Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Vantage At Andover Llc during CMS and state inspections, most recent first.
Resident rooms were not maintained in good repair, clean, and homelike on two care units. A resident bathroom had a leaking sink, no cold water, water on the floor and wall, stained and sagging ceiling tiles, and a peeling baseboard, while staff said they used a blanket to catch the water and brought water from other rooms for care. Other rooms had missing closet doors, damaged walls, ripped window screens, and chipped or peeling surfaces. Staff and leadership stated the issues were not documented in TELS, and the facility could not provide records showing the concerns were being addressed.
Inaccurate Documentation of Medications, Treatments, and Refusals: The facility failed to accurately chart meds and treatments for multiple residents. A nurse did not document ordered blood sugar checks or hydrocodone administration for a resident with DM and pain, seizure pads were charted as implemented even though a resident with a seizure disorder refused them, and wound dressing changes were documented as completed for two residents despite observations and staff statements indicating the care was not accurately reflected in the MAR/TAR.
PHI was left visible and accessible on a medication cart on a nursing unit. A surveyor observed an open EHR screen and a report sheet with printed and handwritten patient information, including full name, DOB, and diagnosis, while a resident and housekeeping staff member were nearby. The nurse later stated she should not have left the PHI visible, and the DON said nursing should ensure PHI is secure and not visible to unauthorized persons.
A resident with cerebral infarction and adjustment disorder with anxiety/depressed mood received PRN Ativan under an order that was entered without a stop date or duration. Although an NP note referenced a 14-day use, the order remained open-ended, the resident received multiple PRN doses, and later documentation continued the medication without an end date; staff and the DON acknowledged the order should have included a duration.
Failure to Follow Ordered Dressing Changes: Two residents had ordered wound dressings left unchanged beyond the daily schedule. One resident with right forearm skin tears and another resident with a right temple lesion were observed with dressings dated earlier than expected, and an LPN acknowledged the dressings should have been changed daily per the physician orders. The DON stated dressing changes should be completed according to physician orders.
A resident with dementia, severe cognitive impairment, and multiple recent falls was found in bed on several occasions without staff in view, with the call bell and hand bell out of reach and the baby monitor positioned away from the resident or not powered on. The care plan and kardex directed staff to keep the call light within reach and use a baby monitor when the resident was in bed, but staff interviews showed the monitor was not consistently used and one nurse relied on frequent checks instead.
Failure to Monitor and Care for IV Site: A resident with acute kidney failure, a right humerus fracture, and heart disease had a peripheral IV in place, but the record lacked an order to monitor or care for the IV site and the care plan did not address it. Surveyors observed a clear dressing without a date, and both an LPN and the DON stated IV sites should be monitored each shift for signs and symptoms of infiltration and infection.
Unsecured Medication Cart: Staff left a medication cart unlocked and unattended on the first-floor unit with nystatin powder and clotrimazole ointment stored on top of the cart. A resident and a housekeeping staff member were observed nearby. An LPN stated the cart should have been locked before walking away, and the DON stated medication carts should be locked and medications not left on top when not in use.
The facility failed to ensure proper food handling practices during meal distribution, leading to potential cross-contamination. An employee was observed not adhering to handwashing and glove use guidelines, handling food items like salad greens and rolls with the same gloves after touching potentially contaminated surfaces. The Food Service Director acknowledged the need for handwashing before glove use to prevent cross-contamination.
The facility failed to maintain a homelike environment by not repairing a broken overhead light in a resident's room and not ensuring hot water in another resident's bathroom. A family member and a resident had previously reported these issues to the staff, but they remained unresolved until identified by a surveyor. The Maintenance Director was unaware of these problems.
A facility failed to accurately code the MDS assessment for a resident, resulting in a deficiency. The resident, with conditions including COPD and stroke, was observed to have missing and broken teeth. Despite nursing assessments indicating broken or missing teeth, the MDS assessments did not reflect this condition. The discrepancy was confirmed by the MDS nurse, who acknowledged the need for modification.
