Inspection Reports for
The Mapleton Andover
1419 W. CENTRAL, ANDOVER, KS, 67002
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
11.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
87% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
78% occupied
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 8
Date: Jan 20, 2026
Visit Reason
Re-Licensure Survey with complaint investigations for an Assisted Living facility conducted on 01/20/26, 01/21/26, and 01/22/26.
Complaint Details
The inspection included complaint investigations numbered 192041, 193396, 193897, 193898, 194817, 194836, 194915, 195645, 196630, 196752, 197430, 197467, 197629, 197695.
Findings
The facility was found deficient in multiple areas including failure to ensure licensed nurse coordination of health care services, lack of self-administration medication assessments, improper medication storage, incomplete documentation of incidents, failure to conduct annual emergency evacuation drill, inadequate dietary supervision and preparation, and failure to ensure proper infection control measures.
Deficiencies (8)
KAR 26-41-204(a): The administrator failed to ensure a licensed nurse provided or coordinated necessary health care services for a resident with pressure ulcers, lacking documentation and interventions to promote wound healing and prevent additional wounds.
KAR 26-41-205(a)(1): The administrator failed to ensure a licensed nurse completed assessments for safe self-administration of insulin for two residents prior to self-injection.
KAR 26-41-205(h)(1)(4): The administrator failed to ensure insulin pens were dated upon removal from refrigeration to prevent use beyond manufacturer expiration.
KAR 26-41-105(f)(11): The administrator failed to ensure documentation of all incidents, symptoms, actions taken, and results related to residents' pressure ulcers and edema.
KAR 26-41-104(d)(4): The administrator failed to ensure completion and documentation of an annual emergency evacuation drill.
KAR 26-41-206(b)(1)(2): The administrator failed to designate a qualified dietary supervisor and ensure dietary staff had approved instructions for preparing a mechanical diet for a resident.
KAR 26-41-206(d): The administrator failed to ensure dietary staff prepared and served foods maintaining flavor, appearance, and proper serving temperature, with observations of cold food and burnt toast.
KAR 26-41-207(b)(4): The administrator failed to ensure monitoring of dishwasher sanitizer levels to maintain sanitary conditions and prevent infection spread.
Report Facts
Deficiencies cited: 8
Resident census: 29
Pressure ulcer measurement: 5.4
Pressure ulcer measurement: 4.7
Insulin pen expiration days: 56
Insulin pen expiration days: 28
Food temperature: 127.9
Food temperature: 128.5
Food temperature: 117.8
Food temperature: 145.5
Food temperature: 131.5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 20, 2026
Visit Reason
The document is a Plan of Correction addressing findings from a Re-Licensure Survey with complaint investigations conducted on January 20, 21, and 22, 2026, at an Assisted Living facility.
Findings
The Plan of Correction responds to multiple complaint investigations and deficiencies identified during the Re-Licensure Survey conducted over three days in January 2026.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 4, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-10-21.
Findings
All deficiencies have been corrected as of the compliance date of 2024-10-31 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 4, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-10-21.
Findings
All deficiencies have been corrected as of the compliance date of 2024-10-31 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 19
Deficiencies: 3
Date: Oct 21, 2024
Visit Reason
The inspection was a resurvey with an attached complaint #189501 at an assisted living facility to verify correction of previous deficiencies.
Complaint Details
The inspection was conducted as a resurvey with attached complaint #189501.
Findings
The facility failed to ensure negotiated service agreements (NSA) for residents described services based on their functional capacity screening and named the licensed nurse responsible for healthcare service plans. Additionally, food storage practices were unsafe, with unlabeled and expired food items found in refrigerators.
Deficiencies (3)
KAR 26-41-202(a)(1) The facility failed to ensure the negotiated service agreement for Residents 1 and 3 described services based on their functional capacity screening.
KAR 26-41-204(d) The facility failed to ensure the negotiated service agreement for Resident 3 named the licensed nurse responsible for implementing and supervising her healthcare service plan.
KAR 26-41-206(e) The facility failed to ensure food items were stored under safe conditions, including unlabeled prepared foods and expired yogurt in refrigerators.
Report Facts
Resident census: 19
Expired yogurt days: 9
Yogurt opened days: 39
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 21, 2024
Visit Reason
The document represents the findings of a resurvey with an attached complaint #189501 conducted at the assisted living facility on 10/21/24.
Complaint Details
The visit was related to complaint #189501 as part of the resurvey process.
Findings
This plan of correction document summarizes the findings from the resurvey and complaint investigation conducted on 10/21/24 at the assisted living facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 16, 2024
Visit Reason
The abbreviated survey was conducted on 01/16/24 in response to complaint #185178 at the assisted living facility.
