Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Alpha Home - A Waters Community during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, dementia with behavioral disturbance, and PTSD had a history of verbal and physical aggression, exit-seeking, and medication refusal, culminating in an incident where the resident struck a nurse and was sent to an acute psychiatric hospital. Facility documentation showed no 30‑day transfer/discharge notice to the resident’s representative, no documentation of appeal rights or bed-hold policy, and a discharge MDS that characterized the hospitalization as an unplanned discharge with return anticipated. After transfer, the psychiatric hospital Social Worker repeatedly attempted to coordinate the resident’s return, but the DON was often unavailable, the receptionist stated the resident was not allowed back, and facility staff gave inconsistent, undocumented explanations that the resident would not be re-admitted or had been discharged to another SNF, despite the hospital and the representative reporting no such acceptance. The facility’s actions and omissions conflicted with its own transfer/discharge policy requiring 30‑day notice for non-emergency discharges, continuity of care planning, and provision of bed-hold information.
A resident with severe cognitive impairment and significant psychiatric and behavioral diagnoses exhibited escalating verbal and physical aggression, leading to emergency transfer to a behavioral hospital. Although staff had previously discussed behavior concerns with the resident’s representative, the record shows no 30‑day notice of facility‑initiated discharge was issued, and no notice of transfer or discharge with appeal rights or attached bed‑hold policy was provided to the representative at the time of transfer or afterward. Documentation reflects that only the resident, not the representative, received the bed‑hold policy despite the resident’s confusion, and there were no subsequent facility notes of communication with the representative or the psychiatric facility. The Administrator and DON later acknowledged that the required 30‑day notice and transfer/discharge and bed‑hold notices were not provided, and the representative reported she never received any paperwork or appeal information.
Resident Council concerns were repeatedly raised about maintenance, nursing, dietary, and activity issues, but the facility did not provide documented responses, follow-up, or written resolutions in the meeting minutes or Action Forms. Residents reported unresolved problems such as cold showers, call light delays, meal quality concerns, and activity staffing issues, and also requested a resident-run store without any documented response. The council stated they felt they were not listened to or taken seriously.
Failure to provide scheduled and individualized activities: the facility did not carry out multiple calendar activities, left residents sitting idle with the TV on, and had staff engaged on cell phones or laptops instead of leading programs. Residents with dementia were not offered meaningful, stage-appropriate engagement, and Resident Council repeatedly reported missed activities, late starts, and requests for more weekend, outing, and culturally relevant programming.
Failure to provide person-centered dementia care and meaningful engagement: A resident with dementia and anxiety was repeatedly managed with restraint-like positioning in heavy chairs wedged under tables when she tried to stand, while staff did not offer calming alternatives, sensory stimulation, or walking breaks. The record also showed repeated PRN lorazepam use for agitation, pacing, and wandering without documented nonpharmacological interventions or redirection attempts. On the secured memory care unit, activities were largely not implemented, and scheduled dementia-friendly programming, social interaction, and meaningful engagement were minimal or absent.
Improper Use of a Chair as a Physical Restraint: A resident with dementia and anxiety was repeatedly placed in a heavy wooden chair and pushed tightly under a table so she could not stand or move freely. Staff said they used the chair because they were afraid she would fall and it kept her from getting up without assistance, but there was no physician order, assessment, or care plan for restraint use.
Missing discharge medication reconciliation for a resident who returned home. The resident had CHF, CKD, arthritis, physical debility, and low back pain, and her MAR included multiple meds such as aspirin, atorvastatin, methotrexate, diuretics, Eliquis, and metoprolol. The record showed meds were sent home, but the reconciliation documentation could not be found, and the RCS confirmed the meds went with the resident.
MDS assessments were coded incorrectly for resident medications for 3 residents. One resident's MDS did not reflect a diuretic or oral hypoglycemic despite orders for furosemide and metformin, another resident's MDS showed a hypnotic without an order, and a third resident's MDS did not show an antidepressant or hypoglycemic agent despite orders for citalopram and sitagliptin. The Regional Clinical Director stated staff were aware of some MDS coding issues and were working on it, and that there was no policy for MDS accuracy.
A resident with anxiety disorder, low back pain, esophagitis, pain, and major depressive disorder had a level 1 PASRR approving a 30-day exempt stay, but the facility did not complete a new level of care assessment after the exemption expired. During interview, the RNC said she would investigate the issue.
Failure to Provide and Document ADL Care: A resident with schizoaffective disorder and major depressive disorder was repeatedly observed in soiled bedding, with body odor, and wearing the same clothing for multiple days, including shorts worn without anything underneath. The resident’s record showed supervision and set-up help for ADLs, but shower sheets documented multiple refusals of care while the MAR did not reflect behaviors, and the record lacked documentation of the refusals and any follow-up interventions.
Lack of Consistent Dialysis Communication: The facility failed to maintain consistent communication with the dialysis center regarding 2 residents receiving dialysis services. One resident with ESRD reported staff did not complete assessments or VS after dialysis, and the record lacked documentation of communication with the dialysis center. Another resident with dementia, CKD, depression, and HTN also had no documentation of communication to the local hospital regarding VS and assessments with dialysis. The RDO stated the facility did not have a communication form being used consistently.
Failure to obtain ordered urine culture after a resident fall. A resident with a history of cardiac arrest, DM2, neuropathy, HTN, anxiety, and muscle weakness was found on the floor next to her bed. The IDT recommended CBC, BMP, UA, and C&S; the CBC, BMP, and urine testing were completed, but the C&S was not completed even after the lab indicated a culture was needed and another urine sample was recommended.
A resident who was totally dependent on staff and at high risk for pressure ulcers developed a stage II coccyx wound that progressed to an unstageable ulcer, requiring hospitalization and surgical debridement. The facility failed to document or implement preventive interventions such as regular turning, incontinence care, and use of barrier creams, and did not promptly identify or address the wound, resulting in actual harm.
A resident with a history of stroke, aphasia, and high fall risk fell out of bed while being cared for by a newly hired CNA working alone, despite requiring extensive assistance. The care plan lacked individualized fall prevention interventions and was not updated after the incident. Required 72-hour post-fall assessments and care plan revisions were not completed, contrary to facility policy.