A resident with a history of chronic conditions was newly diagnosed with schizoaffective disorder, but the facility failed to refer them for a PASARR evaluation to assess the need for specialized services. Despite the significant change in mental health status, the necessary referral was not completed, as confirmed by the facility's social worker.
A resident with a high risk for pressure ulcers was not provided appropriate care when new skin injuries were identified. The facility failed to notify the physician, measure the wounds, or obtain treatment orders, contrary to their policy. Interviews with staff confirmed that standard procedures were not followed, and the medical record lacked documentation of necessary actions.
A facility failed to implement a hand splint for a resident as per the rehabilitation care plan. The resident, with left-side hemiplegia, was observed without the splint, which should be worn at night. There was no physician's order or documentation in the resident's records, leading to inconsistent application. Staff interviews revealed awareness of the splint's use but no formal documentation or order to ensure compliance.
A facility failed to maintain proper catheter care for a resident, as the urinary drainage bag was repeatedly observed on the floor, contrary to facility policy. The resident, who requires substantial assistance and is dependent on staff for toileting, confirmed they did not place the bag on the floor. Staff acknowledged the issue, suggesting bed movement might have caused the bag to fall.
The facility failed to serve food at safe and appetizing temperatures, as observed during a resident group meeting and test tray evaluations. Residents reported that the food is consistently cold and bland. Test trays revealed that milk, sweet potatoes, ham, zucchini, yogurt, and chocolate cake were not served at appropriate temperatures, with some items being lukewarm and watery. These findings were shared with the Food Service Director.
Resident Rooms Not Maintained in Good Repair
Penalty
Summary
The facility failed to ensure resident rooms were maintained in good repair, clean, and homelike on two of three resident care units. On the first-floor unit, one resident room had missing closet doors, a scuffed and altered-looking metal doorway frame with bent metal, chipped paint, and cracked plaster, and two ceiling tiles in the closet with large dark brown discoloration that appeared to be water stains. Another resident room had a bathroom with a wet white blanket on the floor under the sink, visible water on the floor and wall, a hot water faucet that caused water to pour out from the bottom of the sink and spray from under the faucet handle, and no cold water from the cold faucet. The bathroom also had two large dark brown water stains across eight ceiling tiles, sagging and discolored tiles, and a baseboard that was peeling off the wall with brown discoloration throughout. Resident #28 stated the bathroom sink had been leaking for over a week, that water was all over the floor and pouring out from under the sink, and that there was no cold water. The resident said staff had been bringing water from another room to provide care and wash hands, and said the nursing staff and maintenance director had been notified but the issue had not been fixed. During later observation, the wet blanket remained under the sink and the leak was still present. A CNA said the sink had been leaking for a while and that staff placed a blanket under it to catch the water and brought water from other rooms for care. Maintenance staff, the nurse, and the unit manager each stated they were not aware of the leak or had not seen it reported in the TELS system, and the maintenance staff reviewed the system and found no report for the leaking sink. On the second-floor unit, one room had a large hole with cracked plaster under the window extending from the shelf to the baseboard, chipped paint and cracked areas on the wall near the bed with exposed plaster near the call bell panel, and chipped laminate peeling around the bathroom sink. Another room had a ripped window screen, and the resident and roommate said the screen had been torn for months and had not been fixed despite being reported to staff. The Administrator stated she was aware of the ripped screens and that issues identified in the building should be reported in the TELS system, but she could not locate information related to the areas identified. Throughout the survey, the facility was unable to provide documentation that the areas of concern were being addressed, and review of the TELS work orders did not show the concerns were documented or identified.
