Inspection Reports for
Life Care Center of Andover

The complaint investigation substantiated that Licensed Nurse G physically and verbally abused Resident 1 on 09/17/25. The abuse was witnessed but not immediately reported by staff. The facility failed to protect the resident and failed to report the incident timely, resulting in immediate jeopardy to resident health and safety.

The facility failed to ensure Resident 1 remained free from staff-to-resident abuse, including physical and verbal abuse by Licensed Nurse G. The facility also failed to immediately report the abuse incident to administrative staff and failed to prevent the alleged perpetrator from ongoing access to residents. Corrective actions were implemented following the incident.

The facility failed to adequately assess and manage severe pain for Resident 1, including ineffective communication among healthcare providers and insufficient follow-up on pain interventions. This resulted in R1 experiencing severe pain for six days and an undetected fracture, placing her at risk for further harm.

The facility had multiple deficiencies including failure to provide adequate bariatric equipment, improper use and storage of call lights and foot pedals, incomplete transfer notifications, inadequate care planning for trauma and activities, inconsistent bathing and ADL assistance, improper pressure ulcer care, inadequate enteral feeding practices, respiratory care issues, incomplete bed rail risk assessments, insufficient staff performance evaluations, incomplete nurse staffing postings, and lapses in infection control and food safety.

The facility had multiple deficiencies including failure to provide adequate bariatric equipment, incomplete care plans for trauma and activities, inconsistent bathing and ADL assistance, improper pressure ulcer care, unsafe respiratory equipment storage, inadequate infection control practices, incomplete staff performance evaluations, and failure to maintain posted nurse staffing data.

The facility failed to ensure an environment free from preventable accidents, resulting in a resident (R1) falling from bed and sustaining a scalp laceration requiring 13 staples. The facility implemented corrective actions including updating the care plan and staff education prior to the survey.

The complaint investigation substantiated that Resident 1 fell during a mechanical lift transfer on 02/20/24 when only one staff member was present, contrary to facility policy requiring two staff. The fall caused a pelvic fracture and immediate jeopardy to resident health.

The facility failed to ensure Resident 1 remained free from accident hazards when a Certified Nurse Aide attempted a mechanical lift transfer alone, causing the resident to fall and fracture her pelvis. The facility implemented corrective actions including staff education, suspension and termination of the involved CNA, and audits of residents requiring mechanical lifts.

The facility had multiple deficiencies including failure to respect resident dignity, inadequate access to call lights, unclean environment, failure to provide bed hold notices, incomplete care plans especially related to oxygen use and pressure ulcers, insufficient bathing and personal hygiene services, lack of restorative care, unsafe medication cart practices, inadequate dietary recipe use, infection control lapses, insufficient staffing and RN coverage, incomplete staff performance reviews, and failure to ensure vaccination documentation.

The complaint investigation substantiated that staff failed to follow the resident's care plan for toileting assistance, resulting in a fall and fracture. The resident required total dependence of two staff for toileting, which was not followed by CNA M.

The facility failed to follow Resident 1's care plan requiring total dependence on two staff for toileting, resulting in the resident sliding out of bed and sustaining a fracture to the right knee. The incident was confirmed by staff interviews, medical assessments, and x-ray results.

The facility failed to ensure respect and dignity for residents, provide adequate bathing and hygiene, maintain proper wound care and positioning, ensure safe wheelchair transport, provide individualized activities, maintain catheter care, and properly administer medications, resulting in multiple deficiencies with minimal harm.

The facility was found deficient in multiple areas including failure to include responsible parties in care plans for cognitively impaired residents, failure to review and revise care plans for pain relief and splint use, incomplete discharge summaries, inadequate assistance with bathing and grooming, inadequate restorative nursing and adaptive equipment, improper transfer techniques, failure to provide pain management interventions, failure to act timely on pharmacy recommendations, and failure to ensure stop orders for psychotropic medications.