A treatment cart containing biologicals, insulin, blood glucose testing supplies, and unidentified pills was found unlocked and unattended near the nurse's station and dining area. The cart's top drawer was open, exposing medications and supplies, while several residents and a visitor were nearby. An LPN responsible for the cart was out of sight, and later admitted to forgetting to secure it as required by facility policy.
A resident with a history of stroke and chronic pain was injured when he slid out of his wheelchair on a facility bus due to improper securing. The lap belt was not installed, and an incorrect cross-belt was used. The bus driver and maintenance director lacked specific training on the new bus equipment, leading to the incident.
The facility did not ensure Resident Council grievances were addressed and reported back for review, affecting four residents. Despite multiple meetings where residents requested more outings and raised care concerns, no responses were documented. Interviews confirmed that residents often did not receive timely feedback, and the Activity Director acknowledged the lapse in the process.
The facility inaccurately coded the MDS for several residents, leading to discrepancies in medication and PASRR Level II requirements. A resident was incorrectly listed as taking an anticoagulant instead of an antiplatelet, while another's need for PASRR Level II was not reflected. Interviews confirmed these errors, and no specific policy for MDS accuracy was in place.
The facility failed to date opened medications on a treatment and a medication cart, including insulin pens and other medications, as observed with a QMA. The facility's policy on medication storage did not address the requirement to date medications when opened.
A resident expressed dissatisfaction with her long facial hair and requested assistance with shaving, which was not promptly addressed by the facility. Despite her care plan indicating a need for staff assistance with ADLs, her preference for a specific staff member to assist was not initially documented or honored, leading to a delay in addressing her grooming needs.
The facility failed to develop comprehensive care plans for two residents, one with ESRD and another with sleep difficulties, leading to deficiencies in addressing their specific medical needs. The care plans did not initially include necessary details related to dialysis and melatonin use, respectively, despite facility policy requirements.
The facility failed to update care plans for two residents. One resident, with depressive and anxiety disorders, had a care plan that did not reflect her refusal of gradual dose reductions for medications. Another resident, with dementia and major depressive disorder, had a care plan indicating a risk for mood decline but did not have an antidepressant in her medication regimen. These issues were identified during record reviews and interviews with the DON and RCS.
A resident with a history of stroke and other medical conditions fell from a wheelchair on a facility bus and was moved back into the chair by staff without a medical assessment. The resident was not properly secured in the bus, and the facility's policy requiring immediate nurse assessment before moving a resident after a fall was not followed. This led to a deficiency in providing appropriate care.
A facility failed to provide necessary care to a resident to prevent worsening contractures in her hand and wrist. Despite therapy recommendations for passive range of motion (PROM) and palm protector use, these were not documented or implemented in her care plan. Observations showed the resident's hand and wrist were contracted without a splint or palm protector, and the contracture angle increased slightly. The Director of Nursing acknowledged the lack of a policy for range of motion treatments, expecting staff to follow therapy recommendations.
A facility failed to document a resident's blood pressure and pulse before administering metoprolol, an antihypertensive medication, as required by the prescription. The resident's care plan included monitoring blood pressure according to the medical doctor's order or facility policy, but the medication administration records for two months lacked this documentation. The facility's policy required vital sign monitoring before administering medications dependent on such measures.
The facility failed to document adequate justification for declining pharmacy recommendations to reduce psychotropic medications for two residents. One resident, with multiple psychiatric diagnoses, had no documented symptoms to support the physician's decision to decline a medication reduction. Another resident's medical record lacked behavior monitoring and non-pharmacological interventions, despite recommendations for gradual dose reduction. The facility's Director of Nursing acknowledged the need for better documentation and behavior monitoring.
A resident with a history of supraventricular tachycardia and chronic respiratory failure experienced left mid-foot pain after an incident with a Hoyer lift. An NP ordered a three-view x-ray to rule out acute injury, but the x-ray was delayed, and no results were initially available in the resident's record. The resident reported ongoing pain and difficulty moving, and the DON confirmed the x-ray was only conducted later, indicating a lapse in timely care.
A facility failed to properly sanitize a blood glucometer used for a resident. An LPN performed a blood sugar test and cleaned the glucometer with a Sani-wipe, allowing it to dry for 5 minutes. However, the facility's policy required a more thorough cleaning process, including wiping the glucometer with a towelette three times horizontally and vertically, and ensuring it remained wet for 2 minutes with a Super Sani cloth wipe. The LPN did not adhere to this procedure, resulting in a deficiency.
A resident with diabetes, chronic kidney disease, and chronic hepatitis did not receive requested influenza, pneumonia, and COVID-19 vaccinations. Despite signed consents for pneumococcal and COVID-19 vaccines, the facility failed to administer them due to unavailability and preference for a clinic session. The influenza vaccine was not documented for acceptance or declination.
A resident with a tracheostomy was admitted to the facility without the necessary physician's orders for tracheostomy care, oxygen, and suctioning. Despite the setup of respiratory equipment by a supply company, the facility did not have a care plan or orders in place until weeks later. The DON acknowledged the oversight, which was contrary to the facility's policy requiring immediate care orders upon admission.
