Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Andbe Home, Inc during CMS and state inspections, most recent first.
The facility failed to maintain safe water temperatures, with readings up to 161°F in resident-accessible areas, posing burn risks. Additionally, a resident with a history of falls did not receive updated interventions, leading to repeated falls. Maintenance staff rerouted hot water without proper monitoring, and care plans were not adjusted despite multiple incidents.
The facility failed to meet food service safety standards, affecting 34 residents. Observations showed missing thermometers in refrigerators, expired and unlabeled food items, and uncovered ice cream being transported. The Dietary Manager and staff confirmed these issues, which violated the facility's policies on food storage and cleanliness.
The facility failed to implement a water management program for Legionella prevention, placing 34 residents at risk. Despite annual city water testing and the use of an osmosis water filtration system, the facility lacked documentation of Legionella preventative measures, such as risk assessments and identification of potential problem areas. Administrative Staff A confirmed the absence of a Legionella prevention plan.
The facility failed to dispose of expired medications, risking residents' safety. Observations revealed expired medications in the north medication cart and east medication room, confirmed by an LN. Despite a policy requiring regular checks and disposal, expired medications were not appropriately managed.
The facility failed to maintain resident dignity during meal assistance, as a CNA was observed standing over two residents while feeding them, contrary to the facility's policy. This behavior was noted on multiple occasions, placing the residents at risk for impaired dignity.
A resident with a urinary catheter experienced unsanitary catheter care, as the tubing frequently touched the floor while self-propelling in a wheelchair. A CNA failed to change gloves after perineal care and did not wash hands, touching various surfaces with soiled gloves. The facility lacked policies on catheter tubing positioning and proper glove and handwashing procedures.
A resident with multiple health conditions, including dysphagia, did not receive uninterrupted assistance during meals, as required by the facility's policy. Observations showed a CNA frequently interrupted feeding to assist another resident, compromising the resident's meal intake and placing them at risk for weight loss. Staff confirmed the resident's weight loss and inconsistent meal intake, acknowledging the need for continuous support.
A resident with chronic pain did not receive prescribed Norco medication due to unavailability, leading to unrelieved pain. The medication was not reordered or followed up on in a timely manner, resulting in the resident experiencing significant pain and difficulty sleeping. The facility lacked a policy for reordering medications, contributing to the oversight.
The facility's kitchen staff failed to follow a recipe for preparing a pureed diet, leading to inconsistencies in food preparation. A dietary staff member estimated serving sizes and used unmeasured amounts of liquids, without following a specific recipe, under the supervision of the Dietary Manager. The facility lacked specific recipes for pureed diets, which placed a resident at risk for impaired nutrition.
Unsafe Water Temperatures and Inadequate Fall Prevention
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, specifically regarding water temperatures in resident-accessible areas. Observations revealed that water temperatures in several resident rooms and common areas were excessively high, reaching up to 161 degrees Fahrenheit, which posed a significant risk of burns to residents. The maintenance staff had rerouted hot water from the laundry heater to the resident areas without adequately monitoring or documenting the water temperatures, leading to dangerously high temperatures in resident-accessible sinks. Additionally, the facility failed to implement effective interventions to prevent falls for a resident with a history of multiple falls. Despite the resident's care plan indicating the use of alarms and other preventive measures, the resident continued to experience falls, some resulting in injuries. The care plan was not updated with new interventions after each fall, and the existing measures were not effective in preventing further incidents. The facility's policies required regular monitoring and documentation of water temperatures and the implementation of specific interventions to prevent falls. However, these protocols were not followed, resulting in immediate jeopardy for residents due to the risk of burns from hot water and the continued risk of falls for a resident with a history of falling. The lack of documentation and failure to adjust care plans contributed to the deficiencies identified by the surveyors.
Removal Plan
- Maintenance Staff U adjusted the valve on the hot water line so the excessively hot water for the laundry would not go into the residential hot water line which was set at 120 degrees F.
- The water heaters were adjusted to maintain an acceptable level between 105-120 degrees F.
- Education was provided to the maintenance supervisor of the water temperature requirements and documentation of auditing water temperature.
- Accident education was assigned to all staff.
