Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Willow Brook Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Failure to Provide Timely Incontinence Care and Feed Resident While Soiled: A resident with severe cognitive impairment, bowel and bladder incontinence, and a pressure ulcer was left in soiled incontinence pads for about 10 hours, including during breakfast when a CNA fed the resident without first providing care. Documentation showed no incontinence care after the prior night shift entry, and staff later confirmed the resident’s soiled condition and a new skin impairment to the left buttock.
The facility failed to provide needed ADL assistance for three residents. One resident with severe cognitive impairment and incontinence was left in urine- and feces-soiled pads for about 10 hours before care was provided, with the odor still present when breakfast was served. Another resident with Alzheimer’s disease was repeatedly observed eating non-finger foods with his/her hands during meals while staff present in the dining room did not cue or assist. A third resident with severe cognitive impairment and malnutrition was also observed eating without the hands-on or total assistance listed in the care plan and kardex, with staff placing meals in front of the resident and walking away.
A facility failed to provide ordered wound care and timely skin monitoring for multiple residents with pressure ulcers. One resident with a coccyx ulcer had wound physician treatment recommendations delayed or missed and was observed lying on heavily soiled incontinence pads before care was provided, while another resident’s hospice wound recommendations for a heel DTI were not implemented and the wound was not measured weekly. Two other residents had buttock pressure ulcers where outside wound clinic instructions and weekly measurements were not properly documented, and a newly admitted resident’s pressure ulcers were not assessed, staged, measured, or monitored weekly as ordered.
Failure to Document Dialysis Residents’ Fluid Intake: The facility failed to document the amount of fluids consumed in mL each shift for three residents on dialysis with ordered fluid restrictions. One resident with intact cognition said he/she was not aware of the restriction, and observations showed beverages on meal trays for two residents. Staff stated nurses were responsible for documenting intake each shift and totaling it over 24 hours, but the TAR/MAR records did not show the required shift-by-shift fluid totals.
Food Served at Improper Temperatures and Pureed Diet Menu Not Followed: The facility failed to serve palatable meals on 2 of 3 units and did not provide pureed diet residents with the menu items listed. Test trays showed hot items such as potatoes, pureed meat, green vegetables, and eggplant parmesan were served warm or lukewarm rather than hot, and a cold salad was not crisp and was served without dressing. Pureed meals on one unit were unrecognizable and lacked gravy on the meat, and the FSD stated pureed diet residents received leftover food from the prior day instead of the planned meal without consulting the RD.
A facility failed to provide a dignified dining experience for three residents with severe cognitive impairment and care needs. One resident repeatedly ate non-finger foods with hands while staff present did not cue or assist with utensils, another was fed while staff stood behind the chair instead of sitting at eye level, and a third was fed breakfast while lying on soiled incontinence pads with urine and feces odor present. Interviews with CNA and nursing leadership confirmed these practices were not considered dignified.
Failure to Notify Provider of Skin/Wound Changes: The facility did not notify the MD/NP of a new buttock skin impairment for one resident with severe cognitive impairment and multiple pressure-related wounds, and did not notify the provider when another resident’s heel DTI opened and began draining. Hospice notes, TARs, and staff interviews showed the heel wound changed from intact eschar to an open wound with drainage, but the only active order remained betadine swabs and no dressing order was added or documented.
Failure to Document and Report a Resident’s Nasal Skin Area: A resident with Alzheimer’s disease and severely impaired cognition had a red, raised area on the nose that was visible during observation, but it was not identified on the weekly skin assessment, was not documented in the care plan, and had no MD/NP treatment order. Staff interviews showed the CNA and nurse were aware of the area, but the nurse did not notify the MD/NP, and the DON acknowledged the area should have been documented and reported. The resident and family reported a history of skin cancer involving the nose.
A resident with hyperlipidemia, morbid obesity, and severe cognitive impairment had a physician order for weekly weights, but staff weighed the resident monthly instead. The record showed a clinically significant weight gain, with no timely reweigh to confirm the increase and no documentation of weight refusal. Interviews with CNA, nursing, RD, NP, physician, and DON staff confirmed the weekly weight order was not followed.
Unlicensed admissions director provided incontinence care to a resident who was severely cognitively impaired and dependent on staff for bowel and bladder care. The Administrator said she was not licensed as a CNA and should not have been giving direct care, while she stated her CNA license had expired and she had not received facility education on incontinence care.
