ANDOVER MANOR REHAB AND NURSING
Open-data reference.
ANDOVER MANOR REHAB AND NURSING is a for profit - limited liability company facility in ANDOVER, MA with 174 certified beds and a 2-star overall CMS rating. The facility has 50 deficiency records on file. Total penalties: $9K.
89 MORTON STREET, ANDOVER, MA 01810
Phone: 9784750944
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 225294
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 174
- Residents
- 121
- In Hospital
- No
- County
- Essex
- Last Inspection
- Jan 9, 2025
Staffing Data
- RN Hours
- 0.44 (nat'l avg: 0.68)
- LPN Hours
- 0.85
- CNA Hours
- 2.21
- Total Nursing Hours
- 3.49 (nat'l avg: 3.89)
- PT Hours
- 0.01
- Nursing Turnover
- 43.9%
- RN Turnover
- 62.5%
What the CMS Record Reveals About ANDOVER MANOR REHAB AND NURSING
ANDOVER MANOR REHAB AND NURSING operates 174 certified beds in ANDOVER, MA with approximately 121 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (2★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, of which 3 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $9K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.49 total nursing hours per resident day (national average 3.89), with RN coverage at 0.44 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, ANDOVER MANOR REHAB AND NURSING falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 43.9%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 7, 2025
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 7, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 7, 2025
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 7, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Feb 7, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 7, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 7, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 7, 2025
Plan the resident's discharge to meet the resident's goals and needs.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 7, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 7, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 7, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 7, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 7, 2025
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 7, 2025
Assess the resident when there is a significant change in condition
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 7, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Feb 7, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Feb 7, 2025
Keep residents' personal and medical records private and confidential.
Category: Resident Rights Deficiencies
Corrected: Feb 7, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Feb 7, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Feb 7, 2025
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 12, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Mar 12, 2024
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Mar 12, 2024
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Mar 12, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Mar 12, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Mar 12, 2024
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 12, 2024
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 12, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 12, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 12, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 12, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 12, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Mar 12, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Mar 12, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Mar 12, 2024
Ensure that residents are fully informed and understand their health status, care and treatments.
Category: Resident Rights Deficiencies
Corrected: Mar 12, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Mar 12, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Oct 31, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: May 12, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 12, 2023
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 3, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jan 23, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jan 23, 2023
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Jan 23, 2023
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Jan 23, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 23, 2023
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.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 23, 2023
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 23, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 23, 2023
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.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 23, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 10.1% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 6.8% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.1% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.4% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 12.7% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.8% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 89.1% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 74.2% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 9.1% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 22.3% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 95.7% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 80.6% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 2.9% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 27.5% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 31.0% | Yes |
Penalty History 1 penalties totaling $9K
| Date | Type | Amount |
|---|---|---|
| May 17, 2023 | Fine | $9K |
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Understanding Nursing Home Data
Related Data from Other Sources
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Hospital quality ratings and safety data for ANDOVER, MA on PlainHospital
Medicare Plans
Compare Medicare plans and coverage options near ANDOVER, MA on PlainMedicare
County Health Data
Health outcomes, access, and quality metrics for Essex on PlainHealth
Frequently Asked Questions
What is the overall CMS rating for ANDOVER MANOR REHAB AND NURSING?
What are the staffing levels at ANDOVER MANOR REHAB AND NURSING?
How many beds does ANDOVER MANOR REHAB AND NURSING have?
Does ANDOVER MANOR REHAB AND NURSING have any deficiencies on record?
Has ANDOVER MANOR REHAB AND NURSING received any fines or penalties?
Who owns ANDOVER MANOR REHAB AND NURSING?
When was ANDOVER MANOR REHAB AND NURSING last inspected?
What quality measures are tracked for ANDOVER MANOR REHAB AND NURSING?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.