Andover Forest Post Acute Care Center

Inspectors wroteBased on observations, interviews and record review, the facility failed to document accurately in the medical record for four Residents (#29, #13, #82 and #4) out of a total sample of 30 residents. Specifically, 1. For Residents (a.) #29 and (b.) #13, the facility inaccurately documented blood pressure vital signs. 2. For Resident (a.) #82 the facility failed to accurately document the setting of an air mattress. (b). #4 the facility failed to accurately document the use of tubi grips.

Inspectors wroteBased on record review and interview the facility failed to accurately complete the Minimum Data Set (MDS) assessments for two Residents (#2 and #5) out of a total sample of 30 residents. Specifically,1.) For Resident #2, the facility coded the Resident as having a diagnosis of Schizophrenia, in error. 2.) For Resident #5 the facility coded the Resident as having had an injection of insulin in error.

Inspectors wroteBased on observation, record review and interview the facility failed to implement physician orders for two Residents (#4 and #82) out of a total sample of 30 residents. Specifically:For Resident #4 the facility failed to implement tubi grips (used for support and compression) daily. For Resident #82 the facility failed to implement the correct air mattress setting.

Inspectors wroteBased on observation and interview the facility failed to dispose of garbage and refuse properly.

Inspectors wroteBased on record review and interview the facility failed to assess 6 Residents (#19, #22, #76, #81, #104 and #120) out of a total sample of 30 residents, using the quarterly review instrument specified by the State and approved by CMS (Centers for Medicare and Medicaid) not less frequently than once every 3 months. Findings iclude:1. Resident #19 was admitted to the facility in June 2025 with diagnoses including cancer, heart disease and anxiety. Review of the Minimum Data set (MDS) assessments indicated a quarterly assessment was completed on 1/7/26. Further review indicated that a quarterly MDS dated [DATE] was still in progress. This is more than the 92-day completion date requirement between MDS assessments. 2. Resident #22 was admitted to the facility in April 2022 with diagnosis including cancer, heart disease and high blood pressure. [...]

Inspectors wroteBased on record review and interview the facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS (Centers for Medicare and Medicaid) system within 14 days after a facility completes a resident's assessment for 2 Residents (#19 and #22) out of a total sample of 30 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure four Residents (#101, #94, #210, and #206) received care in accordance with professional standards of practice, out of a total sample of 27 residents. Specifically, 1. For Resident #101, the facility failed to ensure nursing obtained physician's orders for a cervical collar (a neck brace which is used to support and immobilize a person's neck.) 2a. For Resident #210, the facility failed to ensure the nurse documented acetaminophen as administered timely. 2b. For Resident #94, the facility failed to ensure the nurse documented acetaminophen as administered timely. 3. For Resident #206, the facility failed to obtain and monitor external measurements of a peripherally inserted central catheter (also known as a PICC line, is a long, flexible tube (catheter) that is inserted into a vein in your upper arm. [...]

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents for three Residents (#98, #88, #49) out of a total sample of 27 residents. Specifically, the facility failed to: 1. For Resident #98, the facility failed to provide assistance with bathing. 2. For Resident #88, the facility failed to provide supervision while eating during mealtimes. 3. For Resident #49, the facility failed to ensure staff provided assistance with managing denture care and ensuring dentures were available for meals.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, 1. The facility failed to ensure medications with shortened expiration dates were dated once opened in three out of three medication carts observed. 2. The facility failed to ensure the medication room was locked when unattended. 3. The facility failed to ensure treatment carts were locked when unattended.

Inspectors wroteBased on record review and interview, the facility failed to ensure advanced directives for one Resident (#94), out of total sample of 27, were executed in accordance with standards of practice. Specifically, the facility failed to ensure Resident #94 signed his/her own MOLST (Medical Orders for Life Sustaining Treatment).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a safe and homelike environment for one Resident (#405), out of 27 total sampled residents. Specifically, the facility failed to ensure Resident #405's nightstand was functional, safe, and in good repair.