Incomplete ADL Documentation for a Cognitively Impaired Resident: The facility failed to complete daily documentation for a resident with severe cognitive impairment, bowel and bladder incontinence, and dependence on staff for incontinence care. Multiple ADL entries were missing across eating, bladder and bowel care, hygiene, dressing, mobility, transfers, toilet transfer, wheelchair use, walking, and shower/bath documentation, and the DON stated there should be no holes in the record because it would create an inaccurate medical record.
Failure to Wear Gloves When Handling Soiled Linen: A CNA was observed handling soiled linen with bare hands, including wet used towels, an adult brief with feces, and a heavily soiled bed soaker. Facility policy required gloves when handling body fluids and soiled items, and staff interviews confirmed the expectation that gloves be worn for dirty linen and universal precautions.
A resident with severe cognitive impairment and multiple diagnoses required two-person assistance for transfers, as per their care plan. However, a CNA transferred the resident alone, resulting in injuries. The facility's investigation confirmed the CNA did not follow the care plan, leading to the deficiency.
The facility failed to maintain professional standards in urinary catheter care for four residents. One resident's drainage bag was not emptied as ordered, another's bag was found on the floor, a third's bag was not emptied and had the wrong catheter size, and a fourth's bag was directly touching the floor. These actions were contrary to the facility's policy, which required regular emptying and keeping the bag off the floor.
The facility failed to follow professional standards for medication storage and handling, with medications not dated upon opening, leading to expired drugs being used. Medications were prepared in advance and stored improperly, and medication carts were left unlocked and unattended, allowing unauthorized access. The DON confirmed that medications should be dated and discarded according to guidelines, and carts should remain locked when unattended.
The facility failed to comply with food safety standards by not labeling and dating food in unit kitchenette refrigerators and improperly handling dented cans. Observations included undated water bottles, food containers, and juice pitchers, as well as dented cans on the can rack. Staff interviews confirmed these practices were against facility policy.
Two residents in the facility were observed without privacy bags for their urinary catheter drainage bags, despite expressing interest in having them. Both residents were cognitively intact and had no documented refusal of care. Staff interviews confirmed that privacy bags should always be used to prevent urine visibility.
A facility failed to assess a resident's ability to self-administer medication, as required by policy. The resident, with diabetes and hyperlipidemia, self-administered a Trulicity injection without documented assessment or consent. Despite being cognitively intact, the facility did not evaluate the resident's mental and physical abilities or obtain consent, as confirmed by the ADON.
A facility failed to implement a comprehensive care plan for a resident, neglecting weekly weight monitoring and not addressing the resident's history of suicide attempts. The resident, with conditions including CHF and depression, experienced a significant weight gain due to missed weekly weigh-ins. Staff interviews revealed an expectation for weekly weights, which were not documented, and a lack of awareness of the resident's suicide attempt history, indicating a failure in care planning.
The facility failed to follow physician orders for a resident's wound care and delayed arranging a necessary urology follow-up for another resident. A resident with skin grafts did not receive the prescribed triple-antibiotic cream during a dressing change, and another resident's urology appointment was not scheduled until five months after hospital discharge.
A resident with cognitive impairment and multiple diagnoses was observed with an undated, saturated dressing on a skin tear, which lacked physician treatment orders. Despite a progress note indicating the wound was resolved, the wound remained open with drainage. Interviews confirmed that treatment orders should have been maintained.
A resident with anoxic brain damage and a stage two pressure ulcer on the left hip did not have a documented physician's order for wound care. Despite the wound physician's recommendations, the treatment was not recorded in the resident's Treatment Administration Record. Nurse #5 provided care based on the wound physician's advice without a confirmed order, and the Director of Nursing acknowledged the lapse in obtaining and documenting the necessary physician's order.
A resident with severe cognitive impairment and a history of falls was not provided with adequate fall prevention measures. Despite a care plan intervention to keep the resident's walker within reach, observations revealed the walker was consistently out of reach. Staff interviews confirmed awareness of the resident's fall risk and the expectation to implement care plan interventions.
A resident with malnutrition and chronic kidney disease experienced significant weight loss after refusing tube feeding. The dietitian recommended increasing a nutritional supplement, Nepro, to three times a day, which was approved by the physician. However, the order was not entered, and the resident did not receive the increased supplement frequency, as confirmed by the dietitian and DON.
A resident with heart failure and hypertension did not receive proper care for a peripheral IV catheter. The facility failed to flush the catheter and monitor the IV site for complications, as required by their policy. The necessary physician's orders for these actions were not documented, leading to a deficiency in care.
