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Deficiency Records for Andover Manor Rehab and Nursing
A list of the most recent deficiencies for Andover Manor Rehab and Nursing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Andover Manor Rehab and Nursing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-17 | 2024-03-12 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-01-17 | 2024-03-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-17 | 2024-03-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-01-17 | 2024-03-12 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-01-17 | 2024-03-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-17 | 2024-03-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-17 | 2024-03-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-17 | 2024-03-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-17 | 2024-03-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-17 | 2024-03-12 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-01-17 | 2024-03-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-01-17 | 2024-03-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-01-17 | 2024-03-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-17 | 2024-03-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-17 | 2024-03-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-01-17 | 2024-03-12 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-01-17 | 2024-03-12 | N |
| Meet other general requirements. | Fire Safety | 2024-01-23 | 2024-02-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-23 | 2024-02-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-23 | 2024-02-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-23 | 2024-02-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-27 | 2023-10-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-17 | 2023-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-17 | 2023-05-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-14 | 2023-04-03 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-27 | 2023-02-06 | N |
| Have an externally vented heating system. | Fire Safety | 2022-12-27 | 2023-02-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-15 | 2023-01-23 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-12-15 | 2023-01-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-15 | 2023-01-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-15 | 2023-01-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-15 | 2023-01-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-15 | 2023-01-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-15 | 2023-01-23 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-15 | 2023-01-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-15 | 2023-01-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-15 | 2023-01-23 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-12-15 | 2023-01-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-15 | 2023-01-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-15 | 2023-01-23 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-12-15 | 2023-01-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-15 | 2023-01-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-12-15 | 2023-01-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-15 | 2023-01-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-15 | 2023-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-15 | 2023-01-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-27 | 2022-08-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-02 | 2022-05-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-02 | 2022-05-03 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-02 | 2022-05-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-02 | 2022-02-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-19 | 2021-09-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-19 | 2021-09-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-19 | 2021-09-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-19 | 2021-09-28 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-08-02 | 2021-09-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-19 | 2021-09-03 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-07-19 | 2021-09-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-19 | 2021-09-03 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-07-19 | 2021-09-03 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-07-19 | 2021-09-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-19 | 2021-09-03 | N |
| Provide activities to meet all resident's needs. | Health | 2021-07-19 | 2021-09-03 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-07-19 | 2021-09-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-19 | 2021-09-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-19 | 2021-09-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-19 | 2021-09-03 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-07-19 | 2021-09-03 | N |
| Provide or obtain dental services for each resident. | Health | 2021-07-19 | 2021-09-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-19 | 2021-09-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-19 | 2021-09-03 | N |
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