Andover Manor Rehab and Nursing

In the surveyor’s words

From the most serious findings on record at Andover Manor Rehab and Nursing, in the surveyor’s own words.

• Actual harm, isolatedF656May 17, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose comprehensive Plan of Care for Activities of Daily Living (ADLs) indicated he/she required assistance of one staff member when eating, the Facility failed to ensure staff implemented and followed interventions identified in his/her comprehensive plan of care related to staff assistance during meals. On 5/03/23, Resident #1 was left alone and without staff assistance in his/her room with his/her breakfast meal, he/she choked on food, became unresponsive, and required the Heimlich Maneuver. […]

• Actual harm, isolatedF689May 17, 2023

  Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had a known history of dysphagia and whose comprehensive plan of care indicated he/she required assistance of one staff member with eating, the Facility failed to ensure he/she was provided with the necessary level of staff assistance while eating in an effort to maintain his/her safety and prevent an episode of choking. On 05/03/23, Resident #1 was left alone in his/her room with his/her breakfast meal. Resident #1 choked, became unresponsive, required the Heimlich Maneuver, was transferred to the Hospital Emergency Department via 911. […]

• Actual harm, isolatedF689Dec 15, 2022

  Based on observations, policy reviews, record reviews, and interviews the facility failed to: 1) maintain the safety of two Residents (#74 and #77) by preventing falls and elopements, out of a total 30 sampled residents, and 2) failed to secure sharp objects in the sharps container on one of three resident units. Findings include The facility policy titled Fall Management, dated as revised 6/15/22, indicated the following: * Patients will be assessed for risk of falling as part of the nursing assessment process. […]

• Actual harm, isolatedF688Jul 19, 2021

  Based on observation, record review and interview, the facility failed to identify and address the development of a new contracture (a shortening/hardening of the joints leading to deformity) of 1 Resident (#13) and failed to create and implement a care plan related to an existing contracture for 1 Resident (#100) out of a total of 23 sampled residents. Findings include: 1. Resident #13 was admitted to the facility in November 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's most recent Minimum Data Set Assessment, dated 4/14/21, indicated that he/she is severely cognitively impaired and requires assistance with dressing, eating and bathing. […]

• Actual harm, isolatedF689Jul 19, 2021

  Based on observation, record review and interview, the facility failed to 1.) provide adequate supervision per the Resident's plan of care related to falls, resulting in a fall with injury for 1 Resident (#67) and 2.) failed to follow a Resident fall plan of care for 1 Resident (#4) out of a total of 23 sampled residents. Findings include: 1.) For Resident #67, the facility failed to provide adequate supervision per his/her plan of care resulting in a fall with injury. Resident #67 was admitted to the facility in November 2018 with diagnoses including Alzheimer's disease, anxiety and abnormalities of gait and mobility. […]