The inspection was triggered by complaints and included a health resurvey and complaint investigation covering multiple citations related to care planning, ADL care, restorative services, accident prevention, pain management, and medication oversight.

The facility failed to include a resident's responsible party in care plan development, failed to review and revise care plans for pain and contractures, failed to complete a discharge summary, failed to provide adequate ADL care including shaving and nail care, failed to provide restorative nursing services and appropriate positioning devices, failed to ensure safe transfers and wheelchair transport, failed to provide pain management interventions, and failed to act on pharmacy consultant recommendations regarding medication orders.

The facility failed to provide routine bathing for certain residents, did not schedule sufficient nursing staff to ensure resident safety and well-being, and administered medications not ordered by physicians to some residents.

Complaint investigation #KS00143749 focused on failure to provide adequate bathing assistance, insufficient nursing staff, and medication administration errors.

The facility failed to provide assistance with bathing to dependent residents due to understaffing, failed to maintain sufficient nursing staff to provide timely care, and failed to administer medications as ordered to multiple residents due to medication supply and reorder issues.

Complaint investigation #KS00142441 and #KS00142612 regarding allegations of neglect and elopement of resident #1.

The facility failed to timely report an allegation of neglect when resident #1 eloped from the building on 5/3/19. The facility also failed to thoroughly investigate the allegation and ensure adequate supervision to prevent the resident from exiting the building, placing the resident in immediate jeopardy.

The facility failed to report and thoroughly investigate an incident of alleged neglect involving resident #1 eloping, and failed to provide adequate supervision to prevent the elopement. The facility has implemented staff education and ongoing monitoring to address these issues.

The facility failed to develop and implement baseline care plans, review and revise care plans after assessments, develop discharge plans, provide treatment and care according to professional standards, ensure fall interventions, maintain an effective quality assessment and assurance program, and implement an antibiotic stewardship program. Corrective actions and staff education have been completed or planned to address these deficiencies.

The facility was found deficient in multiple areas including failure to notify physicians of resident health changes, failure to report and investigate suspected neglect, failure to develop individualized care plans, inadequate social services related to grief counseling, medication administration errors, and failure to provide physician-ordered diets. The facility has implemented corrective actions and staff education to address these deficiencies.

The facility was found not in substantial compliance with multiple deficiencies including failure to complete baseline care plans, failure to review and revise care plans, failure to develop and implement effective discharge planning, failure to provide quality care including timely assessments and treatments, failure to ensure fall prevention interventions, and failure to maintain an effective quality assurance program including antibiotic stewardship.

The facility was found not to be in substantial compliance with multiple regulatory requirements including baseline care plans, care plan revisions, discharge planning, quality of care, fall prevention, and infection control. Deficiencies included failure to complete baseline care plans, failure to revise care plans after assessments, inadequate discharge planning, failure to provide timely and appropriate care leading to resident harm, failure to implement fall prevention interventions, and ineffective antibiotic stewardship.

The complaint investigations involved multiple residents with issues including failure to notify physicians timely of significant changes, failure to report and investigate neglect, medication errors, inadequate care planning, failure to provide social services, and failure to provide diets as ordered.

The facility failed to ensure timely physician notification for significant resident decline, failed to report and investigate neglect allegations, failed to develop individualized care plans, failed to provide timely social services, and failed to prevent significant medication errors including administration of discontinued or incorrect medications. Additionally, the facility did not consistently provide diets per physician orders.

The facility was found deficient in multiple areas including privacy during care, cleanliness, misappropriation of property, documentation of resident information, discharge planning, care planning, nursing care, medication management, staffing sufficiency, and infection control. The facility has implemented corrective actions including staff education, audits, and policy revisions to achieve substantial compliance by 3/8/2019.

The survey found the facility was not in substantial compliance and constituted Immediate Jeopardy, Past Non-compliance to resident health or safety for F689, CFR 483.25(d)(1)(2). Enforcement remedies will be recommended without opportunity for correction before imposition.

The plan indicates that past noncompliance issues identified under tags F0000 and F689-J required no further plan of correction.

