Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 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.
Unsanitary food storage and kitchen sanitation: A dietary staff member served breakfast without a proper hairnet, and later another staff member wore a hairnet with hair exposed. Surveyors found multiple food items in refrigerators and dry storage without open dates or labels, expired and dented items, food stored on the floor, spoiled lettuce, dark fryer oil with debris, dirty fryer baskets, unclean utensil storage, and greasy buildup on kitchen surfaces. Facility staff verified that food should be stored in closed, labeled containers and that the kitchen cleaning schedule should be followed.
The QAA Committee failed to identify and address multiple deficient practices, including missing Medicare/Medicaid coverage liability notices, lack of a stop date for an as-needed antianxiety med, missing bed hold notification, failure to report a change in condition after an unresponsive episode, inadequate fall investigations, failure to address weight loss, missing dialysis assessments and care planning, kitchen sanitation issues, an incomplete facility assessment, and failure to provide EBP for a resident with a Foley catheter. Admin staff stated monthly QAA meetings were held with the MD, but the facility had not self-identified or corrected the deficiencies through PI monitoring.
Failure to provide required Medicare beneficiary notices. The facility could not produce evidence that one resident or representative received the CMS 10055 and CMS 10123 forms after skilled services ended, and could not show that two other residents received the CMS 10055 form after skilled services ended. An admin staff member verified the missing notices, and the facility did not provide a beneficiary notification policy.
A facility failed to document stop dates for PRN lorazepam/Ativan orders for three residents with dementia, anxiety, and other cognitive or behavioral issues. The records showed the PRN psychotropic orders lacked the required 14-day limit or documented prescriber rationale for extended use, and staff verified the missing stop dates in the EMR.
Missing Recapitulation of Stay and Bed Hold Notice: A resident with fractures, pain, and intact cognition was discharged home with an immobilizer, but the EMR lacked a complete recapitulation of stay and the facility could not produce a recapitulation or discharge summary policy. In a separate case, a resident with hydrocephalus, CKD, DM, and ASHD was transferred to the hospital, but the record lacked evidence that a bed hold notice was provided to the resident or representative, and the facility did not have a Bed Hold Notification policy.
Failure to Follow Transfer Care Plan and Respond to Change in Condition: A resident with hypotension, dementia, DM2, CKD, and HTN was supposed to be transferred with a full-body mechanical lift, but staff used a sit-to-stand lift instead and the resident passed out. The nurse documented initial VS and brief assessment findings, but the chart lacked follow-up documentation, and staff stated they had stopped calling the MD when the episodes occurred even though the event was a change in condition.
Failure to investigate repeated falls and identify root causes. Residents with cognitive impairment, mobility issues, and prior fall history experienced multiple falls and lowering-to-the-floor events during transfers, from a recliner, wheelchair, and bed. Fall investigations repeatedly documented baseline assessments and care plan review, but the facility did not use RCA or have a structured fall committee, and staff reported inconsistent awareness of fall interventions.
Failure to Notify MD of Ongoing Weight Loss: A resident with severe cognitive impairment, depression, and poor intake experienced progressive weight loss from 87.6 lbs to 69.4 lbs. The RD documented repeated weight-loss concerns and suggested increasing protein supplements and adding gelatin, but nursing records lacked evidence that the MD was notified of the continued significant loss. Staff interviews confirmed the resident often refused meals, dietary support was limited by staffing issues, and the care plan lacked resident-centered interventions and preferences.
A resident with ESRD, intact cognition, and multiple care needs did not receive dialysis care and services consistent with professional standards. The care plan and physician orders lacked dialysis-specific details such as access site assessment, dialysis center information, and clear fluid-restriction responsibilities, and there was no documentation of port assessment for infection or bleeding. Staff were unsure who monitored the 24-hour fluid total, the facility did not know the dialysis center’s contact information, no post-dialysis communication was returned, and the facility lacked a contract and dialysis policy.
