Andover Forest Post Acute Care Center

In the surveyor’s words

From the most serious findings on record at Andover Forest Post Acute Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF805Apr 12, 2024

  Based on observation, record review and interview, the facility failed to ensure diets as ordered by the physician were served in proper form for one Resident (#68) out of a total of 29 sampled residents. Specifically, on 1/22/24, Resident #68 was served a lunch meal, not in accordance with the diet order, resulting in Resident #68 choking and requiring the Heimlich maneuver (an emergency procedure which involves abdominal thrusts to dislodge foreign bodies or food from the throats of choking victims). Findings include: Review of the facility's Therapeutic Diets Policy, dated November 2022 indicated: Therapeutic diets shall be prescribed by the attending physician. […]

• Actual harm, isolatedF656Sep 26, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was severely cognitively impaired and was observed by several nursing staff to display exit seeking behaviors, the Facility failed to ensure a comprehensive person-centered care plan was developed and implemented related to his/her risk for elopement. On 09/14/23 Resident #1 exited the unit in his/her wheelchair through a fire door exit into a stair well, fell from his/her wheelchair down several stairs onto a landing and sustained a left ankle fracture. Findings Include: Review of the Facility Policy titled Person-Centered Care Plan, dated as revised 10/24/22, indicated a comprehensive individualized Care Plan will be developed within seven days after completion of the comprehensive assessment. […]

• Actual harm, isolatedF689Sep 26, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was severely cognitively impaired, was wheelchair bound, and who had been observed since admission to exit seeking behaviors, the Facility failed to ensure he/she was provided with an adequate level of supervision in an effort to maintain his/her safety in an effort to prevent an incident/accident resulting in an injury. On 09/14/23, prior to being transferred out of bed, Resident #1 verbalized to Certified Nurse Aide (CNA) #1 that he/she was going away and shortly afterwards he/she had exited the unit through an alarmed fire exit door and was found on the landing at the bottom of the staircase. […]

• Actual harm, isolatedF656Aug 29, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plan of Care indicated he/she was dependent on two staff members for bed mobility and positioning, and had a known behavior of sliding him/herself off the bed and onto the floor, with an intervention to keep the bed in the lowest position when in bed, the Facility failed to ensure nursing staff consistently implemented and followed interventions from his/her Plan of Care while meeting his/her care needs. On 08/12/23, Certified Nurse Aide (CNA) #1 provided care including turning and repositioning to Resident #1 while he/she was in bed, without another staff member present to assist her. […]

• Actual harm, isolatedF689Aug 29, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required physical assistance from two staff members for bed mobility, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety and prevent an incident/accident resulting in injury. On 08/12/23, Certified Nurse Aide #1, provided care to Resident #1, which included repositioning him/her, without another staff member present to assist her. CNA #1 rolled Resident #1 onto his/her side in bed, left him/her like that , and left him/her alone in bed while she went across the hall to get linen. Resident #1 rolled off his/her bed, hit the left side of his/her forehead on the nightstand, and landed on the floor. […]