Andover Village Retirement Community

In the surveyor’s words

From the most serious findings on record at Andover Village Retirement Community, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF656Jul 23, 2026

  Based on observation, interviews, record review, and review of facility policy, the facility failed to implement care planned interventions to address dining needs for Resident #65. This affected one (Resident #65) resident of 20 residents reviewed for care plans. The facility census was 61.Findings include: Review of the medical record for Resident #65 revealed an admission date of 08/09/22 with diagnoses including dysphagia (difficulty swallowing), depression, anxiety disorder, restlessness and agitation, and dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 had moderate cognitive impairment, adequate hearing, and unclear speech. […]

• No harm, potential for more than minimal, isolatedF692Jul 23, 2026

  Based on record review, interview and review of facility policy, the facility failed to obtain weekly weights for Resident #14 who was at nutritional risk for weight loss. This affected one (Resident #14) of five residents reviewed for nutrition. The facility identified 11 residents (Resident #14, #12, #18, #8, #30, #31, #72, #36, #71, #42, and #10) with physician orders for weekly weights. The facility census was 61.Findings include:Review of the medical record for Resident #14 revealed an admission date of 11/09/25 with diagnoses including malignant neoplasm of prostate, anorexia, mild protein calorie malnutrition, dysphagia ( difficulty swallowing) , and dementia without behavior disturbance.Review of the care plan, date initiated 11/13/25, revealed Resident #14 was at nutritional risk… […]

• No harm, potential for more than minimal, isolatedF761Jul 23, 2026

  Based on observation, interviews, record review and review of facility policy, the facility failed to ensure medications were properly stored and secured. This affected two Residents (#4 and #59) out of 17 residents observed for medication storage. The facility had a total census of 61.Findings include:1.Review of the medical record for Resident #4 revealed an admission date of 10/18/22 with diagnoses including acute kidney failure, fracture of right fibula and right tibia, chronic respiratory failure, morbid obesity, dependence on supplemental oxygen, and pulmonary hypertension.Review of the admission collection assessment dated [DATE] revealed Resident #4 was not to self-administer medications. […]

• No harm, potential for more than minimal, isolatedF686Nov 25, 2025

  Based on observation, interview, record review, and review of facility policy revealed the facility did not ensure pressure ulcer injuries were assessed and documented timely and accurately when identified. This affected one Resident (#64) out of three residents reviewed for pressure ulcers. This had the potential to affect seven Residents (#8, #9, #10 #14, #18, #29, and #43) the facility identified with pressure ulcers. The facility census was 63.Findings Include:Review of closed medical record for Resident #64 revealed an admission date of 07/10/25 and she was discharged home with home health on 08/19/25. She later readmitted back to the facility on [DATE] and then was sent to the hospital on [DATE]. […]

• No harm, potential for more than minimal, isolatedF842Nov 25, 2025

  Based on record review and facility staff interview the facility failed to ensure the medical record was accurate. This affected one, Resident #64, of three reviewed for wounds. The facility census was 63. Findings Include:Review of closed medical record for Resident #64 revealed an admission date of 07/10/25 and she was discharged home with home health on 08/19/25. She later readmitted back to the facility on [DATE] and then was sent to the hospital on [DATE]. Her diagnoses included fracture of right femur, malignant neoplasm of breast, malignant neoplasm of lung, malignant neoplasm of the bone, and hypertension. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #64 had intact cognition and had impairment on one of her lower extremities. […]