Failure to Readmit Psychiatric Resident and Follow Required Transfer/Discharge Procedures
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident to return following a psychiatric hospitalization and failure to follow required transfer/discharge and bed-hold procedures. The resident had been admitted with multiple mental health diagnoses, including schizoaffective disorder bipolar type, dementia with behavioral disturbance, and PTSD. The facility’s own assessment indicated it provided care for residents with these conditions and behaviors requiring interventions. Prior to the final hospitalization, the resident had a documented history of verbal and physical aggression, exit-seeking, and refusal of medications and meals, with multiple progress notes describing attempts to leave the unit, threats toward staff and other residents, and physical aggression such as pushing a walker into staff and raising a fist. On one occasion, the resident’s escalating behaviors led to police escorting the resident out of the facility. The resident was later re-admitted and continued to exhibit verbal aggression, threats, and attempts to push a chair into another resident, which resulted in a transfer to an acute psychiatric hospital. Subsequent documentation described ongoing challenging behaviors, including demanding unavailable food items, verbal aggression and profanity toward staff, accusations against other residents, refusal of medications, calling 911 claiming poisoning, and physical aggression such as throwing items and threatening to overturn the medication cart. Despite this pattern, the record lacked documentation that a 30‑day notice of transfer or discharge was issued due to the resident’s behaviors, and a care plan meeting note with the resident’s representative did not document that a transfer/discharge notice was provided or that alternative placement was required. On the date of the final incident, the resident struck a nurse in the face with a closed fist and grabbed the nurse’s head when the nurse attempted to prevent the resident from exiting the unit. 911 was called, and the resident was transferred to a behavioral facility. The daughter was notified of the transfer, but the note lacked documentation that she was provided with a transfer/discharge notice, appeal rights, or the bed-hold policy. A discharge MDS indicated an unplanned discharge to a short-term hospital with return anticipated. A subsequent SSD note stated that, after a prior psychiatric hospitalization, the resident and POA had been told that any violent behavior would result in immediate discharge to a hospital with no option to return. After the resident’s transfer, the psychiatric hospital Social Worker repeatedly attempted to contact the DON to determine if the resident could return, leaving multiple messages and sending clinical information, while the facility’s receptionist stated the resident was not allowed back and that her representative had picked up her belongings. Over the following weeks and months, the psychiatric hospital Social Worker documented multiple unsuccessful attempts to reach the DON, intermittent brief contacts, and inconsistent information from the facility. The DON at various times requested clinical information, stated the resident would not be accepted back until stabilized on oral medications, and later indicated she believed the resident had been discharged to another SNF, though she could not provide documentation of such an acceptance or notification. The SSD reported that the IDT had determined on the date of the last hospitalization that the resident would not be re-admitted based on prior discussions with the representative about behavior, and the SSD believed the resident had been discharged to another SNF. The psychiatric hospital Social Worker and the resident’s representative both indicated there had been no confirmed acceptance by another SNF and no communication to them of such a plan. The facility’s own transfer/discharge policy required 30‑day notice for non-emergency transfers/discharges, provisions for continuity of care, and provision of bed-hold information before hospital transfers, but the record lacked documentation that these requirements were met for this resident, and the resident remained at the psychiatric hospital because the facility refused to re-admit her and did not assist with discharge planning.
Failure to Provide Required Transfer/Discharge Notice, Appeal Rights, and Bed-Hold Information
Penalty
Summary
The deficiency involves the facility’s failure to provide required notices of transfer or discharge, appeal rights, and bed-hold policy information to a resident’s representative in connection with a hospital transfer and subsequent facility-initiated discharge. The resident, who had diagnoses including schizoaffective disorder bipolar type, dementia with behavioral disturbance, and post-traumatic stress disorder, had a history and physical noting safety risk factors such as childhood maltreatment, impulsive tendencies, and aggression. A comprehensive MDS showed severe cognitive impairment and verbal behavioral symptoms. Interdisciplinary documentation described escalating challenging behaviors, including verbal aggression, threats, accusations toward other residents, refusal of medications, inappropriate phone use, calling 911 claiming poisoning, and physical aggression such as throwing items and threatening to overturn the medication cart. These records did not document that a 30‑day notice of transfer or discharge was issued due to the resident’s behaviors. A care plan meeting with the resident’s representative was held and the resident’s behaviors were discussed, with staff requesting information on effective interventions. However, the care plan note did not document that the representative was informed that the resident needed alternative placement or that a 30‑day notice of transfer or discharge was provided. On the date of transfer, a nursing progress note documented that the resident attempted to exit the unit, struck a nurse in the face with a closed fist, grabbed the nurse’s head, and that 911 was called, resulting in transfer to a behavioral facility. The daughter was notified of the transfer, but the note lacked documentation that she was provided with a notice of transfer or discharge, information on how to appeal the discharge, or the bed-hold policy. A discharge MDS characterized the event as an unplanned discharge to a short‑term hospital with return anticipated. A bed‑hold policy form completed that day indicated the resident was being transferred due to physical aggression and showed the bed‑hold policy was provided to the resident, but there was no documentation that it was provided to the resident’s representative despite the resident’s cognitive status. The record lacked any notice of transfer or discharge accompanying the hospitalization. A detailed SSD note on the day of transfer described the aggressive incident, referenced prior counseling of the resident and POA that violent behavior would result in immediate discharge with no option to return, and documented attempts to contact the POA and communication with a second daughter. This note did not document that a notice of transfer or discharge or bed‑hold policy was provided to the representative at the time of transfer or afterward, nor that a 30‑day notice had been issued before the hospital transfer. There were no further facility progress notes after this SSD entry, and no documentation of additional communication with the representative or the psychiatric facility. Notes from the acute psychiatric facility later recorded that the resident’s representative stated she had not received a 30‑day notice and believed the resident was supposed to return, and that the psychiatric facility Social Worker told the facility DON that a 30‑day notice needed to be given. In interviews, the Administrator and DON acknowledged that a 30‑day notice of transfer or discharge was not issued and that the representative was not provided the notice of transfer or discharge or bed‑hold policy with this transfer. The SSD reported assuming notices went with the ambulance for confused residents and was unaware the resident remained in the psychiatric facility. The resident’s representative confirmed she received no paperwork, including a notice of transfer or discharge or bed‑hold policy, and stated she would have appealed if she had known how, underscoring that the required notice and appeal information were not provided as mandated by facility policy and state forms.
