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Inspection visit

Inspection

ANDOVER MANOR REHAB AND NURSINGCMS #22529425 citations on this visit
25 citations recorded

Citations

25 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0372GeneralS&S Fpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0712GeneralS&S Fpotential for harm

    F712 - Frequency of physician visits

    Have simulated fire drills held at unexpected times.

  • 0550GeneralS&S Dpotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0585GeneralS&S Dpotential for harm

    F585 - Grievances

    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.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0677GeneralS&S Dpotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0689GeneralS&S Epotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0761GeneralS&S Dpotential for harm

    F761 - Labeling of Drugs and Biologicals

    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.

  • 0791GeneralS&S Dpotential for harm

    F791 - Dental Services

    Provide or obtain dental services for each resident.

  • 0808GeneralS&S Dpotential for harm

    F808 - Therapeutic Diets

    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.

  • 0825GeneralS&S Dpotential for harm

    F825 - Specialized rehabilitative services

    Provide or get specialized rehabilitative services as required for a resident.

  • 0842GeneralS&S Dpotential for harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0880GeneralS&S Dpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0908GeneralS&S Dpotential for harm

    F908 - Maintain all mechanical, electrical, and patient care equipment in safe

    Keep all essential equipment working safely.

  • 0015GeneralS&S Fpotential for harm

    Address subsistence needs for staff and patients.

  • 0034GeneralS&S Fpotential for harm

    Provide a means of sharing information on occupancy/needs.

  • 0211GeneralS&S Fpotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0293GeneralS&S Fpotential for harm

    Have properly located and lighted "Exit" signs.

  • 0311GeneralS&S Fpotential for harm

    Have an enclosure around a vertical opening shaft.

  • 0324GeneralS&S Fpotential for harm

    Provide properly protected cooking facilities.

  • 0345GeneralS&S Fpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0353GeneralS&S Fpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0914GeneralS&S Fpotential for harm

    F914 - Be designed or equipped to assure full visual privacy for each

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  • 0918GeneralS&S Fpotential for harm

    F918 - Bathroom Facilities

    Have generator or other power source capable of supplying service within 10 seconds.

FAQ · About this visit

Common questions about this visit

What happened during the January 15, 2026 survey of ANDOVER MANOR REHAB AND NURSING?

This was a inspection survey of ANDOVER MANOR REHAB AND NURSING on January 15, 2026. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at ANDOVER MANOR REHAB AND NURSING on January 15, 2026?

Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure smoke barriers are constructed to a 1 hour fire resistance rating."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.