Inaccurate Documentation of Medications, Treatments, and Refusals
Penalty
Summary
The facility failed to accurately document care in the medical record for four sampled residents. The cited policy required medications administered and treatments or services performed to be documented in the resident record, with documentation that was objective, complete, and accurate, including the date and time care was provided and whether the resident refused the treatment. For one resident with diabetes and osteoarthritis, the MAR did not show weekly blood sugar checks or administration of hydrocodone-acetaminophen as ordered on two Wednesdays. The resident stated nurses always check blood sugars as ordered. The nurse responsible for those shifts said he did check the blood sugars and removed the hydrocodone-acetaminophen from the controlled substance box, but forgot to document both the blood sugar results and the medication administration. The DON stated the documentation should have been completed before the nurse left for the day. For another resident with a seizure disorder and moderate cognitive impairment, the surveyor observed the resident in bed without seizure pads on the bilateral side rails on multiple occasions, and the pads were found against the wall in the room. The resident said he or she always refuses the seizure pads because they are disliked. The TAR nevertheless showed the seizure pads as implemented on multiple shifts, and nursing staff acknowledged the resident often refused them and that documentation should have reflected refusal rather than implementation. The progress notes did not document any refusal. Two additional residents had wound dressing documentation that did not match what was observed. One resident with right forearm skin tears was observed with two dressings dated two days earlier, and the resident said the dressing had not been changed the day before. The TAR showed the dressing change as completed, while a nurse later stated that if the dressing was not changed, the record should not show that it was. Another resident with a right temple and right ear lesion was observed with a dressing dated two days earlier, yet the TAR documented the dressing as changed as ordered. Nursing staff stated the dressing should have been changed daily and that the record should accurately reflect the care provided.
PHI Left Visible on Medication Cart
Penalty
Summary
The facility failed to keep resident PHI private and confidential on one of two nursing units. The facility policy titled HIPAA, revised 7/12/2012, stated that confidential healthcare information is to be limited to the minimum necessary and that individuals shall not access information for residents for whom they are not responsible for providing healthcare. On 8/21/25 at 8:01 A.M., the surveyor observed on the first-floor unit medication cart an open computer screen with an electronic health record and a document labeled Report Sheet containing printed and handwritten patient information, including full name, date of birth, and diagnosis. The surveyor was able to read the PHI, and the nurse was not present at the cart while a resident and a housekeeping staff member were in the area by the computer screen with visible patient information. At 8:05 A.M., Nurse #1 returned and stated she should not have left the PHI visible and accessible on the medication cart. During an interview at 8:41 A.M., the DON said nursing should ensure PHI is secure and not visible to those not authorized.
Open-Ended PRN Ativan Order Without Required Duration
Penalty
Summary
The facility failed to ensure that a PRN antianxiety medication for one resident was limited to 14 days and that the prescriber documented the rationale for continued use and the duration of the PRN order. Resident #39 was admitted with diagnoses including cerebral infarction and adjustment disorder with mixed anxiety and depressed mood, and had intact cognition on the MDS. The resident’s record showed an order for Ativan 0.25 mg by mouth every 12 hours as needed for anxiety, entered on 7/3/25, but the order did not include a stop date or duration for use. Although a nurse practitioner note on 7/3/25 stated the medication would be used as needed for anxiety/depression x 14 days, the actual order remained open-ended. The resident’s MAR showed PRN Ativan was administered four times in August 2025 after the initial order date. A later NP note on 8/14/25 stated to continue Ativan 0.25 mg twice daily as needed, but the order still did not include a duration or end date. A pharmacist note on 8/6/25 recommended stopping PRN lorazepam. During interviews, Nurse #6 stated PRN psychotropic medication orders should be for 2 weeks and then have an end date, Unit Manager #2 said the order should have included a duration, and the DON stated the NP should have addressed the pharmacist recommendation and the order should not have been written without an end date.