A resident with COPD and dependent on oxygen was found with a dirty oxygen concentrator filter, contrary to the facility's policy and physician's orders. The resident was cognitively intact and being weaned off oxygen. The facility's policy required weekly cleaning of the filter, which was not adhered to, as confirmed by staff interviews.
The facility failed to ensure proper dialysis care for residents, including obtaining physician orders and documenting post-dialysis weights. A resident lacked active orders for dialysis treatment, while two others had inconsistent weight documentation. Interviews revealed staff were unaware of these deficiencies, and discrepancies were found in weight records.
A resident received incorrect medications due to errors by a nurse, resulting in a medication error rate of 6.25%. The nurse administered the wrong form of aspirin and an incorrect dose of calcium plus vitamin D3, contrary to the physician's orders. The facility's policy requires correct medication administration by verifying the physician's order and medication label.
A facility failed to implement its infection prevention and control program during wound care. Observations showed that a nurse and a CNA did not perform hand hygiene after removing gloves while treating a resident with leg wounds. Despite handling soiled dressings and using an electronic tablet, they repeatedly changed gloves without washing or sanitizing their hands. Interviews confirmed the oversight, with staff acknowledging the lapse and the DON affirming the need for hand hygiene between glove changes.
The facility failed to transmit MDS discharge assessments to CMS within the required timeframe for two residents. Despite completion, the assessments were not transmitted, as confirmed by the DON and an MDS Nurse, leading to non-compliance with CMS guidelines.
A resident was inaccurately coded as comatose in the MDS, leading to a failure in assessing key areas such as hearing and cognitive patterns. Observations and staff interviews revealed the resident was communicative and interactive, contradicting the MDS coding. The DON confirmed the resident's improved condition and the need for accurate MDS representation.
Failure to Provide Timely Incontinence Care and Feed Resident While Soiled
Penalty
Summary
The facility failed to keep one resident free from neglect when staff did not provide timely incontinence care and assisted the resident with breakfast while the resident remained in soiled incontinence pads. The resident was admitted with diagnoses including a sacrum pressure ulcer, congestive heart failure, stroke, and chronic kidney disease, and the most recent MDS indicated severe cognitive impairment with incontinence of both bowel and bladder and dependence on staff for incontinence care. The resident’s care plans directed staff to check approximately every 2 hours and provide incontinence care as needed. On the morning of the survey, a strong odor of urine and feces was observed in the corridor and in the resident’s room. The resident was found lying on 3 incontinence pads, and when a CNA entered to bring breakfast, the CNA did not remove the soiled pads or provide incontinence care before feeding the resident. Later that morning, another CNA provided incontinence care and the removed pads were observed to be significantly soiled with urine and feces. Review of documentation showed the last recorded incontinence care had been provided at 11:15 P.M. the prior night, about 10 hours earlier, with no documented care during the overnight and early morning hours before breakfast. The resident’s nursing progress note and wound visit note documented a new skin impairment to the left buttock measuring 2.6 x 2 cm, described as end-stage skin failure. Staff interviews confirmed that the resident was incontinent of bowel and bladder, should be checked every 2 hours, and should not be left in saturated incontinence pads. The nurse, unit manager, DON, and nurse practitioner all stated that failing to provide incontinence care and feeding the resident while soiled was neglect.
Failure to Provide Needed ADL Assistance With Incontinence Care and Meals
Penalty
Summary
The facility failed to provide assistance with activities of daily living for three residents. One resident with severe cognitive impairment, bowel and bladder incontinence, and dependence on staff for incontinence care was observed lying on three incontinent pads that were strongly soiled with urine and feces. The odor was present in the corridor and in the room, and the resident was still in the soiled pads when breakfast was brought in. The last documented incontinence care had been provided 10 hours earlier, and the resident’s care plan called for checks approximately every 2 hours and incontinence care as needed. A second resident with severe cognitive impairment and a diagnosis of Alzheimer’s disease was observed during multiple meals eating non-finger foods with his/her hands without cueing or assistance from staff. At breakfast, lunch, and subsequent breakfasts, the resident was seen eating scrambled eggs, waffles with syrup, potatoes, peas, toast, and other foods by hand while staff were present in the dining room but did not intervene. The resident’s care plan indicated supervision with eating and drinking, and the physician order allowed finger foods as a dietary supplement, but the observations showed the resident was not provided the cueing or assistance documented as needed. A third resident with severe cognitive impairment and malnutrition was observed eating meals without the hands-on assistance and total assistance listed in the care plan and kardex. The resident was seen using his/her hands to eat waffles, eggs, chicken salad, peas, and oatmeal, dropping food and spilling items onto his/her lap while staff remained in the dining room or walked away after placing the meal in front of the resident. On one occasion, a staff member later acknowledged the resident needed help, and on another occasion staff eventually began assisting after the meal had already been left unattended. The resident’s plan of care and kardex both stated that eating required hands-on assistance and total assistance.
