Life Care Center Of Andover

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Aide (CMA) R reported she had just completed ANE training the previous week. CMA R reported Resident R1 required a lot of redirection due to his behavior.During an interview on 10/06/25 at 10:40 AM, Administrative Nurse D stated she expected staff to report any type of abuse alleged or witnessed immediately to the administrative staff.During an interview on 10/06/25 at 02:40 PM, Administrative Staff A reported LN G did not have formal dementia training since being hired on 12/30/24. Additionally, Administrative Staff A reported the facility would use Hand in Hand (a training series for nursing homes, on person-centered care of persons with dementia and prevention of abuse) but said LN G did attend a monthly staff meeting via Zoom on 09/10/25 that reviewed working with dementia and behaviors- behavioral management and documentation, along with several other topics.The facility's policy Abuse Prevention dated 05/06/25 documented that the residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation. Identify, correct, and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur, including trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and ensure that the staff assigned have knowledge of the individual residents' needs, care needs and behavioral symptoms, if any.On 10/06/25 at 03:50 PM, Administrative Staff A and Consultant Staff II received a copy of the Immediate Jeopardy [IJ] Template and were notified that the facility failed to ensure residents remained free from staff-to-resident abuse, placing Resident R1 in IJ.The facility completed corrective actions on 09/19/25, which included the following:1. The Social Service Director/Designee interviewed all current in-house residents who were alert and oriented with an assessed BIMS score of 12 or higher. All residents with an assessed BIMS score of 12 or higher were interviewed to determine if they had experienced or witnessed misappropriation. No additional concerns were noted during the interviews. No findings were noted.2. The Regional Director of Clinical Services educated the Director of Nursing and the Executive Director on the incident of reportable event management and record review on 09/18/25.3. The Director of Nursing/Designee reviewed behavior notes, progress notes, psychosocial notes, health status notes, event notes, and plan of care for all residents in the prior 14 days to audit for potential abuse-related events not previously investigated on 09/18/25.4. The Director of Nursing/Designee initiated staff education

on reporting of suspected Abuse, Neglect, and Exploitation, including misappropriation of 09/18/25. Nursing Staff employees would have education provided prior to their next scheduled shift.5. The Director of Nursing/Designee initiated staff education on incident and reporting event management for interdisciplinary team (IDT) on 09/19/25, including Executive Director, Director of Nursing, Assistant Director of Nursing, Director of Rehabilitation, Social Service Director, Business Office Manager, Health Information Management, Activity Director, Dietary Manger, Infection Prevention, MDS Coordinator, and Admission. IDT would have education provided prior to working their next scheduled shift.6. The Director of Nursing/Designee would randomly ask five staff members what to do if ANE, including injuries of unknown origin, was suspected five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter.7. The results of the above audits would be submitted to Quality Assurance and Performance Improvement (QAPI) Committee for further review and or action, as well as any trends identified.On 10/06/25 at 02:00 PM, the surveyor verified implementation of the above corrective actions to address the staff-to-resident abuse. The scope and severity remained at a J.

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

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Andover

621 W 21st Andover, KS 67002

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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

table to Resident R1's left side. Resident R1 hit his cup of coffee with his left hand backwards, and the coffee went on that female resident and on to the floor. Staff intervened immediately.During an interview on 10/06/25 at 10:40 AM, Administrative Nurse D stated she expected staff to report any type of abuse alleged or witnessed immediately to the administrative staff.The facility's policy Abuse Prevention dated 05/06/25 documented all alleged or suspected violations involving mistreatment, abuse, neglect, injuries of unknown origin (e.g., bruising and skin tears) will be immediately reported to theadministrator and/or director of nursing. All associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative. All residents, families, resident representatives, and visitors are encouraged to immediately report incidents of suspected resident abuse and/or neglect to facility administration. When an incident of resident abuse is suspected, the incident must be reported to thesupervisor regardless of the time lapse since the incident occurred. The supervisor notifies the director of nursing and the executive director of the alleged incident.On 10/06/25 at 03:50 PM, Administrative Staff

