Cycle 1
Health 2025-08-21 · Fire 2025-08-21
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Andover, MA
Vantage at Andover LLC
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
80 Andover Street, Andover, MA
(978) 470-3434
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
135
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vantage Care
Operator or chain grouping
Approved since
1992-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.38
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.04
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.79
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.50
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
4.00
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,167
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9940
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.78
Baseline 22.63% · Performance 20.79% · Measure score 2.78 · Achievement 1.38 · Improvement 2.78
Healthcare-associated infections
4.51
Baseline 7.21% · Performance 6.49% · Measure score 4.51 · Achievement 4.51 · Improvement 2.78
Total nurse turnover
7.02
Baseline 61.39% · Performance 35.00% · Measure score 7.02 · Achievement 7.02 · Improvement 6.72
Adjusted total nurse staffing
2.11
Baseline 4.03 hours · Performance 3.68 hours · Measure score 2.11 · Achievement 2.11 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.15% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 307 · Observed rate 10.42% · Lower 95% interval 8.98% |
| Discharge to community | 59.68% |
50.57%
9.1 pts better
|
Better than the National Rate · Eligible stays 317 · Observed rate 57.1% · Lower 95% interval 54.11% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.07% |
95.27%
3.8 pts better
|
Numerator 213 · Denominator 215 |
| Falls with major injury | 1.86% |
0.77%
1.1 pts worse
|
Numerator 4 · Denominator 215 |
| Discharge self-care score | 44.71% |
53.69%
9 pts worse
|
Numerator 76 · Denominator 170 |
| Discharge mobility score | 55.88% |
50.94%
4.9 pts better
|
Numerator 95 · Denominator 170 |
| Pressure ulcers or injuries, new or worsened | 2.79% |
2.29%
0.5 pts worse
|
Numerator 6 · Denominator 215 · Adjusted rate 3.21% |
| Healthcare-associated infections requiring hospitalization | 6.49% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 217 · Observed rate 5.07% · Lower 95% interval 3.98% |
| Staff COVID-19 vaccination coverage | 19.61% |
8.2%
11.4 pts better
|
Numerator 30 · Denominator 153 |
| Staff flu vaccination coverage | 42.37% |
42%
0.4 pts better
|
Numerator 75 · Denominator 177 |
| Discharge function score | 47.65% |
56.45%
8.8 pts worse
|
Numerator 81 · Denominator 170 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 93 · Denominator 93 |
| Transfer of health information to patient | 97.85% |
96.28%
1.6 pts better
|
Numerator 91 · Denominator 93 |
| Resident COVID-19 vaccinations up to date | 34.65% |
25.2%
9.4 pts better
|
Numerator 35 · Denominator 101 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.9
0.3 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.1 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.6 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
92.2%
4.1 pts better
|
93.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 94.6% · Q3 95.9% · Q4 98.0% · 4Q avg 96.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
94.8%
3.6 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.9% |
3.5%
4.4 pts worse
|
3.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 7.1% · Q3 10.2% · Q4 5.9% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
12.0%
12 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
5.2%
2.7 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.8% |
19.2%
5.4 pts better
|
19.6%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 11.9% · Q3 12.5% · Q4 10.3% · 4Q avg 13.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
22.5%
7.3 pts better
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 4.0% · Q3 21.1% · Q4 20.0% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.7% |
17.7%
1 pts worse
|
16.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 19.4% · Q3 13.6% · Q4 12.7% · 4Q avg 18.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.8% |
17.6%
7.8 pts better
|
14.9%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 16.7% · Q3 12.5% · Q4 0.0% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.0%
0.3 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.9% · Q3 0.0% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
2.0%
1.5 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.1% |
21.7%
13.4 pts worse
|
19.8%
15.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.2% · Q2 37.7% · Q3 38.6% · Q4 22.2% · 4Q avg 35.1% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.6%
1.7 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.9% · Q3 0.0% · Q4 1.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
77.1%
19.7 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 94.8% · Q3 98.5% · Q4 98.1% · 4Q avg 96.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.5% |
11.8%
3.7 pts worse
|
12.0%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 14.3% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.3%
0.5 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 3.9% · Q4 2.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.3% |
77.7%
18.6 pts better
|
79.7%
16.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
25.8%
0.5 pts better
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 21.7% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-08 · Fire 2024-08-08
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-06-21 · Fire 2023-06-21
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-21
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-09-30
F · Potential for more than minimal harm
2025-08-21
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-09-30
F · Potential for more than minimal harm
2025-08-21
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-09-30
F · Potential for more than minimal harm
2025-08-21
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-09-30
F · Potential for more than minimal harm
2025-08-21
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-09-30
F · Potential for more than minimal harm
2025-08-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-30
F · Potential for more than minimal harm
2025-08-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-30
F · Potential for more than minimal harm
2025-08-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-30
F · Potential for more than minimal harm
2025-08-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-30
F · Potential for more than minimal harm
2025-08-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-30
F · Potential for more than minimal harm
2025-08-21
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-09-30
F · Potential for more than minimal harm
2025-08-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-30
F · Potential for more than minimal harm
2025-08-21
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-09-30
F · Potential for more than minimal harm
2025-08-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-08-21
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-09-30
F · Potential for more than minimal harm
2024-08-08
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-09-26
F · Potential for more than minimal harm
2024-08-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-26
F · Potential for more than minimal harm
2024-08-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-21
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-09-12
E · Potential for more than minimal harm
2025-08-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-21
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-21
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-21
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-21
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-09-12
E · Potential for more than minimal harm
2024-08-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-08-08
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-08-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-08-08
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-08-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-08-08
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-08-08
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-08-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-25
D · Potential for more than minimal harm
2023-06-21
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-21
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-07-07
Penalties and ownership
What sits behind the stars
Ownership
Bear Mountain Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Doyle, Thomas
5% Or Greater Indirect Ownership Interest · Individual
Wynne, John
5% Or Greater Indirect Ownership Interest · Individual
Ziskin, Scott
5% Or Greater Indirect Ownership Interest · Individual
Doyle, Thomas
Corporate Officer · Individual
Paullis, Connie
W-2 Managing Employee · Individual
Wynne, John
Corporate Officer · Individual
Ziskin, Scott
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Andover Manor Rehab And Nursing
Andover, MA
2-star overall rating with 2-star inspections with $9,311 in total fines with 20 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Andover Forest Post Acute Care Center
North Andover, MA
2-star overall rating with 2-star inspections with $44,265 in total fines with 12 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Royal Meadow View Center
North Reading, MA
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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