Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Andover Village Retirement Community during CMS and state inspections, most recent first.
Failure to Follow Care Planned Feeding Interventions: A resident with dysphagia and dementia required max assist with eating and had a care plan directing staff to feed her in her room, use pleasant conversation, and provide verbal and physical cues. During dinner, a CNA stood over the resident in the dining room, repeatedly tried to place food in her mouth while she kept her lips closed and pushed food away, and did not explain the food or converse pleasantly; the CNA later said she was unaware of the care plan.
A resident at nutritional risk with dx including cancer, anorexia, malnutrition, dysphagia, and dementia had physician-ordered weekly weights that were not consistently obtained or documented. The TAR and weight summary lacked several required weights, and staff interviews confirmed the missed documentation with no refusals recorded. The RD stated weekly weights were needed to monitor the resident’s low body weight and variable intake.
Medications were found left at bedside for two residents without orders for self-administration or bedside storage. One resident had saline eye drops and two pills on the bedside table, and another resident had clotrimazole-betamethasone cream at bedside and reported using it after each void, despite the order being for q12h use. The residents’ records showed they were not approved to self-administer, and an LPN confirmed there were no self-administration orders in the EMR.
A resident with multiple health conditions developed a pressure ulcer on the heel that was identified by a CNA and assessed by an LPN, who notified the DON and the resident's family. Despite this, the wound was not documented or assessed in the medical record at the time it was found, and later documentation inaccurately stated the wound was discovered after an appointment, following the DON's directive. This failure to follow facility policy for timely assessment and documentation of pressure ulcers had the potential to affect other residents with similar conditions.
A resident with impaired mobility and cancer developed a pressure ulcer on the right heel that was first identified by a CNA and assessed by an LPN, who notified the resident's daughter and the DON. However, the wound was not documented in the medical record at the time of discovery, and subsequent nursing notes falsely indicated the wound was new upon the resident's return from an appointment, misclassifying it as community-acquired. Interviews confirmed the wound was present earlier and that the medical record was falsified, resulting in inaccurate documentation.
A respiratory therapist failed to maintain sterile technique during tracheostomy care for a resident with chronic respiratory failure by touching a light cord with a sterile gloved hand and continuing the procedure without changing gloves or re-washing hands, resulting in a breach of infection control protocols. The facility's policy required aseptic technique but did not specifically address avoiding contact with other surfaces during care.
Two residents in a facility did not receive their ordered ROM restorative programs consistently. One resident with multiple diagnoses, including quadriplegia, had an inconsistent passive ROM program, while another resident with Alzheimer's and a hip prosthesis did not receive the required active ROM program. Staff interviews confirmed the programs were not completed as ordered, and facility policies on restorative care were not followed.
A facility failed to provide adequate tracheostomy care and timely respiratory evaluations for a resident with chronic respiratory failure. Despite physician orders for regular checks, there was no consistent documentation of care. The resident's mother, a nurse, felt compelled to perform the care herself due to the facility's inaction. Observations showed respiratory therapists did not perform necessary evaluations, and the facility lacked a formal plan to address the mother's involvement in care.
A resident with hypertension and cardiac murmur did not receive her morning medications as intended. The nurse left the medication cup on the resident's bedside table, and the resident forgot to take them after breakfast. The nurse documented the medications as administered on the MAR, contrary to the facility's policy requiring nurses to remain with residents during medication administration.
Failure to Follow Care Planned Feeding Interventions
Penalty
Summary
The facility failed to implement care planned interventions to address dining needs for Resident #65, who was admitted with dysphagia, depression, anxiety disorder, restlessness and agitation, and dementia without behavioral disturbance. The quarterly MDS showed moderate cognitive impairment, adequate hearing, unclear speech, and maximal assistance needed for eating. The care plan, initiated for a self-care deficit in eating related to cognitive deficits, impaired mobility, need for verbal and physical cues, required assistance with eating, and weakness, directed staff to feed the resident all meals in her room for 15 minutes, converse with her during meals, alternate bites with fluids, allow her to choose the order of foods when possible, and provide verbal and physical prompts and cues. During observation, Resident #65 was in the dining room for dinner and was being assisted by a CNA who stood next to her while repeatedly attempting to place spoons of food to her lips. The resident kept her lips tightly closed, moaned and whimpered, tried to push the food away, and the CNA told her, "You need to eat this." After five unsuccessful attempts, the CNA forcefully set the spoon down and stated in a frustrated tone that she did not know what to do and asked whether the resident always ate like this. The CNA did not explain the foods being offered or engage in pleasant conversation, and later stated she was unaware the resident had a care plan for eating related to dementia. An LPN stated the resident was usually pleasant and would eat or take medicine if staff spoke pleasantly with her, and the restorative RN confirmed the care plan interventions were intended to help staff successfully feed the resident in a calm setting.
