Andover Village Retirement Community
Inspection Findings
F-Tag F0686
F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
an area to her right heel. She revealed LPN #616 had stated the area was red but blanchable and asked her to get an order from the physician for the area. She revealed she did not assess Resident #64's heel since LPN #616 had stated she did, but she did contacted PCP #900 for an order to apply skin prep and pad and protect the area with a foam dressing three times a week. She revealed she never told LPN #616 or heard the DON tell LPN #616 to not document on the area as well as not complete a wound assessment. LPN/ Wound Nurse #612 verified she had documented on 07/28/25 per the Wound Assessment that the wound was community acquired as she was going by the information LPN #616 had told her specifically that LPN #616 had checked her skin prior to leaving on the appointment and she did not have any new skin impairment. She revealed LPN #616 had stated on Resident #64's return from the appointment she had the area to her right heel. Review of facility policy labeled, Pressure Ulcer Risk and Skin Assessment dated 12/17/13 revealed it was the facility policy that all residents would receive routine assessments. The policy revealed if a CNA observes a skin alteration he/ she would inform the nurse and
the identified skin change would be addressed by the nurse with an assessment, documentation in the nursing notes and physician/ family notification. This deficiency represents non-compliance investigated under Complaint Number 2619877, and 2603148.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Andover Village Retirement Community
486 S Main St Andover, OH 44003
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm
any new skin impairment. She revealed LPN #616 had stated on Resident #64's return from the appointment she had the area to her right heel. This deficiency represents non-compliance investigated under Complaint Number 2650968.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Andover Village Retirement Community
486 S Main St Andover, OH 44003
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0880
F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
aseptic procedures. The staff was to remove and dispose of the inner cannula and replace with another sterile inner cannula. In addition, the policy revealed for tracheostomy site and stoma care the staff was to apply clean gloves and clean with saline soaked gauze pads using a single sweep for each side, then rinse and dry in same manner. There was nothing in the policy regarding ensuring to maintain aseptic technique including not touching other items or surfaces during care including pulling the light cord. Review of facility competency test labeled, Trach Care Competency dated 04/18/25 and completed by RT #600 with the DON overseeing revealed the staff was to wash their hands, don gown, gloves and mask (if applicable). The staff was to remove and dispose of the trach dressing while observing the condition of the surrounding skin. The competency revealed the staff was to remove gloves, wash hands and don sterile gloves and proceed to clean the skin under the flange, pat area dry with sterile gauze and replace sterile trach dressing. The competency revealed the staff was to dispose of inner cannula and replace with another disposable sterile inner cannula. The policy revealed the staff was to remove their gloves and wash their hands. This deficiency represents non-compliance investigated under Complaint Number 2650968.
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Facility ID:
If continuation sheet
ANDOVER VILLAGE RETIREMENT COMMUNITY in ANDOVER, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ANDOVER, OH, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ANDOVER VILLAGE RETIREMENT COMMUNITY or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.