Resident Council Concerns Not Documented or Resolved
Penalty
Summary
The facility failed to provide documented responses, follow-up, or written resolutions to recurring concerns raised by the Resident Council. Review of Resident Council Meeting Minutes from January 2025 through November 2025 showed repeated complaints with minimal or no response in the Action Forms or minutes. The concerns included unresolved maintenance issues such as cold water during showers, very cold dining room temperatures, broken lights, leaking bathrooms, damaged nightstands, missing trash cans, and furniture repairs not completed. Residents also repeatedly reported nursing concerns including medication refusals not being respected, staff ignoring or responding slowly to call lights, and residents missing showers or not receiving assistance as requested. The minutes also reflected repeated dietary concerns, including poor quality meals, small portions, untimely delivery of room trays, and cold food, with no documented written response or corrective action. Residents further raised ongoing activity concerns such as weekend staffing, activities starting on time, more creative or challenging activities, staff engagement, off-campus outings, and greater resident involvement, again without documented response or resolution. In February, residents requested opening a resident-run store in the activity room, but there was no documented response. During the Resident Council meeting interview, the President, Secretary, and three other regular attendees stated that several concerns had not been addressed and that they felt they were not listened to or taken seriously.
Failure to Provide Scheduled and Individualized Activities
Penalty
Summary
The facility failed to provide activities as scheduled on the posted monthly activity calendar and failed to deliver activities with adequate staff engagement or supervision. The calendar listed routine daily activities such as Daily Chronicle, Prayer & Scripture, balloon toss, bowling, tic-tac-toe, snack and chat, bingo, coffee socials, nails, hand washing, sing alongs, and crafts, but multiple observations showed these activities were not occurring as scheduled. On 12/2/25, no coffee social was observed, the Daily Chronicle was not read or discussed, no Daily Prayer or Scripture was provided, no Color by Number activity occurred, and an Activity Assistant was observed on a personal cell phone while five residents sat unoccupied and a puddle of liquid remained on the floor beneath a resident’s chair. On 12/3/25, observations showed only two residents present in the activity room with the television on during the scheduled coffee social, with no broader invitation or social facilitation. At 11:05 a.m., no activities were occurring and no activity staff were present in the room; no Hand Washing activity was observed. Later that day, prayer was conducted with the television left on, no scripture was read, no residents participated, and no additional residents were invited. The scheduled Balloon Toss and Sing Along did not occur. Additional observations showed no activity or nursing staff present in the main dining room while residents sat idle, an Activity Assistant leaving residents unsupervised for more than 10 minutes, and an Activity Assistant working on a laptop rather than facilitating activities. The facility also failed to individualize activities to meet the needs of residents with dementia. Observations showed residents were left with only the television playing for extended periods, multiple residents were not invited to activities that did occur, and activities lacked dementia-stage specific adaptations. Resident 56 was observed repeatedly attempting to stand, reaching across tables, and fidgeting without individualized sensory items or mobility-based activities. Resident Council minutes documented repeated requests for improved and added activities, including weekend programming, outings, culturally appropriate games, baking, painting, and other meaningful activities, and residents stated that activities often started late or did not happen at all. During the Resident Council Meeting, the President, Secretary, and other residents reported ongoing concerns that had not been addressed.
Failure to Provide Person-Centered Dementia Care and Meaningful Engagement
Penalty
Summary
The facility failed to provide individualized, person-centered dementia care for multiple residents with cognitive impairment by responding to behaviors with restraint-like practices instead of dementia-appropriate interventions, using PRN medications before nonpharmacological interventions, and failing to provide meaningful activities or engagement. The deficient practice was identified on a secured memory care unit and was described as having the potential to affect 21 of 21 residents on that unit. Resident 56, a long-term care resident on the secured memory care unit, had diagnoses including dementia with behavioral disturbance and generalized anxiety. During observations, she was repeatedly placed in large, heavy wooden chairs that were pushed or wedged under tables so she could not move freely after making repeated attempts to stand. On one occasion, she was seated in the main dining/activity room without activity engagement or sensory stimulation. During a bowling activity, increased noise and stimulation were observed to increase her signs of overstimulation and anxiety, including repeated attempts to stand, walk away, and grab activity materials, but staff repeatedly told her to sit back down. She was moved to a table at the back of the room, but again positioned in a heavy chair stuck under the table, and staff continued the same activity without redirecting her to a quieter area or offering an individualized calming alternative. On another observation, Resident 56 was seated in a wheelchair and made repeated attempts to stand. An unidentified hospice aide and Activity Aide 7 placed her into a larger, heavier chair and lifted the table to wedge the arms of the chair underneath, preventing her from pushing back or standing. She appeared frustrated, pursed her lips, curled her hand into a fist, shook her head no, and felt around the edge of the table for a solution. She was not offered a sensory alternative, a walking break, or other person-centered intervention. Record review showed repeated PRN lorazepam administration for agitation, anxiety, pacing, wandering, and entering other residents' rooms, with no documented rationale and/or no documented person-centered nonpharmacological interventions or redirections attempted on multiple dates. In several entries, the medication was given for behaviors such as running up and down the hall, pacing rapidly, or being agitated, and the documentation did not include details of attempted redirection strategies. The resident's care plans addressed wandering, limited activity involvement, behavioral disturbances, and anxiety, with interventions including documenting wandering activity and interventions attempted, providing activity programming consistent with abilities, one-on-one support as needed, encouraging family involvement, monitoring effectiveness, and offering choices. Throughout the survey period, minimal to no activity engagement was observed in the secured memory care unit. No dementia-friendly or sensory stimulation programming was observed, and activities listed on the calendar were not implemented throughout the week. Staff were not observed inviting residents to participate. Coffee Social consisted only of coffee being offered to residents already in the room, without meaningful social interaction, conversation, or reminiscing. The Daily Chronicle was scheduled each morning but was not observed being read or reviewed. Handwashing, Scripture and Prayer, and Sing Along were listed activities but were not consistently observed, and one prayer activity lasted less than two minutes with no scripture read. During interview, the Administrator and Social Service Director stated the activity department and life enrichment programming needed improvement, and the Administrator said he wanted to start a new dementia-specific program and provide additional education and training.