The complaint investigation #138867 was substantiated by findings that the facility failed to respond to an exit door alarm, resulting in a resident elopement on 2/28/19.

The facility failed to respond timely to a door alarm, allowing a cognitively impaired resident at risk for elopement to exit the building and walk to a neighboring assisted living facility in cold weather. The resident was found safe with no injury. The facility implemented corrective actions including increased monitoring, staff education, and policy reinforcement.

Complaint investigation #137208 included allegations of resident dignity violations, unsanitary conditions, property misappropriation, inadequate care, and medication issues. Several allegations were substantiated.

The facility was found deficient in multiple areas including failure to maintain resident dignity during care, unsanitary conditions in shower rooms and dining areas, failure to protect resident property, inadequate transfer and discharge documentation, incomplete baseline and comprehensive care plans, insufficient assistance with activities of daily living, inadequate nursing assessments after condition changes, failure to prevent pressure ulcers, improper catheter care, insufficient staffing, incomplete nurse aide evaluations and training, improper psychotropic medication management, expired and improperly stored medications, inadequate dental care, serving food at improper temperatures, infection control lapses, and failure to maintain a sanitary environment.

The facility identified deficiencies related to care plans for resident activities and pressure ulcer care. Corrective actions include education for staff, audits of care plans and documentation, and monitoring compliance to prevent recurrence.

The inspection was triggered by complaint investigations #135013 and #135487. The findings included failure to develop comprehensive care plans for activities and failure to provide adequate treatment and monitoring for pressure ulcers.

The facility failed to develop comprehensive care plans including activity provisions for 2 of 4 sampled residents and failed to provide necessary treatment and monitoring to promote healing of pressure ulcers for 2 of 4 sampled residents.

The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective January 24, 2019.

The Plan of Correction addresses medication-related deficiencies, including incorrect dosage information and administration routes for several residents. The facility outlines corrective actions, education, audits, and ongoing monitoring to ensure compliance and prevent future occurrences.

The survey found a 'D' level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective June 27, 2018.

The survey found the most serious deficiency to be a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective June 27, 2018.

The deficiencies were identified during complaint investigation #129501 related to medication errors and improper administration.

The facility failed to ensure three residents received medications as ordered by the physician, including incorrect dosages, improper routes of administration, and unclear medication orders.

All deficiencies cited in the prior inspection have been corrected as of the compliance date of 04/11/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The Plan of Correction addresses multiple deficiencies related to resident rights, advance directives, environmental cleanliness, staff reference checks, comprehensive resident assessments, care planning, restorative programs, infection control, staffing, medication management, dietary services, and equipment maintenance.

The inspection included complaint investigations for multiple complaint numbers as listed in the initial comments section.

The facility was found deficient in multiple areas including resident rights, advance directives, safe environment, staff reference checks, comprehensive assessments, care planning, activities of daily living assistance, pressure ulcer prevention and treatment, medication management including black box warnings, staffing levels, dietary services, infection control, and equipment maintenance.

The facility developed and implemented corrective actions addressing deficiencies related to environmental cleanliness, care plan updates for residents with special dietary and care needs, bathing assistance, catheter care, and audits to ensure ongoing compliance.

The survey found a most serious deficiency at an "E" level indicating no actual harm but potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective February 6, 2018.

The inspection was triggered by complaint investigations #124422 and #125155.

The facility failed to maintain a clean and sanitary environment, ensure proper care plan revisions, provide adequate bathing and personal hygiene for dependent residents, maintain catheter and bowel care, offer toileting opportunities as planned, and provide therapeutic diets as ordered for dialysis residents.

This Plan of Correction addresses deficiencies cited during a complaint investigation at Life Care Center of Andover.

The facility identified deficiencies related to assistance with activities of daily living including bathing and oral care, prevention of infections and maintenance of bladder function, and timely provision of dental services. Corrective actions include audits, education, care plan updates, and monitoring to ensure compliance and prevent recurrence.