Failure to Follow Ordered Dressing Changes
Penalty
Summary
The facility failed to implement the plan of care for two residents by not changing ordered dressings as directed. Resident #95 was admitted with diagnoses including skin tears to the right forearm, skin cancer, and gout. The physician’s order for the right forearm skin tears directed staff to cleanse the wound, apply xeroform, and cover with a dry protective dressing every day shift. On observation, the resident was found in bed with two dressings on the right upper arm dated 8/17/25, and the resident stated that the nurse did not change the dressing the previous day. Nurse #2 later stated that the dressing was changed that day and acknowledged that the dressing should have been changed on 8/18/25 because it was ordered daily. Resident #96 was admitted with diagnoses including heart disease, liver disease, and cancer, and had a recent treatment to the right side of the face for skin cancer. The physician’s order for the right ear lesion and right temple directed Iodosorb and a dry protective dressing to be changed daily and as needed every day shift. On observation, the resident was found in bed with a dressing dated 8/17/25 on the right temple area. Nurse #2 stated that the dressing should have been changed daily and said he did not notice the date on the old dressing before removing it. The DON stated that dressing changes should be completed according to physician orders.
Failure to Provide Ordered Fall Supervision and Call Bell Access
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices were in place for a resident with severe cognitive impairment and a history of multiple recent falls. The resident was admitted with dementia, had a BIMS score of 1 out of 15 on the most recent MDS, and had 3 or more falls in the prior quarter. Nursing and physician notes documented multiple recent falls, including a fall that resulted in a humerus fracture and later falls that resulted in scalp sutures. The resident’s active fall care plan directed staff to keep the call light within reach and to use a baby monitor when the resident was in bed, with staff in the dayroom when out of bed. However, survey observations on multiple occasions found the resident in bed without any staff within view, with the call bell on the floor and a hand bell on the windowsill, both out of reach. The baby monitor camera was observed on the roommate’s side of the room facing away from the resident, and at one point the monitor at the nurse’s station showed only the resident’s bathroom rather than the resident. On another observation, the monitor at the nurse’s station was not powered on and had no video feed of the resident’s room. During interviews, staff stated that the baby monitor should have been directed at the resident when unattended in bed and that all interventions listed on the kardex should be implemented. One nurse stated she did not use the baby monitor because she believed it was ineffective and instead relied on frequent checks, while also being unaware that the resident was not being given a call bell. The DON stated that staff should implement all care plan and kardex interventions, document refusal or revise the plan if an intervention was ineffective, and that the resident’s call bell should have been within reach if that was the intervention.
Failure to Monitor and Care for IV Site
Penalty
Summary
The facility failed to provide care and maintenance of a peripherally inserted IV catheter for Resident #94 and failed to monitor the IV site and develop a plan of care for the IV. Resident #94 was admitted in August 2025 with diagnoses including acute kidney failure, a fracture of the right humerus, and heart disease. A progress note dated 8/18/25 indicated the resident was alert and oriented x3. On 8/19/25 at 8:01 A.M., surveyors observed the resident with a peripherally inserted IV line in the left antecubital space and a clear dressing over the site without a date. Review of the physician's orders showed an order dated 8/14/25 to start a peripheral IV line and administer normal saline at 50 milliliters per hour for one liter, but the orders for August 2025 did not include an order to monitor the IV site or how to care for it. The care plan dated 8/17/25 also did not include a focus to monitor or care for the IV site. During interviews, Nurse #2 stated he could not locate an order for IV site monitoring or care in the medical record and said the IV site should be monitored every shift for signs and symptoms of infiltration and infection. The resident stated the IV was inserted in the facility the prior week, and the DON stated that all IV sites should be monitored each shift for signs and symptoms of infiltration and infection and that the medical record should indicate monitoring of the IV site.
