Mechanical Equipment
Penalty
Summary
The facility failed to ensure that essential mechanical equipment was in safe, operating condition. Specifically, two of the facility's elevators were not in safe operating condition since December 2023. Upon entry to the facility, surveyors observed one of the two elevators was out of order. Multiple residents reported that having only one working elevator for months affected timely food delivery and their ability to attend activities. The Ombudsman confirmed that the elevator had been out of order for months, causing significant issues for residents and visitors. The Maintenance Director acknowledged the ongoing issues with the servicing company, including concerns related to the cost of fixing the elevator and potential penalties for breaching the contract. Emails between the facility and the elevator service company indicated that the non-working elevator had been down since December 2023, with ongoing concerns about the cost and payment for repairs and services, and the servicing company’s inability to staff or send out employees for repairs. The Maintenance Director could not explain why an alternative company had not been utilized to expedite the repairs of the elevator. Additionally, the facility failed to ensure that the heat in the main dining room on the ground floor was operational since December 2023. Surveyors observed that no residents were eating their meals in the main dining room during breakfast and lunch meals. Resident Council meeting minutes and interviews with residents and staff confirmed that the main dining room had not been used for meals due to the lack of heat. The Maintenance Director mentioned ongoing communication with the servicing company regarding repairing the heat and the need to either replace parts or completely replace the unit for the main dining area. Emails indicated that the heat was not functioning since January 2024, and quotes to replace the system had been approved by the facility in February and March 2024. As of the date of the survey, the heat was still not operational in the main dining room.
Inaccurate MDS Assessment for Resolved Pressure Ulcer
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident, leading to a deficiency. Specifically, the MDS Nurse incorrectly coded a resolved pressure ulcer as still present for a resident. The resident had been admitted with diagnoses including diabetes, adult failure to thrive, and dysphagia. The MDS assessment dated 2/28/24 indicated the resident had a stage two pressure ulcer, but the ulcer had actually been resolved as of 12/6/23, according to the hospice wound record report and observations by the surveyor and staff interviews. The MDS Nurse admitted to coding the pressure ulcer based on outdated information from December 2023 and did not conduct a current assessment or interview direct care staff. The Director of Nursing confirmed that the MDS Nurse should have followed the Resident Assessment Instrument (RAI) Manual for completing MDS assessments. This failure to accurately assess and document the resident's condition led to the identified deficiency.
Failure to Implement and Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure the plan of care was developed and implemented for two residents. For Resident #10, who has severe cognitive impairment and requires supervision and assistance with eating, the facility did not provide continual supervision during meals. Observations over several days showed Resident #10 eating alone in his/her room without staff present, despite the care plan and Kardex indicating the need for continuous supervision. Interviews with staff revealed inconsistencies in understanding and implementing the required level of assistance for Resident #10 during meals. For Resident #102, who has a history of restlessness, agitation, and adjustment disorder with depressed mood, the facility failed to update the care plan after an incident of assaultive behavior toward staff. Resident #102's smoking privileges were revoked following the incident, but the care plan did not reflect this change or the new arrangement for family to supervise smoking. Interviews with staff confirmed the incident and the change in smoking supervision, but the medical record and care plan lacked documentation of these updates. These deficiencies highlight the facility's failure to adhere to its policies on providing necessary care and services for residents who cannot carry out activities of daily living independently and to update care plans to reflect significant changes in residents' conditions and behaviors.