Failure to Follow EBP During Catheter Care: A CMA provided catheter care to a resident with an indwelling catheter while wearing gloves only and no gown. The resident’s room lacked EBP signage and the needed PPE, including gowns, even though an admin nurse verified that PPE should be used for catheter care. The facility’s IPC program policy stated it was intended to help prevent the development and transmission of communicable diseases and infections.
Incomplete Facility Assessment: The facility failed to complete a thorough facility-wide assessment to determine the resources needed to care for residents competently during routine operations and emergencies. The undated self-assessment did not identify staffing levels by unit, census, or acuity; did not specify needed RN, LPN/LVN, CMA, or CNA coverage for all shifts, including evenings and weekends; did not document required staff competencies; and did not fully list outside service agreements for lab, radiology, therapy, hospital, or transportation. Administrative staff confirmed the assessment was incomplete, and the facility lacked a Facility Assessment Policy.
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.
Unsanitary food storage and kitchen sanitation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner for residents receiving meals from the kitchen. During the initial kitchen tour, a dietary staff member prepared and served breakfast without a hairnet. The double-door stainless refrigerator contained multiple improperly stored items, including heavy whipping cream past its expiration date, deli meats and cheeses in bags without open dates or labels, sausage patties and links in an unlabeled bag, shredded cheese taped shut without an open date, and turkey slices without an open date. The fryer oil was dark with debris floating on the surface, the fryer baskets had crusty material attached, and the walk-in freezer floor had a hash brown patty and a potato cube sitting on it. Additional observations showed three boxes of ice cream mix stored directly on the walk-in refrigerator floor, a bag of lettuce with brown, slime-like contents, rusted metal shelving holding fruit juices, cardboard boxes of potato chips on the dry storage floor, and a dented #10 can of sloppy joe sauce. Vanilla icing was labeled with an open date of 10/29/26, and the kitchen floor baseboards and equipment had dark, blackish, greasy material around the edges. On a later kitchen observation, a dietary staff member wore a hairnet that covered only the top half of the head with hair exposed, the fryer oil remained dark with debris, clean utensil storage contained an unclean plastic container with food debris, a bottle of strawberry syrup had an open date of 07/05/25, and steam table lids were unclean. Facility staff verified that food should be stored in closed, labeled containers and that the kitchen cleaning schedule should be followed.
QAA Committee Failed to Identify Multiple Deficient Practices
Penalty
Summary
The facility failed to ensure its Quality Assessment and Assurance (QAA) Committee adequately identified deficient areas of practice and developed and implemented plans of action to correct them. Survey findings included multiple deficiencies that were not self-identified or corrected through performance improvement monitoring, including failure to provide Medicare/Medicaid Coverage Liability Notice forms 10055 and 10123 regarding non-coverage of skilled services, failure to ensure a stop date for a resident’s as-needed antianxiety medication, and failure to provide bed hold notification to a resident or representative when the resident was admitted to the hospital. Additional findings included failure to report a resident’s change of condition after an unresponsive episode and failure to follow up on charting after the incident, failure to investigate falls and determine root causes for several residents, failure to provide nutritional care or notify the physician of a resident’s weight loss, and failure to provide pre- and post-dialysis assessments, a dialysis contract, and a care plan for a resident receiving dialysis. The facility also failed to wear hairnets, clean the kitchen, and discard unlabeled food, failed to complete the facility assessment for the 35 residents in the building, and failed to provide Enhanced Barrier Protection for a resident with a Foley catheter. Administrative staff stated the QAA meetings were held monthly and included the medical director, and confirmed the deficiencies had not been self-identified and corrected through QAA monitoring.