Improper Use of a Chair as a Physical Restraint
Penalty
Summary
The facility failed to ensure a resident was free from the use of physical restraints when staff placed Resident 56 in a heavy, immobile wooden chair and positioned the table over the chair arms to prevent her from standing or moving freely. Resident 56, a long-term care resident on the secured memory care unit with diagnoses including dementia with behavioral symptoms and generalized anxiety, was repeatedly observed attempting to stand from her wheelchair in the dining/activity area. During these observations, staff moved her into a large wooden chair and wedged the chair under the table so she could not push back or move the chair, and she appeared frustrated while trying to find a way around the table. The record review showed no physician order, assessment, or care plan for the use of physical restraints. Her care plan identified her as high risk for falls related to impaired mobility and cognition, and noted she liked to walk for most of her free time. Staff interviews indicated they used the heavy wooden chairs because they were afraid she would fall and because the chairs kept her from getting up without assistance. The facility policy stated physical restraint is only to be used as a last resort and is never to be used for staff convenience or discipline, and that if a resident cannot remove the device on command, it is considered a physical restraint.
Missing Discharge Medication Reconciliation
Penalty
Summary
The facility failed to properly reconcile medications for a resident who discharged home. The resident had diagnoses including congestive heart failure, chronic kidney disease, arthritis, physical debility, and low back pain, and her record showed she discharged home on 9/16/25 with medications sent home with her. The record lacked documentation of medication reconciliation at discharge. Her discharge care plan indicated she wanted to return home, and her MAR listed multiple medications, including aspirin, atorvastatin, folic acid, methotrexate, montelukast, spironolactone, torsemide, vitamin D3, Breztri, Eliquis, metoprolol succinate ER, and cetirizine. During interview, the Regional Nurse Consultant stated the medications went home with the resident but could not locate the reconciliation documentation.
MDS assessments were coded incorrectly for resident medications
Penalty
Summary
The facility failed to code residents' MDS assessments accurately for the types of medications they were receiving for 3 of 5 residents reviewed. Resident 3 had diagnoses including heart failure, depression, type 2 DM, neuropathy, and hypertension. Her record showed orders for furosemide 40 mg daily for CHF and metformin HCl 500 mg twice daily for DM, but her MDS did not indicate that she was taking a diuretic or an oral hypoglycemic medication. Her care plan identified type II DM with risk for hypo/hyperglycemia and risk for dehydration related to diuretic therapy. Resident 69 had diagnoses including anxiety disorder, low back pain, esophagitis, pain, and major depressive disorder. Her MDS indicated she received a hypnotic medication, but the record lacked an order for a hypnotic. Resident 6 had diagnoses including dementia, chronic kidney disease, depression, and essential hypertension. He was prescribed citalopram hydrobromide 10 mg daily and sitagliptin 25 mg daily, but his MDS did not indicate that he was receiving an antidepressant or a hypoglycemic agent. During interview, the Regional Clinical Director stated they were aware of some MDS coding issues and were working on it, and also stated there was no policy for MDS accuracy and that they referred to the RAI for information.
PASRR Level of Care Assessment Not Updated After 30-Day Exempt Expired
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed correctly for one resident when the resident’s 30-day exempt level expired and a new level of care assessment was not obtained. Resident 69 had diagnoses including anxiety disorder, low back pain, esophagitis, pain, and major depressive disorder. Her level 1 PASRR was dated [DATE] and indicated approval for a 30-day exempt stay, with a new level of care assessment needed for any date past [DATE] if she remained in the facility. During record review and interview, the Regional Nurse Consultant stated she would investigate the issue. The survey exit provided no additional information.
Failure to Provide and Document ADL Care
Penalty
Summary
The facility failed to ensure that Resident 13 was clean, appropriately dressed and groomed, and that his bedding was changed when soiled. On 12/1/25, the resident’s room had several brown stains on the sheets and a strong body odor was noted. The resident was observed self-propelling from the bathroom in a wheelchair wearing a navy-blue shirt and red basketball shorts around his thighs, with nothing underneath the shorts. The resident had bilateral below-the-knee amputations and, when he self-transferred into bed, he scooted his bare bottom across the sheets. On 12/2/25, the resident was observed lying in bed awake and resting. He was wearing the same shirt seen the day before, and the sheets and pillowcase appeared to be the same soiled linens observed previously, including a yellow-brown ring on the pillowcase where his head rested. On 12/3/25, he was again observed sitting at the side of the bed eating lunch in the same navy-blue shirt and red basketball shorts, making this the third day in a row he was seen in the same outfit. His pillowcase and sheets still appeared unchanged and soiled based on the same stains. The resident’s record identified diagnoses including schizoaffective disorder and major depressive disorder. His most current MDS, dated 9/5/25, indicated supervision and set-up help for all ADLs. The record also showed an active order for behavior monitoring every shift, including refusal of care, but the MARs for June, August, September, and November did not show behaviors for those months despite shower sheets documenting multiple shower refusals. Several shower sheets documented refusals on 6/7/25, 8/2/25, 9/9/25, 9/16/25, 9/30/25, 11/2/25, 11/12/25, 11/16/25, 11/19/25, 11/21/25, 11/23/25, and 11/26/25, and the record lacked documentation of those refusals and any subsequent interventions used. The RNC stated she had recently been made aware of the ADL concerns and that the behavior monitoring documentation did not reflect the resident’s actual condition or behaviors.
Lack of Consistent Dialysis Communication
Penalty
Summary
The facility failed to ensure consistent communication between the facility and the dialysis center regarding the care of 2 residents receiving dialysis services. One resident, who had end stage renal disease and an active order for dialysis every Monday, Wednesday, and Friday, stated that staff did not perform any assessment or vital signs when he returned from dialysis and only welcomed him back and helped him settle when needed. Review of his medical record showed no documentation of communication between the facility and the dialysis center. A second resident, with diagnoses including dementia, chronic kidney disease, depression, and essential hypertension, also had no documentation in the medical record of communication to the local hospital regarding vital signs and assessments related to dialysis. The Regional Director of Operations stated the facility did not have a communication form that was being used consistently.
Failure to Obtain Ordered Urine Culture After Fall
Penalty
Summary
The facility failed to obtain a urine culture and sensitivity after a resident was found on the floor next to her bed. The resident had diagnoses including history of cardiac arrest, type 2 diabetes, neuropathy, hypertension, generalized anxiety, and muscle weakness. After the fall, the interdisciplinary team recommended labs including a CBC, BMP, urinalysis, and culture and sensitivity. The facility completed the STAT CBC, BMP, and urine testing, and the lab indicated a culture with results to follow, but the culture was not completed. During interview, the Regional Nurse Consultant stated the lab was unable to obtain a C&S and recommended collecting another urine sample, but this was not completed, and the resident was started on a prophylactic antibiotic to treat the urinary tract infection.