Failure to Review and Revise Care Plan with IDT
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised with the interdisciplinary team (IDT) as required for one resident. Specifically, the facility did not review and update Resident #59's skin care plan after each Minimum Data Set (MDS) assessment. Resident #59, who was admitted in May 2019 with diagnoses including diabetes, adult failure to thrive, and dysphagia, had a stage two pressure ulcer as indicated in the MDS assessment dated 2/28/24. Despite the pressure ulcer being resolved by 12/6/23, the care plan was not updated to reflect the current status, and interventions such as the use of protective boots and Xerofoam dressings were not revised accordingly. Observations and interviews revealed that Resident #59 did not have any pressure ulcers and was not using protective boots or receiving treatment on the left heel at the time of the survey. Certified Nurse Assistants and nurses confirmed that the resident had not worn booties for a long time and that the pressure ulcer had healed months ago. The Unit Manager and the Director of Nursing acknowledged that the care plan should have been reviewed and revised during the quarterly care plan review but was not. This oversight led to the deficiency noted in the report.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for Resident #87, who has Alzheimer's disease and is fully incontinent of bladder and bowel. The resident, who is dependent on staff for all activities of daily living, was observed multiple times over two days without receiving necessary incontinence care. On the first day, the resident was observed from 8:22 A.M. to 11:27 A.M. without any staff checking for incontinence. On the second day, the resident was observed from 7:42 A.M. to 1:30 P.M. without being checked or changed, resulting in a saturated incontinence brief with a strong odor of urine, indicating multiple urinary voiding episodes. Interviews with staff confirmed that the resident had not received incontinence care for over five hours on the second day. CNA #2, who was not assigned to the resident but was helping the assigned CNA, found the resident's incontinence brief to be heavily soiled. CNA #6, who was assigned to the resident, admitted that she had not provided incontinence care since getting the resident out of bed at 7:00 A.M. Nurse #2 and the Director of Nursing both acknowledged that the resident should have been provided incontinence care every two to three hours to prevent skin breakdown.
Failure to Follow Up on Vision Services for Resident
Penalty
Summary
The facility failed to provide necessary follow-up for vision services for a resident diagnosed with macular degeneration and legal blindness. Despite a recommendation from an optometry consultation on 9/27/23 for an outside optometrist evaluation, the facility did not schedule an appointment with the resident's preferred community eye doctor. The resident, who was cognitively intact with a BIMS score of 14 out of 15, expressed dissatisfaction with the current glasses and a desire to see their own eye doctor. The physician's order from 10/31/22 and the plan of care from 11/25/22 both indicated the need for vision evaluation, but these were not adequately followed up on by the facility staff. Interviews with the resident, a Certified Nurse Assistant, the Unit Manager, and the Director of Nursing revealed that the resident's request to see their community eye doctor was known but not acted upon. The Unit Manager acknowledged the oversight in not booking the appointment, and the Director of Nursing confirmed that nursing staff should have scheduled the visit. This lack of follow-up resulted in the resident not receiving the desired and potentially necessary vision care from their preferred provider.
Failure to Maintain Oxygen Concentrator Filter
Penalty
Summary
The facility failed to provide weekly cleanings of an oxygen concentrator filter for a resident with chronic obstructive pulmonary disease and emphysema. The resident's physician orders required oxygen administration at 1-2 liters per minute via nasal cannula to maintain oxygen saturation greater than 90%. However, there was no reference to changing or cleaning the oxygen concentrator filter in the resident's physician orders, treatment administration record, or progress notes. The facility's nursing form indicated that oxygen concentrator filters should be checked and cleaned every Sunday night, but the filter for this resident had not been checked for cleanliness in the past 35 days. During an observation, the surveyor noted that the oxygen concentrator filter was completely covered in a layer of white dust approximately three millimeters deep. Interviews with the nursing staff revealed that they were unaware of the physician orders or facility policy regarding the maintenance of the oxygen concentrator filter. The Director of Nursing was also unable to locate any documentation indicating that weekly cleanings had occurred. This lack of awareness and documentation led to the deficiency in providing appropriate respiratory care for the resident.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to ensure a person-centered plan of care with individualized interventions for Trauma-Informed Care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, admitted in November 2023, had a BIMS score of 15, indicating cognitive intactness. Despite this, the clinical care plans reviewed on April 10, 2024, did not include a trauma-informed care plan. A family member reported the resident's difficulty in adjusting to the facility, and the social worker was unaware of the PTSD diagnosis, indicating a lack of communication and proper care planning for the resident's specific needs.