Failure to Provide Required Medicare Beneficiary Notices
Penalty
Summary
The facility failed to provide required Medicare beneficiary notices for three residents whose skilled services had ended and who remained in the facility. For R42, skilled services ended on 12/26/25, and the facility was unable to provide evidence that R42 or the representative received the CMS Skilled Nursing Facility Advanced Beneficiary Notice (CMS 10055) or the CMS Notice of Medicare Non-Coverage (CMS 10123). For R6, skilled services ended on 03/26/26, and the facility was unable to provide evidence that R6 received the CMS 10055 form. For R7, skilled services ended on 02/03/26, and the facility was unable to provide evidence that R7 received the CMS 10055 form. On 05/06/26 at 03:50 PM, Administrative Staff A verified that the facility did not provide R42 the CMS 10123 or CMS 10055 forms and did not provide R6 and R7 with the CMS 10055 form. The facility also did not provide a beneficiary notification policy.
Missing Stop Dates for PRN Lorazepam Orders
Penalty
Summary
The facility failed to obtain a stop date for PRN lorazepam orders for three residents, resulting in psychotropic medications being continued without the required documented duration or rationale. The report identified that the facility’s Psychotropic Medication Use policy limited PRN psychotropic orders to 14 days unless the prescriber documented the reason for extending use and the duration of the order. For one resident with vascular dementia, violent behavior, and depression, the record showed severely impaired cognition, substantial assistance needs with toileting, bathing, and personal hygiene, and frequent physical and verbal behaviors with rejection of care. The physician ordered Ativan 0.5 mg three times daily PRN for violent, aggressive behaviors, but the order did not include a stop date. Staff described the resident as having significant behaviors, including screaming threats, pacing the hallway, and receiving scheduled and PRN Ativan. For a second resident with memory deficit, pain, muscle weakness, and anxiety, the record showed severely impaired cognition, wandering, and use of antianxiety and antipsychotic medications. The physician ordered Ativan 0.25 mg three times daily PRN for anxiety, but the order lacked a stop date, and the EMR did not contain the documented stop date or rationale for continued use. For a third resident with dementia and anxiety, the physician ordered lorazepam 0.5 mg PRN without a stop date, and the EMR lacked evidence of a specified duration or physician rationale for extended PRN use. Administrative staff verified the missing 14-day stop date and the absence of documentation supporting continued PRN use.
Missing Recapitulation of Stay and Bed Hold Notice
Penalty
Summary
The facility failed to complete a recapitulation of stay for a resident with diagnoses including a left humerus fracture, a displaced fracture of the right ring finger, and pain. The resident’s records showed intact cognition on the admission and quarterly MDS assessments, with varying levels of assistance needed for toileting hygiene, showers, dressing, mobility, transfers, and ambulation. The care plan included interventions for medication administration, pain relief measures, therapy five times a week, staff assistance with care, encouragement for independence, and a plan for rehabilitation at home when the resident could care for herself. Nursing notes documented that the resident was discharged home with an immobilizer and left the facility with her medications, but the EMR did not contain a complete recapitulation of her stay. Administrative Nurse D stated nurses usually completed the recapitulation but could not find one, and the facility did not provide a policy for recapitulation or discharge summary. The facility also failed to provide evidence that a copy of the bed hold policy was given to a resident or representative when the resident was transferred to the hospital. The resident’s record documented hydrocephalus, chronic kidney disease, diabetes mellitus, and atherosclerotic heart disease, with moderately impaired cognition on the admission MDS and assistance needs for oral and personal hygiene and toileting. Progress notes showed the resident left the building with a family member for a procedure, later was expected to have a shunt placed and remain in the hospital for several days, and then returned to the facility for skilled care. The clinical record lacked evidence that a bed hold notice was provided before the hospital transfer. Administrative Staff A stated the facility should have provided the bed hold notice before discharge to the hospital and confirmed it was not provided, and the facility did not have a Bed Hold Notification policy.