Inspectors wroteBased on record review and interview, the facility failed to document the communication needs of one Resident (#97), out of a sample of 27 residents. Specifically, the facility failed to develop a care plan identifying Resident #97's preferred language of communication.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide care and treatment in accordance with professional standards of practice for one Resident (#62) out of a total sample of 27 Residents. Specifically, for Resident #62, the facility failed to: 1a. ensure there was an active physician's order for the use of an air mattress and 1b. ensure weekly skin checks were being performed and documented as ordered by the physician.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide necessary treatment, services, interventions to promote healing and prevent new ulcers from developing for one Resident (#101), who had a pressure ulcer, out of 27 total sampled residents. Specifically, the facility failed to obtain a physician order for the use of an air mattress for pressure ulcer management and failed to ensure the air mattress was at an appropriate setting.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure professional standards of practice for the care of an indwelling urinary catheter (a tube placed through the urethra into the bladder to drain urine) for one Resident (#46) out of a total sample of 27 residents. Specifically, the facility failed to ensure they obtained physician's orders for the use and care of Resident #46's indwelling urinary catheter.

Inspectors wroteBased on record review and interview, the facility failed to provide behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for two Residents (#96 and #88), out of a total of 27 sampled residents. Specifically: 1. For Resident #96, the facility failed to offer behavioral health services related to substance abuse timely. 2. For Resident #88, the facility failed to implement recommendations made by the Behavioral Health Nurse Practitioner related to labs.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure staff maintained an accurate medical record for two Residents, (#42 and #62), out of a sample of 27 residents. Specifically: 1. For Resident #42, the facility documented that he/she was wearing a fracture boot to his/her right leg when he/she was not. 2. For Resident #62, the facility documented that weekly checks were completed when they were not in the Resident's medical record.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure for one Resident (#27), out of a total sample of 27 residents, that enhanced barrier precautions were implemented in accordance with infection control standards of care.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure diets as ordered by the physician were served in proper form for one Resident (#68) out of a total of 29 sampled residents. Specifically, on 1/22/24, Resident #68 was served a lunch meal, not in accordance with the diet order, resulting in Resident #68 choking and requiring the Heimlich maneuver (an emergency procedure which involves abdominal thrusts to dislodge foreign bodies or food from the throats of choking victims).

Inspectors wroteBased on record reviews, policy review, and interviews, the facility failed to assess for eligibility, and offer pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for two Residents (#49 and #87) out of a total of five residents reviewed.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure mechanical equipment was in safe, operating condition. Specifically, the facility failed to ensure that: 1. Two of two elevators were in a safe operating condition, since December 2023 (approximately four months prior to the date of survey). 2. The heat in the main dining room on the ground floor was in operational condition since December 2023 (approximately four months prior to the date of survey).

Inspectors wroteBased on record review and interview, the facility failed to complete a Minimum Data Set (MDS) assessment that accurately reflected the status of one Resident (#59), out of a total sample of 29 residents. Specifically, for Resident #59, the MDS Nurse coded a pressure ulcer that was resolved.

Inspectors wroteBased on policy review, observations, interviews, and record review, the facility failed to ensure the plan of care was developed and implemented for two Residents (#10, and #102) out of a total sample of 29 residents. Specifically: 1.) For Resident #10, the facility failed to provide assistance with Activities of Daily Living (ADLs) including continual supervision with meals. 2.) For Resident #102 the facility failed to develop and implement a care plan after newly identified assaultive behavior toward staff and loss of smoking privileges with staff occurred. Findings Include: 1.) Review of the facility policy titled Activities of Daily Living, undated, indicated the following: *Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure care plans were reviewed with the interdisciplinary team (IDT) as required for one Resident (#59), out of a total sample of 29 residents. Specifically, the facility failed to review and revise Resident #59's skin care plan with the IDT after each Minimum Data Set (MDS) assessment.

Inspectors wroteBased on observation, record review and interview the facility failed for one Resident (#87) out of a total sample of 29 residents, to provide activities of daily living (ADL). Specifically, for Resident #87, who is incontinent of bladder and bowel, incontinence care was not provided timely.