Failure to Provide Ordered Wound Care and Weekly Skin Monitoring
Penalty
Summary
The facility failed to provide necessary pressure ulcer care and to prevent new skin breakdown for multiple residents with existing wounds. Resident #45 was admitted with a sacrum/coccyx pressure ulcer, severe cognitive impairment, and incontinence of bowel and bladder with dependence on staff for incontinence care. The skin assessment and admission/readmission screener did not fully describe or measure the coccyx wound. After the wound physician evaluated the resident and documented a stage 3 coccyx pressure area measuring 1.6 x 0.9 x 0.3 cm on 8/26/25, the physician’s recommended treatment was not implemented in the medical record until 9/3/25. The September TAR also showed missed wound treatments on 9/8/25 and 9/10/25. Resident #45 was also observed on 9/9/25 lying on three soiled incontinence pads with a strong odor of urine and feces in the room. The surveyor observed the resident’s breakfast being served before incontinence care was provided, and the removed pads were significantly soiled. The last documented incontinence care had been at 11:15 P.M. the prior night, leaving a long gap without documented care. Later that same day, a new skin impairment to the left buttock was documented by the wound physician and nursing progress note as a new skin failure wound. Resident #17 had severe cognitive impairment and a left heel pressure-related deep tissue injury. Hospice wound recommendations included betadine, ABD pad coverage, and later alginate when the wound opened, but the record did not show those recommendations were addressed or implemented. On survey, the left heel was observed open with red granulation tissue and no dressing in place, and the nurse stated there was no physician order for a dressing. The wound was also not measured weekly as required, with the last documented measurement occurring weeks earlier. Resident #2 had bilateral buttock pressure ulcers and was seen by an outside wound clinic, which recommended saline irrigation, Dakins-moistened packing, and dressing changes twice daily. The facility’s orders and TAR did not reflect those wound clinic instructions, and the record showed the recommendations were not acknowledged or transcribed appropriately. In addition, weekly wound measurements ordered for the right and left buttocks were not documented for several weeks, despite the wounds being followed in the record and by staff notes. Resident #23 was admitted with diabetes, spinal cord abscess, and a left heel pressure ulcer, and the report states the facility failed to assess, document, measure, and stage pressure ulcers upon admission and weekly as ordered, and failed to ensure weekly skin assessments were completed and documented.
Failure to Document Dialysis Residents’ Fluid Restriction Intake
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for three residents who required renal dialysis and had physician-ordered fluid restrictions. The deficiency involved failure to ensure the ordered fluid restriction amounts in milliliters were tallied and documented every shift, as required by the facility policy on encouraging and restricting fluids, which stated that the amount of fluids consumed during the shift should be documented in the medical record. Resident #2 was admitted with end stage renal disease and dependence on renal dialysis, and the most recent MDS indicated intact cognition and dependence on dialysis. The resident had a physician order for an 1800 mL fluid restriction broken down into nursing and dietary amounts, and the care plan directed staff to maintain the fluid restriction as ordered. Review of the TAR from 7/29/25 to 9/10/25 failed to show the total amount of fluids consumed per shift documented in milliliters. Resident #34 was admitted with end stage renal disease dependent on renal dialysis, and the MDS indicated intact cognition and dependence on dialysis. During observation, the resident was eating lunch with milk, cranberry juice, and coffee on the tray, and the resident stated he/she was not aware of being on fluid restriction. The physician order called for an 1800 mL fluid restriction, and the MAR from 5/16/25 to 9/10/25 failed to indicate the total amount of fluids consumed per shift. Resident #93 was admitted with end stage renal disease, dependence on renal dialysis, and acute on chronic diastolic congestive heart failure, and the MDS indicated severe impaired cognition and dependence on dialysis. During observation, the resident was eating breakfast with milk, juice, and coffee on the tray. The physician order called for a 2000 mL fluid restriction, and the MAR from 8/22/25 to 9/10/25 failed to indicate the total amount of fluids consumed per shift.