Failure to Follow Transfer Care Plan and Respond to Change in Condition
Penalty
Summary
The facility failed to follow R4’s care plan for transfers when staff used a sit-to-stand lift instead of the ordered full-body mechanical lift. R4 had diagnoses including hypotension, dementia without behavioral disturbances, type 2 DM, chronic kidney disease, and hypertension, and the MDS documented that R4 was dependent on staff for transfers, lower body dressing, and toileting hygiene. The care plan directed staff to transfer R4 with two staff and a full lift until further notice, but it did not include directions for what to do if R4 had a vasovagal response. The record also showed that R4 was receiving metoprolol for hypertension, and the physician noted that the medication could contribute to orthostatic hypotension and would be reduced while blood pressure and pulse were monitored. When staff used the sit-to-stand lift, R4 passed out, had a large loose bowel movement, and later slowly regained consciousness. The nurse documented vital signs and noted that R4’s lungs were clear, but the EMR lacked further follow-up charting after the incident. Staff interviews showed that the event had become routine and that the physician was not being called when R4 passed out, despite the facility’s policy requiring notification for a significant change in condition or incident. Administrative staff stated the episode was a change in condition and that the nurse should have contacted the physician and continued monitoring and charting after the event.
Failure to Investigate Repeated Falls and Identify Root Causes
Penalty
Summary
The facility failed to accurately investigate the root cause of repeated falls and implement effective interventions for residents with multiple fall events, including residents with significant cognitive impairment, mobility limitations, and prior injury history. The report states that the facility did not use root cause analysis for falls, did not have a structured fall committee, and that some interventions were repeated without being effective. The facility’s own policy required staff to begin identifying possible or likely causes within 24 hours of a fall and continue evaluating information until the cause was identified or could not be found. One resident had diagnoses including hip dislocation, stroke, depression, CHF, and syncope/collapse, used a wheelchair, had one-sided functional impairment, and had a history of pain and therapy services. This resident experienced multiple falls and lowering-to-the-floor events during transfers and while using a recliner or bed. The documented incidents included a lift transfer when a foot came off the foot stand, a transfer when the resident’s knees gave out, a toilet transfer when the resident became weak, a recliner event when the chair moved to a standing position and the resident slid to the floor, and an unwitnessed bed fall. The fall investigations repeatedly documented no harm factors or baseline range of motion findings and noted care plan review and added fall prevention interventions, but they lacked root cause analysis. Staff later reported that the facility had stopped using the sit-to-stand lift and had switched to a full-body lift, while administrative nursing staff acknowledged that root cause analysis was not used and that repeated interventions were not effective. A second resident with Alzheimer’s disease, repeated falls, restlessness, and agitation had severely impaired decision-making and wandering behavior. The resident’s record showed multiple fall risk assessments and a care plan with interventions such as safety checks, clutter reduction, footwear, bed positioning, and closet door closure. The resident had several fall investigations, including being found on the floor in a closet, sliding from a wheelchair full of books, sliding off a bed while reaching for shoes, and falling forward out of a recliner with a forehead abrasion. Staff interviews showed uncertainty about the resident’s fall interventions and recent fall history, and administrative nursing staff again stated there was no fall committee and no root cause analysis performed for falls. A third resident with memory deficit, pain, and muscle weakness also had repeated falls, including sliding out of a wheelchair and falling from a bed with head injury and pain, while staff later reported inconsistent awareness of the resident’s fall history and interventions. Across these residents, the facility documented falls and care plan changes, but the investigations did not identify root causes as required by policy.