- Medical Director was notified.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, impacting all 34 residents who received meals from the facility's kitchen. Observations revealed multiple deficiencies, including the absence of thermometers in the nourishment refrigerator/freezers and the presence of expired food items, such as a package of simply steamed cauliflower. Additionally, the kitchen's two-door silver fridge lacked a backup thermometer and contained unlabeled and undated food items, including eggs and cheese. The facility also had issues with unlabeled and undated bins of powdered milk, noodles, and flour. Furthermore, two ceiling vents in the kitchen were observed with a gray fuzzy substance. Staff were observed transporting uncovered bowls of ice cream in the facility halls, which was verified by a CNA who acknowledged that the ice cream should have been covered. The Dietary Manager confirmed the issues with labeling and dating food items and the lack of thermometers, stating that nursing staff were responsible for placing thermometers in the nourishment center refrigerators. The facility's policies on cleaning, sanitation, and food storage were not followed, as evidenced by the lack of compliance with maintaining cleanliness, proper food storage, and temperature monitoring, placing residents at risk for foodborne illness.
Failure to Implement Legionella Prevention Program
Penalty
Summary
The facility, with a census of 34 residents, failed to implement a water management program specifically for Legionella disease prevention. This deficiency was identified through interviews and record reviews, revealing that the facility did not have documentation of Legionella preventative measures, such as risk assessments and identification of potential problem areas. The facility's Water Temperature Check Log only documented temperature checks for laundry, kitchen, common areas, and resident rooms on a weekly basis, but lacked any measures for Legionella prevention. Administrative Staff A confirmed that while the city tested the water annually and the facility used an osmosis water filtration system for drinking water, there was no Legionella or waterborne pathogen prevention plan in place. This oversight placed the residents at risk of contracting Legionella pneumonia.
Expired Medications Not Disposed of Properly
Penalty
Summary
The facility failed to appropriately dispose of expired medications, which placed residents at risk of receiving ineffective medication. During an observation on June 10, 2024, at 08:15 AM, it was found that the north medication cart contained expired medications, including a bottle of stool softener with an expiration date of December 2023, a bottle of calcium complete with an expiration date of June 2023, and a bottle of liquid Gerilanta with an expiration date of December 2023. Licensed Nurse J confirmed that these medications should have been disposed of. Additionally, at 08:52 AM, the east medication room was observed to contain expired medications, including a bottle of extra strength pain relief Tylenol/diphenhydramine with an expiration date of May 2024 and a bottle of gas relief with an expiration date of February 2024, which were also verified by LN J as needing disposal. On June 13, 2024, Administrative Nurse D confirmed that staff were responsible for checking medication carts and rooms for expired medications twice weekly and disposing of them. The facility's Medication Labeling and Storage policy, dated February 2023, stated that staff should contact the dispensing pharmacy for instructions on returning or destroying discontinued or outdated medications. Despite these procedures, the facility did not dispose of expired medications as required, leading to the deficiency noted in the report.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain and enhance the dignity and respect of residents during meal assistance, as observed with two residents, R5 and R33. Certified Nurse Aide (CNA) O was seen standing over these residents while assisting them with eating, which is against the facility's policy. On multiple occasions, CNA O stood over R5 and R33 while feeding them, instead of sitting beside them, which is considered a more dignified approach. This behavior was observed during meal times on two consecutive days, where CNA O alternated between standing and sitting while assisting the residents. The facility's policy, dated March 2022, clearly states that residents should be assisted with meals in a manner that meets their individual needs, ensuring safety, comfort, and dignity. This includes not standing over residents while feeding them. Both Dietary Staff BB and Administrative Nurse D confirmed that staff should not stand over residents during meal assistance. The failure to adhere to this policy placed the residents at risk for impaired dignity, as the staff's actions did not align with the facility's standards for respectful and dignified care.