Failure to Prevent and Manage Pressure Ulcer Resulting in Harm
Penalty
Summary
A resident with a history of nontraumatic intracerebral hemorrhage, aphasia, dysphagia, and total dependence for activities of daily living was admitted to the facility without any skin impairment. Upon admission, assessments identified the resident as high risk for pressure ulcers due to immobility, incontinence, and comorbidities. The care plan included interventions such as keeping the resident clean and dry, performing peri care after each incontinent episode, and using emollients and barrier creams as recommended by the wound nurse practitioner. However, the clinical record lacked documentation that these preventive measures were implemented, including the use of emollients, barrier creams, regular turning and repositioning, and off-loading. Within two weeks of admission, the resident developed a stage II pressure ulcer on the coccyx, which rapidly progressed to an unstageable wound requiring surgical debridement and hospitalization. Documentation was missing regarding the identification of the wound, notification of the physician or family, and initiation of appropriate nursing interventions when the wound was first observed. Preventive skin care orders were not documented in the Medication Administration Records, and there was no evidence that a personalized skin care plan was developed or implemented prior to the development of the pressure ulcer. Interviews with staff and review of facility policy revealed that the resident was dependent on staff for all care, including incontinence management and repositioning, but there was no documentation to confirm these interventions were consistently provided. The facility's policy required prompt identification of at-risk residents and immediate implementation of specific interventions, but the record did not show that these steps were taken before the pressure ulcer developed. The lack of preventive care and timely intervention resulted in actual harm to the resident, who required hospitalization and advanced wound care.
Failure to Individualize and Implement Fall Prevention Interventions and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that fall prevention interventions were individualized and implemented for a resident with significant medical needs, and did not complete required fall follow-up assessments and care plan updates after a fall incident. The resident, who had a history of stroke, aphasia, dysphagia, pressure ulcer, and right-sided weakness, was identified as high risk for falls and required extensive assistance from two or more staff for bed mobility and transfers. Despite these needs, the resident fell out of bed while being cared for by a newly hired CNA working alone during a check and change. The care plan at the time lacked resident-specific interventions and was not updated following the fall. Additionally, the clinical record did not contain documentation of 72-hour post-fall assessments with vital signs, a Post Fall Review assessment, or updates to the care plan as required by facility policy. Interviews with the DON and LPN confirmed that the fall occurred during care provided by a single aide, and that the care plan had not been appropriately individualized or revised after the incident. The facility's policy required documentation and investigation after falls, as well as the implementation of new care plan interventions, but these steps were not completed for this resident.
Unattended and Unlocked Treatment Cart with Exposed Medications and Supplies
Penalty
Summary
During a random observation, a treatment cart containing tubes and bottles of biologicals, including medications for skin conditions and wounds, was found unlocked and unattended near the nurse's station, outside the main dining room, and close to the entry of a hallway. The top drawer of the cart was open, exposing insulin, blood glucose testing supplies, a box of exposed lancets, bottles of blood glucose strips, packaged dressings, and alcohol pads. Additionally, a plastic medication cup with unidentified pills and capsules was left unsecured on top of the cart. Eight residents were observed in the main dining room within view of the cart, and one resident was standing beside it. A visitor was also present near the unsecured cart, conversing with the resident for over two minutes while the cart remained unattended. The LPN responsible for the cart was inside the nurse's station, approximately twelve feet away and out of sight of the treatment cart. Upon noticing the situation, the LPN quickly secured the cart by closing the drawer, locking it, and moving it inside the nurse's station. The LPN later acknowledged that the cart should not have been left unlocked but stated she became distracted by another resident and forgot about it. Facility policy requires that medication carts and supplies be locked or attended by authorized personnel at all times, and that external medications be kept in a treatment cart or a separate, labeled drawer.
Resident Injury Due to Improper Securing on Facility Bus
Penalty
Summary
The facility failed to prevent potential accidents when transportation staff were not adequately trained on new bus equipment, leading to an incident where a resident was not properly secured with a safety lap belt. This resulted in the resident sliding out of his wheelchair during transit on the facility bus, causing him to sustain a fracture of the L1 vertebra with a 20% height loss. The resident, who had a history of stroke, left-sided weakness, vascular dementia, and chronic pain, was on his way to a dental appointment when the incident occurred. Upon review, it was found that the resident was not properly secured into the bus prior to departure. The lap belt, which was necessary for securing the resident, was still in its original packaging and had not been installed. Instead, an incorrect cross-belt was used, which was buckled into the adjacent seat's clip across the aisle. This improper securing method contributed to the resident's fall from the wheelchair. The investigation revealed that the bus driver and maintenance director had not received job-specific orientation or training for transportation safety on the new facility bus. The new bus had been delivered earlier in the year, and basic functions were reviewed with the administrator and a regional consultant, but no formal training was documented for the staff responsible for resident transport.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances raised by the Resident Council were followed up on and reported back to the council for review and approval. This deficiency was identified through interviews and record reviews, revealing that the facility did not document responses to requests and grievances made by the Resident Council. Specifically, during meetings held on various dates, residents expressed desires for more outings and raised concerns about general nursing care, including call light response times and staff behavior. However, there was no documentation of any responses to these concerns. Interviews with residents and the Activity Director (AD) confirmed that residents often did not receive timely responses to their grievances. The AD acknowledged that the process should involve submitting response forms to department heads to ensure residents receive feedback at subsequent meetings. The facility's policy on Resident Council participation emphasizes the importance of timely responses to concerns, yet this process was not adhered to, as evidenced by the lack of documented responses to the council's minutes.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for five residents, leading to discrepancies in their medical records. Resident 9 was incorrectly coded as taking an anticoagulant when she was prescribed aspirin, an antiplatelet. Similarly, Resident 12's MDS inaccurately indicated she was on an anticoagulant, despite her prescriptions for aspirin and Plavix, both antiplatelet medications. Resident 11's MDS also incorrectly listed an anticoagulant instead of the antiplatelet aspirin he was taking. These inaccuracies in medication coding could potentially affect the residents' care plans and risk assessments. Additionally, Resident 47's MDS failed to reflect the requirement for a PASRR Level II, despite documentation indicating the necessity due to his mental health conditions. Resident 33's MDS inaccurately recorded the use of an anticoagulant, which was not supported by her medical orders. Interviews with the Director of Nursing and the Regional Nurse Consultant confirmed these discrepancies, and it was noted that there was no specific policy for ensuring MDS accuracy, with reliance placed on the RAI manual.