Unsecured Medication Cart
Penalty
Summary
The facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements when a medication cart was left unlocked and unsupervised on the first-floor unit. During the observation, one bottle of nystatin powder and one container of clotrimazole ointment were seen on top of the medication cart while a resident and a housekeeping staff member were in the area. The facility policy titled Storage of Medications stated that medications and biologicals are to be stored safely, securely, and properly and are accessible only to authorized personnel. During interview, Nurse #1 stated she should not have left the medications on top of the cart and that the cart should have been locked before she walked away from it while in a resident's room. The DON stated she expected nursing staff to lock medication carts and not keep medications stored on top of the carts when they were not in use.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to ensure proper food handling practices during meal distribution in the kitchen, leading to potential cross-contamination. The facility's policy on handwashing and glove use, dated 9/14/20, outlines the necessity of washing hands before putting on gloves and changing gloves when transitioning between tasks or after potential contamination. However, during the lunch meal distribution, an employee, referred to as [NAME] #1, was observed not adhering to these guidelines. After recording food temperatures, the employee removed gloves and donned new ones without performing hand hygiene. Subsequently, the employee touched potentially contaminated surfaces and directly handled food items such as salad greens and rolls with the same gloves, which could lead to cross-contamination. The surveyor observed multiple instances where the employee used gloved hands to handle different food items without changing gloves or washing hands in between tasks. This included touching the pan cover on the stove and then handling salad greens and rolls. During an interview, the Food Service Director acknowledged that handwashing should occur before putting on gloves and that food should not be touched directly to prevent cross-contamination. These observations indicate a failure to follow established food safety protocols, potentially compromising the sanitary conditions of the meal distribution process.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment in two resident rooms on the second floor. In one instance, a family member reported that the overhead bed light in a resident's room was not functioning, and this issue had been previously communicated to the staff. During an observation, the surveyor confirmed that the light was indeed not working. In another instance, a resident reported that the bathroom water in their room was only lukewarm and not reaching a hot temperature, despite having informed the staff about this ongoing issue. The surveyor measured the hot water temperature at 68 degrees Fahrenheit, confirming the resident's complaint. The Maintenance Director was unaware of these issues until informed by the surveyor.
Inaccurate MDS Assessment of Resident's Oral/Dental Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident, leading to a deficiency. Specifically, two comprehensive MDS assessments did not reflect the oral/dental status of a resident who had obvious or likely carious or broken natural teeth. The resident, admitted in November 2023 with conditions including chronic obstructive pulmonary disease, transient cerebral ischemic attack, anxiety, and mood disorder, was observed to have missing lower teeth and some partial teeth. Nursing assessments and oral assessments documented the presence of broken or missing teeth, but the MDS assessments dated November 15, 2023, and July 3, 2024, did not indicate this condition. The discrepancy was confirmed during an interview with the MDS nurse, who acknowledged the need to modify the MDS assessments to accurately reflect the resident's oral/dental status.
Failure to Refer Resident for PASARR Evaluation After New SMI Diagnosis
Penalty
Summary
The facility failed to ensure that a resident was referred for a Preadmission Screening and Resident Review (PASARR) evaluation after being newly diagnosed with schizoaffective disorder. The resident, who was admitted in February 2020, had a history of chronic obstructive pulmonary disease, chronic pain syndrome, and anxiety disorder. A physician's order dated April 5, 2022, added the diagnosis of schizoaffective disorder to the resident's medical record. Despite this significant change in the resident's mental health status, the facility did not complete a referral for a PASARR evaluation to determine the need for specialized services. The resident's medical records showed that a Level 1 PASARR screening conducted in December 2020 was negative for serious mental illness (SMI). However, the new diagnosis of schizoaffective disorder, which was documented in the Minimum Data Set (MDS), indicated a need for a post-admission Level II evaluation. Interviews with the facility's social worker revealed that a PASARR referral should have been triggered by the new diagnosis, but it was not completed. The social worker acknowledged the oversight and mentioned that they were working on submitting the necessary PASARR for the resident.
Failure to Report and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident. The resident, who was admitted in February 2022, had diagnoses including venous insufficiency, dementia, and moderate protein calorie malnutrition, and was at risk for developing pressure ulcers. A care plan was initiated to monitor and document skin injuries, but the facility did not adhere to its policy. On a weekly skin check, an open area on the right hip and redness on the left hip were identified, but the necessary steps were not taken. The physician was not notified, the wounds were not measured, and no treatment order was obtained. Interviews with the Unit Manager and Assistant Director of Nursing revealed that the standard procedure for handling new skin injuries was not followed. The Unit Manager stated that the nurse should notify the physician and consult with the wound doctor, while the Assistant Director of Nursing mentioned that an incident report should be filled out and she should be notified. However, these actions were not taken in the case of the resident, as confirmed by the review of the medical record, which showed no indication that the physician or nurse practitioner was informed about the resident's skin condition.