A and Consultant Staff II received a copy of the Immediate Jeopardy [IJ] Template and were notified that

the facility failed to ensure staff reported occurrences of abuse immediately to the Administrator placing Resident R1

in IJ.The facility completed corrective actions on 09/19/25, which included the following:1. The Social Service Director/Designee interviewed all current in-house residents who were alert and oriented with an assessed BIMS score of 12 or higher. All residents with an assessed BIMS score of 12 or higher were interviewed to determine if they had experienced or witnessed misappropriation. No additional concerns were noted during the interviews. No findings were noted.2. The Regional Director of Clinical Services educated the Director of Nursing and the Executive Director on the incident of reportable event management and record review on 09/18/25.3. The Director of Nursing/Designee reviewed behavior notes, progress notes, psychosocial notes, health status notes, event notes, and plan of care for all residents in

the prior 14 days to audit for potential abuse-related events not previously investigated on 09/18/25.4. The Director of Nursing/Designee initiated staff education on reporting of suspected Abuse, Neglect, and Exploitation, including misappropriation of 09/18/25. Nursing Staff employees would have education provided prior to their next scheduled shift.5. The Director of Nursing/Designee initiated staff education on incident and reporting event management for interdisciplinary team (IDT) on 09/19/25, including Executive Director, Director of Nursing, Assistant Director of Nursing, Director of Rehabilitation, Social Service Director, Business Office Manager, Health Information Management, Activity Director, Dietary Manger, Infection Prevention, MDS Coordinator, and Admission. IDT would have education provided prior to working their next scheduled shift.6. The Director of Nursing/Designee would randomly ask five staff members what to do if ANE, including injuries of unknown origin, was suspected five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter.7. The results of the above audits would be submitted to Quality Assurance and Performance Improvement (QAPI) Committee for further review and or action, as well as any trends identified.On 10/06/25 at 02:00 PM, the surveyor verified implementation of

the above corrective actions. The scope and severity remained at a J.

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

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Andover

621 W 21st Andover, KS 67002

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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

staff meeting via Zoom on 09/10/25 that reviewed working with dementia and behaviors- behavioral management and documentation, along with several other topics. Administrative Staff A verified LN G completed his whole shift the evening on 09/17/25 through 09/18/25 including continuing to provide care to Resident R1.The facility's policy Abuse-Protection of Residents dated 05/06/25 documented the following methods to ensure the protection of residents during an investigation may include but are not limited to; Responding immediately to protect the alleged victim and integrity of the investigation; Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Immediate notification of the alleged victim's practitioner and the family or responsible party; Removal of access by the alleged perpetrator to the alleged victim and assurance that ongoing safety and protection is provided for

the alleged victim and, as appropriate, other residents.On 10/06/25 at 03:50 PM, Administrative Staff A and Consultant Staff II received a copy of the Immediate Jeopardy [IJ] Template and were notified that the facility failed to prevent LN G from ongoing and unrestricted access to residents on the locked memory care unit after LN G abused Rl placed the residents on the locked unit in immediate jeopardy. The facility completed corrective actions on 09/19/25, which included the following:1. The Social Service Director/Designee interviewed all current in-house residents who were alert and oriented with an assessed BIMS score of 12 or higher. All residents with an assessed BIMS score of 12 or higher were interviewed to determine if they had experienced or witnessed misappropriation. No additional concerns were noted

during the interviews. No findings were noted.2. The Regional Director of Clinical Services educated the Director of Nursing and the Executive Director on the incident of reportable event management and record

review on 09/18/25.3. The Director of Nursing/Designee reviewed behavior notes, progress notes, psychosocial notes, health status notes, event notes, and plan of care for all residents in the prior 14 days to audit for potential abuse-related events not previously investigated on 09/18/25.4. The Director of Nursing/Designee initiated staff education on reporting of suspected Abuse, Neglect, and Exploitation, including misappropriation of 09/18/25. Nursing Staff employees would have education provided prior to their next scheduled shift.5. The Director of Nursing/Designee initiated staff education on incident and reporting event management for interdisciplinary team (IDT) on 09/19/25, including Executive Director, Director of Nursing, Assistant Director of Nursing, Director of Rehabilitation, Social Service Director, Business Office Manager, Health Information Management, Activity Director, Dietary Manger, Infection Prevention, MDS Coordinator, and Admission. IDT would have education provided prior to working their next scheduled shift.6. The Director of Nursing/Designee would randomly ask five staff members what to do if ANE, including injuries of unknown origin, was suspected five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter.7. The results of the above audits would be submitted to Quality Assurance and Performance Improvement (QAPI) Committee for further review and or action, as well as any trends identified.On 10/06/25 at 02:00 PM, the surveyor verified implementation of the above corrective actions. The scope and severity remained at a K.

Event ID:

Facility ID:

If continuation sheet