Complaint Details
Complaint #185178 was investigated and found to have no deficiencies.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 16, 2024
Visit Reason
The abbreviated survey was conducted in response to complaint #185178 at the assisted living facility.
Complaint Details
Complaint #185178 was investigated and resulted in no deficiency citations.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation at the assisted living facility.
Complaint Details
Complaint investigation 179954 was conducted and resulted in no citations.
Findings
The complaint investigation conducted on 12/04/2023 resulted in no citations or deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 21, 2023
Visit Reason
The abbreviated survey was conducted on 11/21/2023 in response to complaints #184133 at the assisted living facility.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 17
Date: Apr 11, 2023
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All deficiencies previously cited in the initial survey were corrected by the facility as of the revisit dates ranging from 04/10/2023 to 04/11/2023.
Deficiencies (17)
Regulation 26-39-103 (d): Previously cited deficiency corrected as of 04/11/2023.
Regulation 26-39-102 (b) (c): Previously cited deficiency corrected as of 04/11/2023.
Regulation 26-41-101 (f) (1): Previously cited deficiency corrected as of 04/11/2023.
Regulation 26-41-201 (d): Previously cited deficiency corrected as of 04/11/2023.
Regulation 26-41-202 (a): Previously cited deficiency corrected as of 04/11/2023.
Regulation 26-41-204 (a): Previously cited deficiency corrected as of 04/11/2023.
Regulation 26-41-204 (i): Previously cited deficiency corrected as of 04/11/2023.
Regulation 26-41-205 (a) (2): Previously cited deficiency corrected as of 04/11/2023.
Regulation 26-41-205 (g) (3): Previously cited deficiency corrected as of 04/10/2023.
Regulation 26-41-205 (g) (4): Previously cited deficiency corrected as of 04/11/2023.
Regulation 26-41-205 (h): Previously cited deficiency corrected as of 04/11/2023.
Regulation 26-41-105 (a): Previously cited deficiency corrected as of 04/11/2023.
Regulation 26-41-104 (a): Previously cited deficiency corrected as of 04/11/2023.
Regulation 26-41-104 (d): Previously cited deficiency corrected as of 04/11/2023.
Regulation 26-41-206 (d): Previously cited deficiency corrected as of 04/10/2023.
Regulation 26-41-206 (e) (1): Previously cited deficiency corrected as of 04/10/2023.
Regulation 26-41-207 (b) (5-6) (c): Previously cited deficiency corrected as of 04/11/2023.
Inspection Report
Re-Inspection
Census: 17
Deficiencies: 18
Date: Mar 14, 2023
Visit Reason
Resurvey with attached complaints at an assisted living facility conducted on 03/13/23 and 03/14/23.
Complaint Details
This was a resurvey with attached complaints #169382, #161662, and #161239.
Findings
The facility was found deficient in multiple areas including failure to ensure resident rights to access records, incomplete advanced directives documentation, neglect in wound care and pressure ulcer management, inaccurate functional capacity screenings, incomplete negotiated service agreements, insufficient staffing for emergency evacuations, improper medication labeling and storage, inadequate infection control compliance, and failure to conduct proper emergency drills.
Deficiencies (18)
K.A.R. 26-39-103(d)(2) The facility failed to ensure access to residents' records for inspection and photocopying by a representative of the department.
K.A.R. 26-39-102(b)(1) The operator failed to ensure validation of advanced directives for residents 314 and 315 as evidenced by missing physician signatures and lack of documentation.
K.A.R. 26-41-101(f)(1)(B) The operator failed to protect residents 313 and 314 from neglect by not documenting skin assessments and interventions to prevent and treat pressure wounds.
K.A.R. 26-41-201(d) The operator failed to ensure each resident's Functional Capacity Screen accurately reflected their abilities, affecting residents 313 and 314.
K.A.R. 26-41-202(a)(1)(2) The operator failed to ensure the Negotiated Service Agreements for residents 313 and 314 identified services for pressure wounds, cognition, vision, and providers.
K.A.R. 26-41-202(h) The operator failed to ensure resident 314's Negotiated Service Agreement was signed by all involved individuals.
K.A.R. 26-41-204(a) The operator failed to ensure licensed nurses provided necessary health care services including documentation of wound assessments for residents 313 and 314.
K.A.R. 26-41-204(i) The operator failed to ensure coordination of healthcare services for resident 313 by qualified staff, including assessment of bedrails and documentation.
K.A.R. 26-41-205(a)(2) The operator failed to ensure the self-administration medication assessment for resident 315 included evaluation of physical, cognitive, and functional ability.