Failure to Implement Hand Splint Use as per Care Plan
Penalty
Summary
The facility failed to implement the use of a hand splint for a resident in accordance with the rehabilitation plan of care. The resident, who was admitted in November 2023, has several diagnoses including hemiplegia affecting the left side. Observations revealed that the resident's left hand splint was not consistently applied as per the care plan, which indicated it should be worn at night and removed in the morning. Interviews with staff and review of the resident's medical records showed a lack of a physician's order for the splint, and the splint schedule was not documented in the Treatment Administration Record, Medication Administration Record, Kardex, or care plans. The Assistant Director of Rehabilitation acknowledged the absence of a physician's order for the splint and was unsure if nursing staff documented its use. The care plan updates indicated that the splint should be applied at bedtime and removed during morning care, but this was not reflected in the resident's records. Interviews with CNAs and nurses revealed that while they were aware of the splint's use, there was no formal documentation or order to ensure compliance with the care plan. The occupational therapist involved in the resident's care confirmed that the resident was being trialed for daytime splint use and had not discontinued the night splint. However, the lack of documentation and formal orders led to inconsistencies in the application of the splint, as staff were not always aware of the requirements. This deficiency highlights a breakdown in communication and documentation processes within the facility, impacting the resident's care plan implementation.
Improper Catheter Care Observed in Resident
Penalty
Summary
The facility failed to ensure proper catheter care for a resident, specifically by not keeping the urinary drainage bag off the floor, which could lead to potential contamination. The facility's policy on Foley catheter care, reviewed in 2023, outlines that the catheter system should remain closed and the collection bag should not be on the floor. Despite this policy, observations during the survey revealed that the urinary drainage bag for a resident was repeatedly found resting on the floor over several days. The resident involved was admitted to the facility in November 2020 and has a history of hemiplegia and hemiparesis following a cerebral infarction, as well as benign prostatic hyperplasia with lower urinary tract symptoms. The resident is cognitively intact but requires substantial assistance for daily activities and is dependent on staff for toileting. During the survey, the resident confirmed that they did not place the bag on the floor and were physically unable to do so. Staff members, including a CNA and a Unit Manager, acknowledged that the bag should not be on the floor and suggested that the movement of the bed might have caused the bag to fall.
Food Temperature and Palatability Deficiency
Penalty
Summary
The facility failed to serve food that is palatable and at a safe and appetizing temperature, as observed during a resident group meeting and test tray evaluations. During the resident group meeting, four out of six participating residents reported that the food served is consistently cold and bland. A test tray conducted later revealed that the milk was at 50 degrees Fahrenheit, the sweet potato was 100 degrees Fahrenheit and tasted lukewarm, and both the ham and zucchini squash were also lukewarm and sitting in water. Another test tray on a different unit showed similar issues, with the ham at 115 degrees Fahrenheit, sweet potato at 130 degrees Fahrenheit, zucchini at 127 degrees Fahrenheit, yogurt at 53 degrees Fahrenheit, and chocolate cake at 74 degrees Fahrenheit. These findings were shared with the Food Service Director during an interview.
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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.
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Nursing homes near 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 | 1.9 mi | ★★★★★ | 25 | 0 |
| Andover Forest Post Acute Care Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Royal Meadow View Center | 4.3 mi | ★★★★★ | 4 | 0 |
| Royal Wood Mill Center | 4.5 mi | ★★★★★ | 4 | 0 |
| Blaire House Of Tewksbury | 4.6 mi | ★★★★★ | 40 | 0 |
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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.