Failure to Date Opened Medications
Penalty
Summary
The facility failed to date medications when opened, as observed during a survey. On the 300-hall treatment cart, a Lantus pen and a Humalog pen, both used for diabetes treatment, were found without dates indicating when they were opened. Additionally, on the 300-hall medication cart, a Flonase bottle and a bottle of ear drops were also found without opening dates. These observations were made with a Qualified Medication Assistant (QMA) present. The facility's policy on medication storage, provided by the Regional Nurse Consultant, did not include information regarding the requirement to date medications when opened.
Failure to Ensure Resident Dignity in Grooming Needs
Penalty
Summary
The facility failed to ensure dignity for a female resident, identified as Resident 33, who expressed dissatisfaction with her long facial hair and requested assistance with shaving. Despite her request, the facility did not promptly address her need for assistance. Resident 33, who had a self-care deficit and required staff assistance with activities of daily living (ADLs), was observed with long facial hair on multiple occasions. She communicated her desire to have the facial hair removed to the staff, but no action was taken to fulfill her request in a timely manner. Resident 33's care plan indicated she had late loss ADLs and required staff assistance, yet her preference for a specific staff member to assist with shaving was not initially documented or honored. The Director of Nursing (DON) later discovered Resident 33's preference for a particular staff member, Qualified Medication Assistant (QMA) 16, to perform the task. However, QMA 16's schedule did not align with the times Resident 33 requested assistance, leading to a delay in addressing her grooming needs. This oversight resulted in a failure to honor the resident's right to dignity and respect, as outlined in the facility's policy on resident rights.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. Resident 47, diagnosed with end-stage renal disease (ESRD), dementia, hypertension, and age-related physical debility, did not have a care plan that addressed his nutritional needs related to ESRD with dialysis. Although a care plan was eventually provided, it was not initially included in his medical record, indicating a lapse in comprehensive care planning. Similarly, Resident 12, who had diagnoses including dementia, chronic kidney disease, major depressive disorder, and anxiety, was prescribed melatonin for difficulty sleeping. However, her care plan did not address her sleep difficulties or the use of melatonin. This oversight highlights a failure to incorporate all aspects of her care needs into the comprehensive care plan. The facility's policy requires that comprehensive care plans be finalized within seven days of completing the full comprehensive minimum data set (MDS) assessments, but this was not adhered to in these cases.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans with changes in resident care for two residents. Resident 25, diagnosed with depressive disorder, generalized anxiety disorder, and a history of opioid abuse, had a care plan addressing the use of medications for behavior management, including Buspar, trazodone, duloxetine, and mirtazapine. However, the care plan did not reflect her refusal to undergo gradual dose reductions (GDR) as per her preference. Resident 12, diagnosed with dementia, major depressive disorder, and insomnia, had a care plan indicating a risk for mood decline related to her major depression diagnosis. Despite this, her medication regimen did not include an antidepressant, which was inconsistent with her care plan. These deficiencies were identified during record reviews and interviews with the Director of Nursing and Regional Nurse Consultant.
Failure to Ensure Medical Assessment Before Moving Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident who experienced a fall was not moved until after a medical assessment was completed. The incident involved a long-term care resident with a history of stroke, weakness/paralysis on the left side, vascular dementia, muscle wasting and atrophy, chronic pain syndrome, and a wedge compression fracture of the L1 vertebra. The resident fell while being transported on the facility bus to a dental appointment, sliding out of his wheelchair and landing on the floor. He complained of pain in his left shoulder/elbow and mentioned hitting his head on the wheelchair. Upon the resident's return to the facility, neurological checks were performed and were within normal limits. However, the resident later exhibited symptoms of nausea and vomiting, leading to a hospital evaluation where an acute to subacute compression fracture of the L1 vertebra was discovered. The investigation revealed that the resident had not been properly secured in the bus prior to departure. The bus driver and maintenance director moved the resident back into his wheelchair without waiting for a medical assessment, contrary to facility policy. The facility's policy requires that any incident or accident, including falls, be reported immediately to a nurse or designated person in charge, and that an immediate assessment be completed by a nurse to determine if the resident can be moved. The Director of Nursing indicated that the bus driver and maintenance director should have called for a medical professional's assessment before moving the resident, as moving him could have worsened any injuries. The facility's failure to adhere to this policy resulted in a deficiency in providing appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Prevent Worsening of Contractures in Resident
Penalty
Summary
The facility failed to provide appropriate care to a resident, identified as Resident 35, to prevent the worsening of contractures in her hand and wrist. Observations on multiple occasions revealed that Resident 35's right hand was contracted into a fist, and her wrist was contracted upward, without the use of a splint or palm protector. Despite recommendations from an Occupational Therapy (OT) referral summary for continued assistance with hand hygiene, passive range of motion (PROM), and palm protector wear to prevent skin breakdown and increase joint mobility, these measures were not documented or implemented in her care plan. Resident 35's medical record lacked documentation of PROM services and an order to wear a palm protector. The Director of Rehab confirmed that although Resident 35 had completed therapy after meeting a goal of decreasing her contracture, the angle of her contracture had increased slightly. The Director of Nursing indicated there was no policy for range of motion treatments and services, but expected nursing staff to follow therapy recommendations. This oversight resulted in a deficiency as the facility did not ensure the resident received necessary treatments and services to prevent the worsening of her condition.