Failure to Ensure Availability of Prescribed Medication
Penalty
Summary
The facility failed to ensure pharmaceutical services met the needs of Resident #108 by not having the prescribed medication, spironolactone, available for administration. Resident #108, who was admitted with diagnoses including hyperaldosteronism and heart failure, had a physician's order for spironolactone to be administered daily. However, during a medication pass, Nurse #2 reported that the medication was not available on two consecutive days, 4/10/24 and 4/11/24. The medication administration record confirmed that the medication was not given on these dates, and Nurse #2 admitted to not notifying the pharmacy or the physician about the unavailability of the medication. The facility's pharmacy policy outlines steps to be taken when a medication is not available, including checking neighboring medication carts, the medication room, and the cubex tower, as well as contacting the pharmacy and the prescriber. Despite these guidelines, the necessary actions were not taken to ensure the availability of spironolactone for Resident #108. The Director of Nursing confirmed that nursing staff should call the physician and the pharmacy when routine medications are unavailable, which was not done in this case.
Failure to Secure Medications
Penalty
Summary
The facility failed to ensure medications were secured for one resident out of a total of 29 sampled residents. The facility's policy, dated November 2021, mandates that medications should be stored in locked compartments when not in use. However, during an interview and observation on April 10, 2024, the surveyor found a bottle of Naproxen, saline nose spray, and eye drops on Resident #93's nightstand. Resident #93, who was admitted in June 2021 with chronic kidney disease and is cognitively intact, mentioned that his/her son brought the Naproxen, and he/she had not taken it recently due to side effects. The clinical record did not indicate any assessment or physician's order for Resident #93 to keep medications in his/her room. On April 11, 2024, the surveyor again observed the same medications on Resident #93's nightstand while the resident was not in the room. Nurse #5 and Unit Manager #2 both stated they were unaware of any residents on the unit who kept their own medications at bedside or self-administered their medications. Unit Manager #2 subsequently removed the medications from the nightstand. This indicates a failure to adhere to the facility's medication storage policy, compromising the safety and security of medications within the facility.
Failure to Provide Dental Services for Resident
Penalty
Summary
The facility failed to provide dental services for a resident who was admitted in October 2022 with diagnoses including macular degeneration, legal blindness, and chronic pain syndrome. The resident, who was cognitively intact with a BIMS score of 14 out of 15, required substantial assistance with oral hygiene, including the management of dentures. Despite a physician's order from October 2022 to obtain dental services as needed, and a specific request from the resident in February 2023 to be seen by dental services, the facility did not follow up on the dental recommendations made on September 18, 2023, for the fabrication of new dentures after the resident lost their original set. The consent form for denture fabrication was left blank and not completed. Interviews with various staff members, including a CNA, a nurse, a unit manager, and the DON, revealed that the resident's need for new dentures was known but not acted upon. The unit manager and the DON both acknowledged that the nursing staff should have followed up on the denture fabrication request made in September 2023 but failed to do so. This inaction resulted in the resident not receiving the necessary dental services to replace their lost dentures, impacting their ability to chew and overall quality of life.
Failure to Follow Prescribed Therapeutic Diet and Fluid Restriction
Penalty
Summary
The facility failed to follow a therapeutic diet as prescribed by the attending physician for a resident who required a fluid restriction. The resident, who had a history of kidney transplant, end-stage renal disease with dependence on renal dialysis, heart failure, and obstructive sleep apnea, was admitted with a physician's order for a renal diet and a 2-liter fluid restriction. However, the facility did not ensure proper fluid distribution between dietary and nursing staff. The diet slips indicated inconsistencies in the fluid amounts provided, with some meals exceeding the allowed fluid limit and others not meeting the total daily fluid allotment. Additionally, the nursing staff and unit manager were unaware of the specific fluid amounts allowed by dietary and nursing, and they were not tracking the resident's fluid intake as required by the physician's order and facility policy. Interviews with the resident, nursing staff, unit manager, and the Regional Food Service Director revealed a lack of communication and coordination regarding the fluid restriction. The resident had additional fluids at the bedside that were not accounted for in the fluid restriction plan. The Director of Nursing confirmed that the fluid restriction should be broken down for both nursing and dietary staff, but this was not being done. The facility's failure to adhere to the prescribed therapeutic diet and fluid restriction resulted in a deficiency in the care provided to the resident.