Missed Weekly Weight Documentation for Resident at Nutritional Risk
Penalty
Summary
The facility failed to obtain and document weekly weights for a resident who was identified as being at nutritional risk for weight loss. The resident had diagnoses including malignant neoplasm of the prostate, anorexia, mild protein calorie malnutrition, dysphagia, and dementia without behavioral disturbance. The care plan identified nutritional risk related to abnormal labs, polypharmacy, intake of less than 75% of meals, refusal to eat, loss of appetite, low BMI, dementia, dysphagia, respiratory failure, cancer, and mild protein malnutrition, with interventions including weekly weights and notification of the RD and physician for significant weight changes. Physician orders directed weekly weights, and the record showed multiple missed weights with no documentation of a weight or refusal in the medical record. Missing weights were identified on 01/04/26, 04/12/26, 04/25/26, 05/10/26, 05/24/26, and 07/01/26. The TAR and weight summary section did not contain documentation for those dates. The MDS quarterly assessment noted the resident needed assistance with eating and mobility and received chemotherapy. Staff interviews confirmed the weekly weight monitoring process and verified the missing documentation. An LPN stated weekly weights could be obtained any shift every seven days and should be documented in the medical record and TAR. The RRN confirmed the resident had weekly weight orders and verified the missing weights, and the ADON also verified the missed weights and that no refusals were documented. The RD stated the resident was at nutrition risk because of low body weight and variable intake, and weekly weights were needed to monitor him.
Medications Left at Bedside Without Orders or Self-Administration Approval
Penalty
Summary
The facility failed to ensure medications were properly stored and secured for two residents. Resident #4 was admitted with diagnoses including acute kidney failure, right tibia and fibula fracture, chronic respiratory failure, morbid obesity, dependence on supplemental oxygen, and pulmonary hypertension. The admission collection assessment indicated the resident was not to self-administer medications, and no later self-administration assessments were completed. During observation, Resident #4 had a bottle of LubriFresh saline eye drops on the bedside table and a medicine cup containing two pills on the bedside table. The resident stated staff allowed her to keep the eye drops at bedside so she could use them as needed and said she liked to take the pills later. Review of provider orders showed no order for self-administration or for medications to be left at bedside. Resident #59 was admitted with diagnoses including pericardial effusion, hypothyroidism, chronic kidney disease, chronic obstructive pulmonary disease, and hypertension. The admission assessment indicated the resident was not to self-administer medications, and the MDS showed severe cognitive impairment with moderate assistance needed for ADLs, hygiene, toileting, transfers, and mobility. During observation, Resident #59 had a large tube of Clotrimazole-Betamethasone topical cream at bedside. The resident stated she used the cream after each void for a vaginal infection and that staff let her keep it at bedside so she could apply it herself. Provider orders showed no order for self-administration or for bedside storage, and the cream was ordered every 12 hours, not after each void. Facility policy stated residents may self-administer medications only if the attending physician and interdisciplinary care planning team determine they have the decision-making capacity to do so safely.
Failure to Timely Assess and Document Pressure Ulcer
Penalty
Summary
A deficiency was identified when the facility failed to ensure timely and accurate assessment and documentation of a pressure ulcer injury for a resident. The resident, who had a history of cancer, impaired mobility, and poor nutrition, was at risk for pressure ulcers and had interventions in place, including skin checks and protective devices. Despite these measures, a discolored area was found on the resident's right heel by a CNA, and an LPN assessed the area, took a photo, and notified the resident's daughter and the DON. However, there was no documentation of the skin impairment in the nursing notes or a wound assessment on the date it was first identified. Further review revealed that the LPN communicated with the DON about the wound, and the DON allegedly suggested waiting to see if the area resolved, which the LPN interpreted as a directive not to document the wound at that time. The LPN later documented the wound as being discovered after the resident returned from an appointment, following the DON's instructions to identify it as community-acquired. Interviews confirmed that the wound was present before the appointment, and the documentation did not accurately reflect the timeline of the wound's discovery and assessment. The facility's policy required that any observed skin alteration be reported, assessed, documented, and communicated to the physician and family. In this case, although the wound was reported and a treatment order was obtained, the required documentation and wound assessment were not completed when the wound was first identified. This failure to follow policy and accurately document the pressure ulcer affected the resident and had the potential to impact other residents identified as having pressure ulcers.
Failure to Accurately Document and Maintain Resident Medical Record
Penalty
Summary
The facility failed to ensure the accuracy and integrity of a resident's medical record, specifically regarding the documentation of a pressure ulcer. A resident with multiple diagnoses, including cancer and impaired mobility, was at risk for pressure ulcers and had interventions in place to prevent skin breakdown. On a specific date, a CNA discovered a dark, discolored area on the resident's right heel, which was assessed by an LPN who took a photo and notified the resident's daughter and the DON. Despite this, there was no documentation in the medical record or wound assessment on the day the area was first identified. Subsequent nursing notes falsely indicated that the resident had no skin impairments prior to leaving for an appointment and that the pressure ulcer was only discovered upon her return, classifying it as community-acquired. Interviews revealed that the LPN, under the impression from the DON's comments, did not document the wound when it was first found and later falsified the record to reflect the wound as new upon the resident's return. The DON and wound nurse confirmed that the area was present earlier and that the medical record did not accurately reflect the timeline of the wound's discovery. The investigation confirmed that the facility did not maintain accurate and timely documentation of the resident's skin condition, and the wound was not properly assessed or recorded when first identified. Orders for treatment were obtained, but the lack of documentation and the subsequent falsification of records led to an inaccurate medical record for the resident.
Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
A deficiency was identified when a respiratory therapist (RT) failed to maintain proper infection control measures during tracheostomy care for a resident with chronic respiratory failure, cerebral infarction, and a tracheostomy. The resident, who was in a persistent vegetative state and required ongoing tracheostomy care, was observed during a routine procedure where the RT donned a gown, washed hands, and applied gloves before beginning care. During the process, the RT touched the light cord with a sterile gloved hand to improve visibility, then continued the procedure without changing gloves or re-washing hands, thereby contaminating the sterile field. The RT acknowledged the lapse in aseptic technique during an interview, confirming that she continued care after contaminating her gloves. The facility's policy required the use of aseptic technique and sterile gloves during tracheostomy care, with specific instructions to avoid cross-contamination. However, the policy did not explicitly address the need to avoid touching other surfaces, such as a light cord, during the procedure. The Director of Nursing confirmed that maintaining a sterile field is necessary and that touching other items during care constitutes an infection control issue. This incident had the potential to affect other residents with tracheostomies in the facility.
Failure to Complete ROM Restorative Programs
Penalty
Summary
The facility failed to ensure that range of motion (ROM) restorative nursing programs were completed as ordered for two residents, Resident #11 and Resident #43. Resident #11, who had diagnoses including muscle weakness, spastic hemiplegia, multiple sclerosis, quadriplegia, and contractures, was supposed to receive a passive ROM program for his upper and lower extremities. However, the documentation revealed that the program was inconsistently completed, with only a few instances of completion or refusal recorded. Interviews with staff confirmed that the restorative programs were not conducted as frequently as required, with staff often being reassigned to other duties. Resident #43, who had a dislocation of an internal left hip prosthesis, Alzheimer's disease, and heart failure, was also affected by the facility's failure to provide consistent ROM restorative programs. His care plan required an active ROM program for his lower extremities, but the documentation showed that the program was not completed as ordered. Interviews with staff confirmed that the resident was not seen six to seven times a week as required, and the restorative program was not documented as completed. The facility's policies on restorative nursing and resident mobility and ROM were not adhered to, as evidenced by the lack of consistent and structured programs for the residents. The policies required that residents with limited ROM receive treatment and services to prevent further decline, with specific interventions and documentation of services provided. However, the facility failed to meet these requirements, leading to deficiencies in the care provided to Residents #11 and #43.
Inadequate Tracheostomy Care and Respiratory Evaluations
Penalty
Summary
The facility failed to provide adequate tracheostomy care and timely respiratory evaluations for a resident with chronic respiratory failure and a tracheostomy. The resident's physician orders required regular oxygen saturation checks, tracheostomy care, and respiratory evaluations, but there was no documented evidence that these were consistently completed. The resident's mother, who is a nurse, expressed concerns about the lack of care and felt compelled to perform the care herself due to the facility's inaction. Observations and interviews revealed that respiratory therapists did not perform necessary evaluations or engage with the resident or the mother during routine checks. The mother reported that the therapists relied on her to perform the care, and she felt unsupported by the facility staff. Despite the mother's requests for more frequent checks, the facility maintained a routine of three checks per 12-hour shift, which the mother found inadequate given the resident's inability to communicate distress. The facility's staff, including the DON and Administrator, acknowledged the mother's involvement in the care but did not have a formal agreement or plan to address the situation. The facility's policy required tracheostomy care to be provided as needed, but the staff did not consistently follow this policy. The lack of proper documentation and adherence to care standards contributed to the deficiency, as the facility did not ensure that the resident received the necessary respiratory care as ordered.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Resident #13, who had diagnoses including hypertension and cardiac murmur, was observed with a medication cup containing nine tablets and capsules on her bedside table. The resident had not taken her morning medications, which included heart medication, as she intended to take them after breakfast but forgot. The nurse, RN #321, had documented on the Medication Administration Record (MAR) that the medications were administered, even though they were not taken by the resident. The facility's policy on medication administration requires that nurses remain with residents while they take their medications and not leave medications in a resident's room without orders to do so. RN #321 acknowledged that she left the medication cup with the resident and should have returned to offer the medications again after breakfast. This oversight led to a significant medication error, as the resident did not receive her prescribed medications at the scheduled time.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Jefferson Healthcare Center | 13.9 mi | ★★★★★ | 5 | 0 |
| Eagle Pointe Skilled Nursing & Rehab | 14.7 mi | ★★★★★ | 4 | 0 |
| Rolling Fields, Inc | 15.3 mi | ★★★★★ | 19 | 0 |
| Saint Paul Homes | 15.4 mi | ★★★★★ | 0 | 0 |
| Kadima Rehabilitation & Nursing At Greenville | 18.1 mi | ★★★★★ | 30 | 1 |
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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 October 2026) and official state health department websites.