Andover Village Retirement: Wound Documentation Failure - OH
The resident at the center of the complaint is identified in inspection records only as Resident #64. She had returned from a medical appointment when the gap in her care record came to light. LPN #616, the nurse who had assessed her on return, acknowledged to inspectors that the resident had "the area to her right heel" when she came back from the appointment. No new skin impairment had been documented.
That acknowledgment, offered during the inspection itself, was the clearest evidence inspectors had. The nurse knew. The record didn't show it.
Federal inspectors completed the complaint survey on November 25, 2025. The deficiency was cited under F0842, which covers the accuracy and completeness of resident clinical records. Inspectors classified the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected.
The finding came through Complaint Number 2650968, meaning someone, a resident, a family member, or a staff member, had contacted authorities before inspectors ever walked through the door.
Wound documentation failures in nursing homes carry consequences that extend well beyond paperwork. When a skin impairment goes unrecorded after a resident returns from an outside appointment, the next nurse to assess that resident has no baseline. She doesn't know when the wound appeared, how large it was, or whether it has changed. A wound that might have been caught and treated early can worsen through days of untracked deterioration. For an elderly resident with compromised circulation or diabetes, a heel wound that goes unmonitored can progress faster than most families realize.
The inspection report does not describe what happened to Resident #64's heel wound after that appointment, whether it was eventually documented, whether it worsened, or whether she received treatment. What the record shows is a single moment: a nurse who saw something, said nothing on paper, and was later asked about it by a federal inspector.
Andover Village Retirement Community operates at 486 S Main St in Andover, a small city in Ashtabula County in northeastern Ohio. The facility's CMS identification number is 365411.
The plan of correction for this deficiency is not included in the inspection documents reviewed. CMS directs anyone seeking that information to contact the nursing home or the Ohio state survey agency directly.
What the record does not answer is how long the gap existed before the complaint was filed, who noticed it first, and whether Resident #64 or her family ever learned that the wound had gone undocumented on her return. The inspection report ends where the paperwork ends. Resident #64's heel wound, and whatever became of it, is not described beyond the moment LPN #616 confirmed it was there.
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.
The resident at the center of the complaint is identified in inspection records only as Resident #64.
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.