Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

ANDOVER MANOR REHAB AND NURSING

ANDOVER, MA · 174 certified beds · Last Life Safety survey January 15, 2026

CMS Certification Number 225294 · first certified February 1987

Ownership

Operated by STERN CONSULTANTS · For profit - Limited Liability company

Ownership changed October 16, 2023 (change of ownership)to ANDOVER MANOR REHAB AND NURSING LLC from 89 MORTON STREET OPERATIONS LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within MA

27 citations — more than 94% of the 341 certified nursing homes in MA. Compared within MA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 12 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens January 2027 — about 3 months from now. This facility’s last Life Safety survey was January 2026. Facilities in MA are typically surveyed 12–15 months after the last one (median 13), measured over 556 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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6 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

3 of the 27 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 27 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.
F-0908 Keep all essential equipment working safely.

How that compares

Citations on file over three years

Compared with the median facility in MA, and nationally. Surveyors differ markedly between states, so the MA figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	27
Median facility in MA	11
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
January 17, 2024	4
January 9, 2025	11
January 15, 2026	12

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2026-01-15
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	2	2026-01-15
K-0324	Provide properly protected cooking facilities.	2	2026-01-15
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2026-01-15
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	2	2025-01-09
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	2	2026-01-15
K-0712	Have simulated fire drills held at unexpected times.	2	2026-01-15
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	1	2025-01-09

What the citations cover

Citations by CMS category

Smoke Deficiencies 10
Egress Deficiencies 5
Gas, Vacuum, and Electrical Systems Deficiencies 3
Emergency Preparedness Deficiencies 3
Other 6

Citations by CMS category
Category	Citations
Smoke Deficiencies	10
Egress Deficiencies	5
Gas, Vacuum, and Electrical Systems Deficiencies	3
Emergency Preparedness Deficiencies	3
Services Deficiencies	2
Construction Deficiencies	2
Miscellaneous Deficiencies	2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

January 15, 2026 — 12 citations

Citations issued on January 15, 2026
Tag	What the surveyor checks	Status
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (February 10, 2026)
E-0034	Provide a means of sharing information on occupancy/needs.	Deficient, Provider has date of correction (February 10, 2026)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (February 10, 2026)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (February 10, 2026)
K-0311	Have an enclosure around a vertical opening shaft.	Deficient, Provider has date of correction (February 10, 2026)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (February 10, 2026)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (February 10, 2026)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (February 10, 2026)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (February 10, 2026)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (February 10, 2026)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (February 10, 2026)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (February 10, 2026)

January 9, 2025 — 11 citations

Citations issued on January 9, 2025
Tag	What the surveyor checks	Status
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (February 21, 2025)
K-0131	Meet requirements for sections of health care facilities separated by fire resistive construction.	Deficient, Provider has date of correction (February 21, 2025)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (March 6, 2025)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (February 21, 2025)
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	Deficient, Provider has date of correction (February 21, 2025)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (February 21, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (February 21, 2025)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (February 21, 2025)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (February 21, 2025)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (February 21, 2025)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (February 21, 2025)

January 17, 2024 — 4 citations

Citations issued on January 17, 2024
Tag	What the surveyor checks	Status
K-0100	Meet other general requirements.	Deficient, Provider has date of correction (February 26, 2024)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (February 26, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (February 26, 2024)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (February 26, 2024)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.