K.A.R. 26-41-205(g)(3) The operator failed to ensure licensed pharmacist or nurse placed full resident names on original packages of over-the-counter medications.
K.A.R. 26-41-205(g)(4) The operator failed to develop policies and procedures for receiving and identifying sample medications including all required conditions.
K.A.R. 26-41-205(h)(4) The operator failed to ensure licensed nurse did not use Tubersol beyond expiration by failing to date the vial when opened.
K.A.R. 26-41-105(a) The operator failed to maintain resident records in accordance with accepted standards of practice for all residents.
K.A.R. 26-41-104(a) The operator failed to provide sufficient qualified staff to safely evacuate residents requiring two-person assist in an emergency, placing all residents in immediate jeopardy.
K.A.R. 26-41-104(d)(4) The operator failed to perform an annual emergency drill including evacuation of residents to a secure location after admission of two residents requiring two-person assist.
K.A.R. 26-41-206(d) The operator failed to ensure two residents in the unattached building were served food at the proper temperature.
K.A.R. 26-41-206(e)(1) The operator failed to ensure dietary staff stored food under safe and sanitary conditions, including uncovered and outdated food items.
K.A.R. 26-41-207(c) The operator failed to ensure compliance with tuberculosis guidelines for resident 315 and three newly hired employees.
Report Facts
Resident census: 17
Pressure ulcer measurements: 4
Pressure ulcer measurements: 5
Number of residents requiring two-person assist: 2
Number of staff during fire drills: 4
Number of days ham was stored: 10
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 13, 2023
Visit Reason
This document represents the findings of a resurvey with attached complaints #169382, #161662, and #161239 at the assisted living facility conducted on 03/13/23 and 03/14/23.
Findings
The document is a plan of correction submitted in response to deficiencies identified during the resurvey and complaint investigations conducted on the specified dates.
Inspection Report
Re-Inspection
Census: 16
Deficiencies: 9
Date: Mar 8, 2021
Visit Reason
The inspection was a resurvey and complaint investigation of the assisted living facility to evaluate compliance with state regulations.
Complaint Details
The inspection included complaint investigations related to allegations of abuse, neglect, and failure to report incidents timely.
Findings
The facility was found deficient in multiple areas including failure to report allegations of abuse timely, incomplete negotiated service agreements, inadequate health care service coordination, improper delegation and competency documentation for medication aides, improper labeling and storage of medications, and lack of a detailed emergency management plan and disaster preparedness.
Deficiencies (9)
KAR 26-41-101 (f)(3) The facility failed to report allegations of sexual abuse timely and did not conduct thorough investigations or submit required reports for residents #740 and #310.
KAR 26-41-202 (a) The facility failed to ensure negotiated service agreements for residents #423, #447, #730, and #818 included descriptions of services and identification of outside providers.
KAR 26-41-204 (a) The facility failed to ensure licensed nurses provided or coordinated necessary health care services in accordance with functional capacity screenings and negotiated service agreements for residents #231, #310, #422, #423, #447, #730, #740, and #818, including falls, behaviors, and elopements.
KAR 26-41-205 (d)(4) The facility failed to ensure licensed nurses oriented and instructed CMAs in blood sugar testing and failed to document competency for CMAs B, D, and E.
KAR 26-41-205 (g)(3) The facility failed to ensure licensed pharmacists or nurses placed the full resident name on over-the-counter medications and on both original packaging and containers for multiple residents.
KAR 26-41-205 (h)(1) The facility failed to ensure only licensed nurses and medication aides had access to stored medications and biologicals; medication cart keys were unsecured.
KAR 26-41-104 (b) The facility failed to develop a detailed written emergency management plan addressing flooding, severe weather, tornado, and explosion.
KAR 26-41-104 (d)(3) The facility failed to conduct quarterly reviews of the emergency management plan with staff and residents.
KAR 28-39-255 (c)(3) The facility failed to ensure the laundry area had locked cabinets for storage of chemicals and supplies.
Report Facts
Resident census: 16
Adult daycare resident count: 1
Number of deficiencies with severity SS=E: 7
Number of deficiencies with severity SS=F: 2
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 8, 2021
Visit Reason
This document is a Plan of Correction related to deficiencies identified in the inspection report dated 03.08.2021 for the Mapleton Andover facility.
Findings
No specific findings or deficiencies are detailed in this Plan of Correction document. It serves as a corrective action response to prior inspection findings.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Sep 8, 2020
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously cited deficiencies identified by regulation numbers 26-41-101 (f)(3) and 26-41-102 (d) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-101 (f)(3): Previously cited deficiency has been corrected as of 09/08/2020.
