Andover Village Retirement: Trach Care Failures - OH
When inspectors visited Andover Village Retirement Community following a complaint, they pulled the written tracheostomy care policy and the competency test the facility used to certify its own staff. What they found wasn't a single moment of carelessness by one worker on one shift. It was an absence — something the facility had never put into writing and apparently never trained anyone to do.
Neither document told staff to avoid touching other surfaces while performing tracheostomy care.
That detail matters because tracheostomy care is among the most infection-sensitive procedures performed in a nursing home. A resident with a trach opening in their throat has a direct pathway between the outside world and their airway. The point of sterile technique is to ensure that nothing — no surface, no cord, no countertop — contaminates the sterile field or the instruments going near that opening. Pulling a light cord with a gloved hand, then continuing care with that same glove, can undo everything that came before it.
The facility's policy covered the mechanics of the procedure. Staff were to remove and dispose of the inner cannula, replace it with a sterile one, clean the skin around the stoma site with saline-soaked gauze using a single sweep per side, then rinse and dry the same way. The steps were there. But the policy said nothing about maintaining aseptic technique throughout — nothing about keeping gloved hands away from door handles, light pulls, bed rails, or any other surface that could carry bacteria.
The competency test told a similar story. The document, dated April 18, 2025, was completed by a respiratory therapist identified in the report as RT #600, with the Director of Nursing overseeing the evaluation. It walked through the procedure in sequence: wash hands, don gown, gloves, and mask as applicable, remove the trach dressing while checking the surrounding skin, remove gloves, wash hands again, don sterile gloves, clean under the flange, pat dry with sterile gauze, replace the dressing, dispose of the inner cannula, replace it with a sterile one, remove gloves, wash hands.
The hand-washing steps were there. The sterile glove change was there. What wasn't there, again, was any instruction to avoid contaminating those sterile gloves by touching other surfaces mid-procedure.
A staff member who follows that competency to the letter could still reach for a light switch, adjust a piece of equipment, or grab a supply off a shelf — and nothing in the document they were trained on would tell them they'd just compromised everything.
Inspectors tagged the deficiency as F0880, the federal citation for infection prevention and control. The level of harm was recorded as minimal harm or potential for actual harm, and the finding was noted to affect a few residents. The inspection was a complaint survey, tied to Complaint Number 2650968.
What the report doesn't say is how long tracheostomy care had been performed under these protocols, or how many times staff had completed the procedure without the missing instruction in place. The competency form was from April 2025. The policy review happened during the November inspection. Whatever happened in between is not in the record.
The residents who require tracheostomy care at Andover Village are among the most medically fragile in the building. A trach is not a routine intervention. The people who have one depend on staff to get the procedure right, every time, because the consequences of infection in that part of the body move fast and hit hard. Pneumonia. Sepsis. A wound that won't close.
The facility's own Director of Nursing sat across from RT #600 in April and signed off on a competency evaluation that didn't include the instruction inspectors later said should have been there. Whether that reflects a gap in the policy the DON was working from, or something else, the report doesn't say.
What it does say is that when inspectors compared what the policy required, what the competency test covered, and what aseptic technique actually demands, something was missing. The facility put it in writing. Inspectors found it in writing. The residents in those rooms had no way of knowing the difference.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Andover Village Retirement Community from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 22, 2026 · Our methodology
ANDOVER VILLAGE RETIREMENT COMMUNITY in ANDOVER, OH was cited for violations during a health inspection on November 25, 2025.
What they found wasn't a single moment of carelessness by one worker on one shift.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.