Failure to Notify Physician of Ongoing Weight Loss
Penalty
Summary
The facility failed to ensure Resident 6 received necessary care and services to address ongoing weight loss and poor intake. Resident 6 had diagnoses including dehydration, depression, hypokalemia, repeated falls, heartburn, and severe cognitive impairment with hallucinations and delusions. The resident was 60 inches tall, weighed 87 pounds on admission, required assistance with eating and mobility, and had a stage 2 pressure ulcer. The nutrition care area assessment lacked an analysis or summary, and the nutritional care plan directed staff to encourage fluids, meals in the dining room, off-menu selections, and weekly weights. The registered dietitian documented progressive weight loss and made repeated recommendations, including a protein supplement twice daily, then three times daily with gelatin at lunch, and later four times daily. The resident’s weight declined from 87.6 pounds to 80 pounds, then to 73.2 pounds, and then to 69.4 pounds, reflecting a 20.6% loss since admission. The record showed no evidence that staff notified the physician of the weight loss after the initial decline, after continued loss, or after the significant ongoing loss documented later. The record also lacked evidence of a physician reevaluation or new dietitian recommendation after the continued decline. During observation and interviews, staff confirmed concerns with intake and weight loss. A nurse reported the resident had refused breakfast and getting out of bed and would drink the supplement with morning medication. Dietary staff reported staffing issues limited participation in care planning and could not verify whether the resident was offered alternatives or snacks. A consultant dietitian verified the significant weight loss and stated nursing staff were responsible for notifying physicians of significant weight loss and recommendations. An administrative nurse confirmed the physician had not been notified of the continued significant weight loss and that the care plan lacked resident-centered interventions, including the resident’s preferences.
Dialysis Care and Communication Deficiencies
Penalty
Summary
The facility failed to ensure a resident with ESRD received dialysis care and services consistent with professional standards of practice. The resident had diagnoses including chronic hypertensive heart disease, depressive disorder, a stage 3 sacral pressure ulcer, and shock, and the admission MDS documented intact cognition, functional assistance needs, pain and shortness of breath, swallowing difficulty, nutritional approaches, and pressure ulcer care. Although the care plan noted end-stage renal failure and dialysis, it lacked dialysis-specific interventions for access site assessment, the dialysis center location, chair time, and clear instructions for how fluid restriction responsibilities were divided between dietary and nursing staff. The physician orders also lacked a specific dialysis facility, and the CAA lacked an analysis or summary for all triggered areas. The record showed the resident was to receive hemodialysis three days a week and that the facility weighed the resident before dialysis and sent evening medications, but there was no documentation of assessment of the dialysis port for signs and symptoms of infection or bleeding. Staff reported the resident received room trays and that dietary provided 400 ml for each meal while nursing handled the remainder of the fluid restriction, but nursing staff were uncertain who was responsible for monitoring the 24-hour fluid intake total. Staff also stated the resident’s family or significant other transported the resident to dialysis, the facility did not know the dialysis center’s address or phone number, and no communication was returned after dialysis regarding the resident’s condition or tolerance of treatment. Administrative staff verified the facility lacked a contract with the dialysis center and lacked information about where the resident had been receiving dialysis after admission, and no dialysis policy was provided.
Failure to Follow EBP During Catheter Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff did not follow Enhanced Barrier Precautions during catheter care for a resident with an indwelling catheter. On 05/07/26 at 12:55 PM, a CMA entered the resident’s room and donned gloves only, without a gown, before emptying the catheter collection bag. The CMA cleansed the end of the catheter tubing, drained amber urine into a urine collection container, wiped the catheter spout with alcohol, replaced the end of the catheter spout, closed the clamp, removed her gloves, and washed her hands. Further observation showed the resident’s room did not have a sign posted inside the room with instructions for EBP and PPE use during catheter care, and the room did not have the necessary PPE equipment, including gowns. At 10:30 AM, Administrative Nurse D verified that staff should wear PPE when providing catheter care for the resident and stated the facility would post signage and provide PPE in resident rooms. The facility’s Infection Prevention and Control Program policy stated it was intended to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections.
Incomplete Facility Assessment
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. Review of an undated Long-Term Care Self-Assessment showed it did not identify the specific staffing levels needed for each unit or the number of RN, LPN/LVN, CMA, and CNA staff needed based on unit needs, resident acuity, and census. The assessment also did not include staffing levels for each shift, including evenings and weekends, did not document the staff competencies and skill sets needed for the resident populations served, and did not fully document contractual agreements with outside providers for laboratory, radiology, therapy, hospital, or transportation services. Administrative staff stated the staffing breakdown per unit should have been completed and confirmed the assessment did not contain that information, and the facility lacked a Facility Assessment Policy.
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.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 19 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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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 July 2026) and official state health department websites.