Failure to Provide Sanitary Catheter Care
Penalty
Summary
The facility staff failed to provide sanitary catheter care for Resident 11, who had a urinary catheter due to neuromuscular dysfunction of the bladder and urine retention. Observations revealed that the resident's catheter tubing frequently touched the floor while self-propelling in a wheelchair, which was confirmed by a licensed nurse who acknowledged that the tubing should be kept off the floor. Additionally, the resident had a history of positive urinary tract infections, including a hospitalization for sepsis secondary to a UTI. Further deficiencies were noted during catheter care provided by a certified nurse aide (CNA). The CNA did not change gloves after providing perineal care and continued to touch various surfaces, including the resident's wheelchair and clothing, with soiled gloves. The CNA also failed to wash hands after completing the care. The facility did not have a policy regarding the positioning of catheter tubing or the proper procedure for changing gloves and handwashing during catheter care, contributing to the unsanitary conditions observed.
Failure to Provide Uninterrupted Meal Assistance
Penalty
Summary
The facility failed to provide uninterrupted assistance to Resident 5 during meals, which placed the resident at risk for weight loss. Resident 5 had a history of epilepsy, generalized anxiety disorder, major depressive disorder, cerebral infarction, and dysphagia. The resident required maximal staff assistance for eating, as documented in the Minimum Data Set (MDS), and was on a pureed diet with nectar thick liquids. Despite these requirements, observations revealed that the Certified Nurse Aide (CNA) assisting Resident 5 frequently interrupted the feeding process by attending to other residents, which compromised the resident's meal intake. Observations on multiple occasions showed that CNA O alternated between assisting Resident 5 and another resident, R33, during meal times. CNA O was seen standing over Resident 5 and feeding her intermittently, which is against the facility's policy that requires staff to sit beside residents while assisting them with meals. This inconsistent assistance was noted during breakfast and lunch, where CNA O repeatedly left Resident 5 to assist other residents, resulting in Resident 5 not receiving the continuous support needed to ensure adequate food intake. Interviews with staff, including Licensed Nurses and Dietary Staff, confirmed that Resident 5's weight had decreased significantly, and the resident's meal intake was inconsistent. Staff acknowledged that uninterrupted assistance could potentially improve Resident 5's eating habits. The facility's policy on meal assistance emphasized the importance of providing support in a manner that ensures safety, comfort, and dignity, which was not adhered to in this case, leading to the deficiency.
Failure in Pain Management Due to Medication Unavailability
Penalty
Summary
The facility failed to ensure adequate pain management for a resident with chronic pain, leading to unrelieved pain. The resident, who had diagnoses of peripheral neuropathy and phantom leg syndrome, was prescribed Norco, an opioid pain medication, to be administered three times a day. However, the medication was unavailable on multiple occasions, and the resident did not receive the prescribed doses. This resulted in the resident experiencing significant pain and difficulty sleeping, as documented in the progress notes and observed by staff. The deficiency occurred due to a failure in the medication reordering process. Although the medication was initially reordered, there was no follow-up when it was not delivered. Staff did not adhere to the facility's expectation of reordering medications seven days in advance or following up with the pharmacy if the medication was not delivered within two days. The facility did not provide a policy regarding the reordering of medications, contributing to the oversight and resulting in the resident's pain management needs not being met.
Failure to Follow Recipe for Pureed Diets
Penalty
Summary
The facility's kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance, specifically in the preparation of a pureed diet for one resident. During an observation, it was noted that the dietary staff did not follow a recipe while preparing the pureed diet. The dietary staff member, DS CC, blended pork chops and mixed vegetables without measuring the portions or following a specific recipe, instead estimating the serving sizes. This was done under the supervision of the Dietary Manager, DM BB, who later confirmed that the facility did not have specific recipes for pureed diets. The facility's policy, revised in 2017, required dietary staff to prepare pureed diets according to provided recipes, measuring food, liquid, and thickener as directed. However, the facility lacked specific recipes for each pureed food item, leading to inconsistencies in preparation. The Dietary Manager acknowledged that different liquids were used to puree food items, but there was no standardized method or recipe for each type of food. This lack of adherence to a standardized recipe placed the resident at risk for impaired nutrition.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Norton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beaver City Manor | 20.4 mi | — | 0 | 0 |
| Logan Manor Community Health Services | 20.8 mi | — | 19 | 0 |
| Phillips County Retirement Center | 31.3 mi | — | 11 | 0 |
| Dawson Place | 32.5 mi | — | 17 | 0 |
| Good Samaritan Society - Colonial Villa | 33.4 mi | — | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.