Improper Food Storage Practices
Penalty
Summary
The facility failed to ensure food was stored in a clean, sanitary, and safe manner to prevent the potential spread of foodborne illness to residents. During an observation, the walk-in refrigerator contained six bowls of salad with wilted yellow leaves that were covered but not labeled or dated. Additionally, twelve more bowls of salad were covered but also not labeled or dated. Approximately ten prepared sandwiches were found loosely wrapped in unsealed sandwich bags. A bucket of hard-boiled eggs was observed with the cover resting loosely on top, not tightly sealed. The Food Service Director confirmed that he would expect all foods to be labeled, dated, and properly sealed.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure nursing maintained an accurate medical record for one resident out of a sample of 29 residents. Specifically, for Resident #42, nursing documented that they obtained blood pressure from the left arm when they did not. Resident #42 was admitted with diagnoses including kidney transplant, end-stage renal disease with dependence on renal dialysis, heart failure, and obstructive sleep apnea. The care plan and physician's orders explicitly stated that no blood pressure should be taken from the left arm due to a dialysis AV fistula. However, records indicated that blood pressure readings were documented as being taken from the left arm on multiple dates in March and April 2024. Interviews with Resident #42 and nursing staff revealed that blood pressure was actually taken from the right arm, contrary to what was documented. Resident #42 confirmed that staff only checked blood pressure on the right arm. Nurses #7 and #8, as well as the Unit Manager and the Director of Nursing, acknowledged that the correct arm should have been documented. Nurse #8 admitted to not accurately documenting the correct arm used for blood pressure readings. This discrepancy in documentation was confirmed by multiple staff members, including the Director of Nursing, who stated that nursing should document the correct arm used for obtaining blood pressure readings.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented to prevent the spread of infection on one of the three resident care units. Specifically, a nurse was observed handling a resident's draining leg while wearing gloves, then removing the gloves and touching medication cards without performing hand hygiene. This action potentially contaminated the desk, individual resident's medication cards, and the medication cart. During an interview, the nurse admitted to not washing or sanitizing his hands after removing the gloves, despite knowing that hand hygiene is required after being in contact with a resident and after glove removal. This failure to follow proper hand hygiene protocols was observed and documented by the surveyor, highlighting a significant lapse in infection control practices within the facility.
Failure to Post Nurse Staffing Information Daily
Penalty
Summary
The facility failed to post nurse staffing information daily, at the start of each shift, as required by federal regulations. Specifically, the survey team was unable to locate the required nurse staffing information postings on 4/10/24, 4/11/24, and 4/12/24. During an interview on 4/12/24 at 9:46 A.M., the Scheduler admitted to not posting the staffing information as required. Additionally, during an interview on 4/12/24 at 10:38 A.M., the Director of Nursing (DON) confirmed that the nurse staffing information should be posted according to federal requirements.
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.
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What surveyors actually found near you
We read the 1,138 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near North Andover
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Andover Manor Rehab And Nursing | 3 mi | ★★★★★ | 25 | 0 |
| Royal Meadow View Center | 3.5 mi | ★★★★★ | 4 | 0 |
| Vantage At Andover Llc | 4.2 mi | ★★★★★ | 38 | 0 |
| Meadows, The | 5 mi | ★★★★★ | 12 | 0 |
| Prescott House | 5.2 mi | ★★★★★ | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.