The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective October 31, 2017.

The complaint investigation #121437 focused on personal hygiene, continence care, and dental services. The findings substantiated failures in bathing assistance, toileting plans, and dental care timeliness.

The facility failed to ensure adequate personal hygiene assistance, individualized toileting plans to maintain bladder function, and timely dental health services for residents. Deficiencies were found in bathing, oral care, toileting assistance, and dental appointment scheduling.

The revisit confirmed that the deficiency identified under regulation 483.25(b)(1) was corrected as of 07/03/2017. No other deficiencies or uncorrected issues were noted.

The facility developed and implemented a system to ensure correction and ongoing compliance with regulations related to pressure ulcer prevention and treatment. Staff education, resident skin assessments, and ongoing audits were established to prevent recurrence.

The survey found a most serious deficiency at F314, related to pressure ulcers, at a level of actual harm that is not immediate jeopardy. Due to the facility's history of noncompliance, no opportunity to correct deficiencies before remedies are imposed was granted.

The survey found a most serious deficiency at F314, related to pressure ulcers, at a level of actual harm that is not immediate jeopardy. Due to the facility's history of noncompliance, no opportunity to correct deficiencies before remedies are imposed was given.

The report represents findings from complaint investigation #117173 regarding pressure ulcer care.

The facility failed to ensure one resident with pressure ulcers received appropriate care to prevent recurrence and worsening of pressure ulcers. The resident developed multiple recurring and new pressure ulcers due to inadequate assessment, monitoring, positioning, and failure to provide physician-ordered treatments.

This inspection was a complaint investigation related to allegations of inadequate care planning, medication administration errors, failure to monitor residents' health parameters, and infection control deficiencies. The complaint number was #106957.

The facility failed to develop comprehensive care plans, ensure quality care for residents including catheter care and medication administration, monitor residents' health parameters as ordered, and maintain an effective infection control program.

All deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.

All previously cited deficiencies listed with regulation numbers 26-40-303 (b)(c), 26-40-305 (c)(1)(2), 26-40-305 (3), and 28-39-163 were corrected as of the revisit date.

The facility developed and implemented corrective actions addressing multiple deficiencies related to urinary catheter care, fluid monitoring, medication administration, infection control, and monitoring of vital signs and bowel movements. The plan includes education for licensed nurses and ongoing audits by nursing leadership to ensure compliance and prevent recurrence.

The facility identified multiple deficiencies affecting residents across various areas including abuse reporting, fall prevention, care planning, environmental conditions, medication management, infection control, staffing, and safety. The Plan of Correction details education, audits, and systemic changes implemented to achieve substantial compliance by October 6, 2016.

The survey found deficiencies at a level of actual harm that is not immediate jeopardy, specifically noncompliance with F314 related to pressure ulcers and substandard quality of care under F323. Due to these deficiencies and the facility's history of noncompliance, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.

The facility had multiple deficiencies including failure to investigate and report falls, promote resident dignity, maintain a clean environment, provide adequate lighting, complete accurate assessments, develop individualized care plans, prevent pressure ulcers, provide appropriate respiratory care, ensure medication accuracy and administration, maintain infection control, and ensure sufficient staffing.

The survey found the most serious deficiencies at the facility to be at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The facility developed and implemented a system to assure correction and continued compliance related to fall prevention. Staff education and ongoing monitoring of residents at risk for falls are part of the corrective actions.

The facility developed and implemented a system to assure correction and continued compliance with regulations related to medication administration, bathing schedules, and timely resident care including call light response and repositioning.

The investigation was based on complaint investigation numbers 95422, 96693, and 96724. The complaint was substantiated as the facility failed to implement fall prevention interventions for a high-risk resident, resulting in injury.

The facility failed to provide planned interventions to prevent falls for one resident, resulting in a fall with a head laceration requiring three staples. The resident was cognitively impaired and left unattended in a wheelchair in their room, contrary to care plan directives.