Regulation 26-41-102 (d): Previously cited deficiency has been corrected as of 09/08/2020.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Sep 8, 2020
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiencies identified by regulation numbers 26-41-101 (f)(3) and 26-41-102 (d) have been corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-101 (f)(3) deficiency was corrected as of 09/08/2020.
Regulation 26-41-102 (d) deficiency was corrected as of 09/08/2020.
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 2
Date: Aug 11, 2020
Visit Reason
The inspection was conducted as an abbreviated survey for complaint investigations #154713 and #154736 over multiple days in August 2020.
Complaint Details
The complaint investigation involved allegations of abuse after a resident was found with shaved pubic hair. The investigation revealed failures in timely suspension of staff and incomplete use of video surveillance to identify perpetrators.
Findings
The facility failed to properly investigate an allegation of abuse involving a resident with shaved pubic hair by not fully utilizing video surveillance and not suspending all staff involved during the investigation. Additionally, the facility failed to have timely criminal background checks and nurse aide registry verifications for certain certified nursing assistants.
Deficiencies (2)
KAR 26-41-101 (f)(3)(B) The facility failed to use all available resources, including video surveillance, to establish a timeline for an abuse allegation and failed to suspend all staff who provided care during the incident timeframe, placing residents at risk.
KAR 26-41-102 (d) The facility failed to have evidence of criminal background checks at the time of hire for 3 certified nursing assistants and lacked nurse aide registry verification for 1 of them before providing care.
Report Facts
Resident census: 10
Staff involved: 3
Certified nursing assistants reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff A | Certified Nursing Assistant | Named in abuse investigation and suspension timeline. |
| Direct care staff B | Certified Nursing Assistant | Named in abuse investigation and work shifts during incident timeframe. |
| Direct care staff C | Certified Nursing Assistant | Named in abuse investigation and work shifts during incident timeframe. |
| CMA D | Certified Medication Aide | Conducted interviews and investigation related to abuse allegation. |
| Operator F | Facility Operator | Provided statements and decisions regarding staff suspension and investigation. |
| Owner H | Facility Owner | Reviewed video footage and communicated with investigators. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 1, 2020
Visit Reason
The visit was a special infection control survey for COVID-19 conducted at the facility.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 25, 2018
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for each identified deficiency.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 25, 2018
Visit Reason
This visit was conducted as a follow-up to verify correction of previously cited deficiencies.
Findings
All previously reported deficiencies were corrected as of the revisit date. The report lists multiple regulatory provisions with completed corrections.
Inspection Report
Re-Inspection
Census: 7
Deficiencies: 6
Date: Aug 29, 2018
Visit Reason
The inspection was a resurvey of an assisted living facility conducted on 8/28 and 8/29/2018 to evaluate compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including incomplete negotiated service agreements lacking descriptions of outside services, missing signatures, failure to document refusal of services, lack of self-administration medication assessments, improper medication administration practices, and noncompliance with tuberculosis screening guidelines.
Deficiencies (6)
KAR 26-41-202 (a) The administrator failed to ensure negotiated service agreements included descriptions of outside services, providers, and payment responsibilities for 2 of 3 residents.
KAR 26-41-202 (f) The administrator failed to ensure negotiated service agreements included documentation of refusal of insulin, enoxaparin, and accu checks, potential negative outcomes, education, and acceptance of risk for 1 of 3 residents.
KAR 26-41-202 (h) The administrator failed to ensure signatures of all parties involved in negotiated service agreements for 2 of 3 residents.
KAR 26-41-205 (a)(1) The licensed nurse failed to perform an assessment to determine if resident could safely self-administer insulin and enoxaparin without staff assistance before beginning self-administration.
KAR 26-41-205 (d) The administrator failed to ensure certified staff administered medications according to physician orders, manufacturer recommendations, and standards of practice for 1 of 3 residents.
KAR 26-41-207 (b)(5-6) (c) The administrator failed to ensure compliance with tuberculosis guidelines for adult care homes for 1 resident and 2 administrative nursing staff lacking two-step TB skin tests.
Report Facts
Resident census: 7
Residents sampled: 3
Blood sugar readings 150-199: 9
Blood sugar readings 200-249: 2
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N008013 POC 5KH611
Visit Reason
This document is a Plan of Correction related to deficiencies identified in a prior inspection report titled 'the mapleton andover covid 7.1.2020'.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a placeholder or administrative record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N008013 POC RU5K11
Visit Reason
This document is a Plan of Correction related to deficiencies identified in a prior inspection of the facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N008013 POC RU5K12
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N008013 POC 7KHR11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility identified as Aspen.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a corrective action plan linked to a previous inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N008013 POC 7KHR12
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
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