Inspectors wroteBased on observation, record review and interviews the facility failed to provide services to ensure that proper treatment and assistive devices to maintain vision were provided for one Resident (#12) out of a total sample of 29 residents. Specifically for Resident #12, the facility failed to follow up on an optometry recommendation from 9/27/23 for an outside optometrist evaluation.

Inspectors wroteBased on interview, record and policy review and observation, the facility failed to provide weekly cleanings of an oxygen concentrator filter for one Resident (#49) out of 29 sampled residents.

Inspectors wroteBased on record review and interview for one Resident (#42), who was admitted with the diagnosis of Post-Traumatic Stress Disorder, the facility failed to ensure a person-centered plan of care with individualized interventions for Trauma-Informed Care was developed, out of a total 29 sampled residents.

Inspectors wroteBased on observation, policy review, record review and interview, the facility failed to ensure pharmaceutical services met the needs of each resident for one Resident (#108) in a total sample of 29 residents. Specifically, for Resident #108, the facility failed to ensure routine drugs were available for administration.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medications were secured for one Resident (#93) out of a total of 29 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to provide dental services for one Resident (#12) out of a total sample of 29 residents. Specifically for Resident #12, the facility failed to follow up on dental recommendations from 9/18/23 for fabrication of dentures.

Inspectors wroteBased on observations, record review and interviews, the facility failed to follow a therapeutic diet as prescribed by the attending physician for one Resident (#42) out of a total sample of 29 residents. Specifically, for Resident #42, who required a physician's order for a fluid restriction, the facility failed to ensure there was a fluid distribution for dietary and nursing to provide. Review of the facility policy, Therapeutic Diets, dated 11/11/22, indicated therapeutic diets shall be prescribed by the attending physician. 2. The clinical dietician, nursing staff, and attending physician will review, along with other orders, the need for, and resident acceptance of, the prescribed therapeutic diet. Review of the facility policy, Prevention of Dehydration, dated 11/5/19, indicated the following: 4. Physician's orders to limit fluids will take priority over calculated fluid needs. 5. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored in a clean, sanitary, and safe manner to prevent the potential spread of foodborne illness to residents.

Inspectors wroteBased on records reviewed and interviews the facility failed to ensure nursing maintained an accurate medical record for one Resident (#42) out of a sample of 29 residents. Specifically, for Resident #42 nursing documented they obtained blood pressure from his/her left arm when they did not.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure infection control practices were implemented to prevent the spread of infection, on one out of three resident care units.

Inspectors wroteBased on observations and interviews, the facility failed to post nursing staff data daily, at the start of each shift, relative to licensed and unlicensed nursing staff directly responsible for resident care per shift. Specifically, the facility failed to post this data, in a prominent place readily accessible to residents and visitors, as required.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who was severely cognitively impaired and was observed by several nursing staff to display exit seeking behaviors, the Facility failed to ensure a comprehensive person-centered care plan was developed and implemented related to his/her risk for elopement. On 09/14/23 Resident #1 exited the unit in his/her wheelchair through a fire door exit into a stair well, fell from his/her wheelchair down several stairs onto a landing and sustained a left ankle fracture. Findings Include: Review of the Facility Policy titled Person-Centered Care Plan, dated as revised 10/24/22, indicated a comprehensive individualized Care Plan will be developed within seven days after completion of the comprehensive assessment. [...]

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who was severely cognitively impaired, was wheelchair bound, and who had been observed since admission to exit seeking behaviors, the Facility failed to ensure he/she was provided with an adequate level of supervision in an effort to maintain his/her safety in an effort to prevent an incident/accident resulting in an injury. On 09/14/23, prior to being transferred out of bed, Resident #1 verbalized to Certified Nurse Aide (CNA) #1 that he/she was going away and shortly afterwards he/she had exited the unit through an alarmed fire exit door and was found on the landing at the bottom of the staircase. Resident #1 was transferred to the Hospital Emergency Department for evaluation and was diagnosed with a left ankle fracture. Findings Include: [...]