The complaint investigation (#95681 and 96112) was substantiated with findings of medication administration failures, inadequate bathing care, and insufficient staffing.

The facility failed to ensure timely administration of pain medications to a resident, failed to provide adequate bathing care to dependent residents as planned, and lacked sufficient nursing staff to meet the physical, mental, and psychosocial needs of residents. Multiple residents and family members reported concerns about delayed call light responses, inadequate care, and understaffing.

The report confirms that the deficiencies previously reported under regulations 483.13(c)(1)(ii)-(iii), (c)(2)-(4) and 483.60(a),(b) were corrected by the revisit date of 06/29/2015.

The facility developed and implemented corrective actions to address medication administration errors and timely receipt of medications for new admissions and readmissions. The plan includes staff education, competency audits, monitoring, and reporting procedures to ensure compliance.

The survey found the most serious deficiencies to be 'D' level, indicating no actual harm but potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance.

The complaint investigation involved two complaint numbers (#87713 and #87726) related to medication errors and neglect. The medication error was substantiated as staff administered insulin to a non-diabetic resident and failed to report the incident to the state agency as required.

The facility failed to report a medication error involving insulin administration to a non-diabetic resident, failed to provide ordered medications in a timely manner on admission for two residents, and administered incorrect medication to one resident. The facility also failed to follow pharmacy delivery and medication administration policies.

The plan outlines corrective actions for multiple deficiencies related to resident care, including notification of changes in resident status, bathing and waking schedules, skin integrity management, care plan accuracy, infection control, staffing, and facility safety.

The report documents that all previously identified deficiencies have been corrected as of the revisit date.

The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective May 8, 2015.

The inspection was triggered by complaint investigations #81259, 82254, 85606.

The facility failed to notify the physician timely of a stage I facility acquired pressure ulcer, failed to provide resident choices for bathing and wake time, failed to provide ongoing activities for one resident, failed to review and revise care plans timely, failed to develop initial care plans for new admissions, failed to provide necessary care and services for pacemaker checks and dialysis coordination, failed to provide adequate ADL care including oral hygiene and bathing, failed to provide timely repositioning for pressure ulcer prevention, failed to provide adequate urinary incontinence care, failed to provide restorative range of motion services as ordered, failed to provide sufficient nursing staff, failed to maintain an effective infection control program, and failed to maintain safe and stable exterior parking areas.

The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective May 8, 2015.

The survey found isolated 'D' level deficiencies with no harm but potential for more than minimal harm, not constituting immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The survey found isolated 'D' level deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The facility identified multiple deficiencies including missing personal items, environmental repairs, inaccurate resident assessments, care plan updates, pressure ulcer prevention, catheter management, medication administration, and infection control. Corrective actions and monitoring plans were implemented for each deficiency.

The report confirms that the deficiency identified as S0235 under regulation 28-39-149 was corrected as of 2014-01-21. No other deficiencies are listed as corrected or uncorrected.

The facility was found deficient in multiple areas including safeguarding resident property, housekeeping and maintenance, assessment accuracy, care planning, treatment services, infection control, medication storage, and fall prevention.

The report documents that the previously reported deficiency under regulation 28-39-158(a) was corrected as of 2012-09-20. No other deficiencies are listed.

The report confirms that all previously reported deficiencies identified on the CMS-2567 have been corrected as of the revisit date.

The report documents that the previously cited deficiency under regulation 28-39-158(a) was corrected as of 2012-09-20. No other deficiencies or issues were noted.

The report confirms that the deficiencies previously cited under regulations 483.35(i), 483.60(b),(d),(e), and 483.65 were corrected as of the revisit date.

The facility developed and implemented corrective actions to address deficiencies related to dietary department sanitation, medication expiration monitoring, safe handling of linens to prevent infection spread, and ensuring a qualified dietary manager.

The facility failed to retain a certified dietary manager and maintain a clean and sanitary dietary department. Food was served at unsafe temperatures, and multiple sanitation issues were observed in the kitchen.