Failure to Monitor Vital Signs Before Administering Antihypertensive Medication
Penalty
Summary
The facility failed to adhere to the prescribed medication administration protocol for a resident diagnosed with hypertension. The resident was prescribed metoprolol, an antihypertensive medication, with specific instructions to hold the medication if the systolic blood pressure was less than 100 or the pulse was less than 60. However, a review of the medication administration records for August and September 2024 revealed a lack of documentation of the resident's blood pressure and pulse prior to administering the medication. This oversight occurred despite the resident's care plan, which included monitoring blood pressure as per the medical doctor's order or facility policy. The facility's policy on drug administration emphasized the necessity of performing vital sign monitoring before administering medications dependent on such measures.
Inadequate Documentation for Declining Psychotropic Medication Reduction
Penalty
Summary
The facility failed to ensure adequate documentation and justification for declining pharmacy recommendations to reduce psychotropic medications for two residents. Resident 34, diagnosed with dementia, schizoaffective disorder, bipolar type, and anxiety, was scheduled for a trial reduction of an antianxiety medication. The physician declined the recommendation, citing symptoms, but there was no documentation of symptoms in the resident's behavior monitoring records or nursing progress notes. The Director of Nursing acknowledged that there were no symptoms of increased or worsening anxiety, and the recommendation should have been accepted or a different reason provided for declining it. Similarly, Resident 9, with diagnoses including schizoaffective disorder, bipolar type, delusional disorder, and major depressive disorder, was prescribed multiple psychotropic medications. The pharmacist recommended a gradual dose reduction, but the request was declined due to the resident reportedly remaining symptomatic. However, the medical record lacked documentation of daily behavior monitoring or symptoms. The care plans for Resident 9 did not include non-pharmacological interventions to address identified behaviors. The Director of Nursing and Regional Nurse Consultant noted the need for detailed reasons for not performing a gradual dose reduction and added behavior monitoring to the resident's medical record.
Failure to Provide Timely X-Ray Services
Penalty
Summary
The facility failed to ensure timely x-ray services for a resident who was reviewed for x-rays. The resident, who had a history of supraventricular tachycardia, chronic respiratory failure, and age-related debility, complained of left mid-foot pain after an incident involving a Hoyer lift pad. A Nurse Practitioner ordered a three-view x-ray of the resident's left foot to rule out acute injury and prescribed acetaminophen for pain management. Despite the order, there were no x-ray results available in the resident's record. The resident reported ongoing soreness in her left foot and difficulty pushing herself up in bed, indicating that the x-ray had not been performed. The Director of Nursing later confirmed that the x-ray was conducted the night before the interview, indicating a delay in providing the necessary diagnostic service. The facility's policy on resident rights emphasizes the importance of enhancing residents' well-being and quality of life, which was not upheld in this instance.
Improper Sanitization of Glucometer
Penalty
Summary
The facility failed to properly sanitize a blood glucometer used for Resident 103. During an observation, an LPN performed a blood sugar test for Resident 103 using a glucometer that was stored on the treatment cart. The LPN indicated that the glucometer was clean from its previous use and proceeded with the blood sugar test. After completing the test, the LPN used a Sani-wipe to clean the monitor and placed it on a Kleenex to dry, stating it would sit for 5 minutes before being returned to its box. However, the facility's policy required the glucometer to be wiped with a towelette three times horizontally and vertically, using a second towelette to ensure it remained wet for 2 minutes with a Super Sani cloth wipe. The LPN did not follow this procedure, leading to a deficiency in infection prevention and control.
Failure to Administer Requested Vaccinations
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 102, received the influenza, pneumonia, and COVID-19 vaccinations as requested. Upon review of Resident 102's medical records, it was found that the sections for these immunizations were left blank. The resident had signed consents for the pneumococcal and COVID-19 vaccines, dated 9/6/24, but there was no documentation for the acceptance or declination of the influenza vaccine. The Director of Nursing (DON) indicated that the pneumonia vaccine was not administered upon admission due to its unavailability and preferred to administer all vaccines during a clinic session. Resident 102's medical history includes diabetes mellitus, chronic kidney disease, and chronic hepatitis, which are significant conditions that necessitate timely vaccinations. Despite the resident's consent and the facility's provision of CDC vaccination information sheets upon admission, the facility did not follow through with the administration of the requested vaccines. This oversight was identified during a review and interview process, highlighting a lapse in the facility's vaccination protocol for residents who have expressed their desire to receive these immunizations.
Failure to Obtain Physician Orders for Tracheostomy Care
Penalty
Summary
The facility failed to ensure that a resident with a tracheostomy had the necessary physician's orders for tracheostomy care, oxygen, oxygen humidity, suctioning, and to maintain oxygen saturation levels above 90%. This deficiency was identified for one of the two residents reviewed with a tracheostomy, referred to as Resident B. Resident B was admitted to the facility with multiple complex medical conditions, including acute respiratory failure with hypoxia, pulmonary embolism, and a history of kidney transplant rejection, among others. Upon admission, the respiratory care supply company set up the necessary respiratory equipment for Resident B, including an Airvo system, oxygen mask, and suctioning equipment. However, the facility did not have a care plan or physician's orders for the tracheostomy care and oxygen management until several weeks after the resident's admission. The Director of Nursing acknowledged that these orders were overlooked and should have been entered into the resident's medical record when the equipment was set up and before the resident's admission. The facility's policy requires that physician orders for a resident's immediate care be in place at the time of admission. This includes orders for dietary needs, medications, and routine care to maintain or improve the resident's functional abilities. Despite this policy, the necessary orders for Resident B's respiratory care were not obtained or implemented in a timely manner, leading to the identified deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 973 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westpark A Waters Community | 1.5 mi | ★★★★★ | 2 | 0 |
| North Capitol Nursing & Rehabilitation Center | 2.3 mi | ★★★★★ | 5 | 0 |
| Tranquility Nursing And Rehab | 3.1 mi | — | 0 | 0 |
| Evergreen Crossing And The Lofts | 3.8 mi | ★★★★★ | 27 | 0 |
| Northwest Manor Health Care Center | 3.8 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.