Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 0 | 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 August 2026) and official state health department websites.