Food Served at Improper Temperatures and Pureed Diet Menu Not Followed
Penalty
Summary
The facility failed to provide palatable food on 2 of 3 units and failed to serve residents on a pureed diet what was listed on the menu. The facility policy titled Food Temperature & Batch Cooking stated that food should be served at proper temperature to ensure food safety and palatability, with acceptable serving temperatures for hot items including potatoes, vegetables, and pureed foods at 140 degrees Fahrenheit or higher, preferably 160 to 175 degrees. On the Concord Unit, pureed meals observed on 9/9/25 and 9/10/25 consisted of 3 mounds of unrecognizable food, did not include gravy on the meat, and looked unappetizing. During a resident council meeting, several residents complained that hot food served at the facility was cold at times. A test tray on the Concord Unit showed potatoes with gravy at 112 degrees Fahrenheit, pureed meat with gravy at 102 degrees Fahrenheit, and green vegetable at 98 degrees Fahrenheit; all were described as warm or lukewarm, not hot, and the meat was not flavorful and could not be identified. A test tray on the [NAME] Unit showed eggplant parmesan at 130 degrees Fahrenheit, spaghetti at 140 degrees Fahrenheit, and salad at 70 degrees Fahrenheit, with the salad not crispy and not served with dressing. The menu listed pork with potatoes and green peas for lunch on 9/9/25, but the Food Service Director stated that the pureed diet residents received the same lunch left over from the prior day because eggplant did not look good pureed, and he did not consult the Registered Dietitian about the menu change. The Administrator stated the facility does not do test trays to ensure palatability and expected meals to be served at the appropriate temperature and to match the menu.
Dignified Dining and Personal Care Failures
Penalty
Summary
The facility failed to provide a dignified dining experience for three residents with significant cognitive impairment and dependence on staff for meal assistance or incontinence care. The report cites the facility’s dignity policy, which states residents are to be treated with dignity and respect at all times and are to be provided a dignified dining experience. The deficiency was based on observations and interviews showing that staff did not consistently provide appropriate dining assistance or preserve dignity during meals. For one resident with Alzheimer’s disease and severely impaired cognition, staff repeatedly placed meals in front of the resident and walked away while the resident ate scrambled eggs, waffles with syrup, potatoes, peas, and other foods with his/her hands instead of receiving cueing or assistance with utensils. This occurred during multiple observed meals, including breakfast and lunch, and the resident was seen rubbing fingers through syrup and licking them after eating. Although staff were present in the dining room, no one intervened to assist or cue the resident to use a utensil. Interviews with CNA and nursing leadership confirmed the resident needed supervision and cueing with meals and that eating non-finger foods with hands was not a dignified dining experience. For a second resident with Alzheimer’s disease and severe cognitive impairment, staff were observed feeding the resident while standing behind the chair rather than seated at eye level. During one meal, a CNA leaned over the resident’s shoulder to feed him/her and later sat in a chair behind the resident while still leaning over to feed and pet the resident’s hair. During another meal, the resident slept at the table while staff present did not sit down to offer feeding assistance, and later a CNA stood behind the resident, placed a spoon in the resident’s hand, and walked away. Interviews confirmed the expectation that staff should be seated at eye level when feeding residents, and leadership stated standing while feeding was not acceptable. For a third resident who was incontinent of bowel and bladder and dependent on staff for incontinence care, the surveyor observed a strong odor of urine and feces in and outside the resident’s room. The resident was lying on three significantly soiled incontinence pads when breakfast was brought in, and the CNA began feeding the resident without first removing the soiled pads or providing incontinence care. The pads were later removed and found to be heavily soiled with urine and feces. The DON stated that eating a meal while soiled with urine and feces is not dignified and that care should have been provided before staff assisted with breakfast.
Failure to Notify Provider of Significant Skin and Wound Changes
Penalty
Summary
The facility failed to notify the physician or nurse practitioner of a significant change in skin condition for two residents. For one resident, who was admitted with diagnoses including a sacrum pressure ulcer, CHF, stroke, and CKD and had severe cognitive impairment, bowel and bladder incontinence, and dependence on staff for incontinent care, the record showed multiple admission skin impairments including a stage 3 coccyx wound and several DTIs. On 9/9/25, a new skin impairment was identified on the left buttock during wound rounds, measured 2.6 x 2 cm and described as end-stage skin failure, but the record did not show that the nurse practitioner or physician was notified of this new wound. Interviews confirmed that staff understood new skin impairments were a change in status that required provider notification. A nurse said she was not aware whether the provider had been notified. The unit manager stated she did not notify the physician of the resident’s new buttock skin impairment. The DON said a new skin impairment would be considered a change of status and expected nursing staff to notify the physician or nurse practitioner, but she was unaware whether that occurred. The nurse practitioner stated she was never notified of the new buttock skin impairment and later said the physician also reported not being notified. For the second resident, who had failure to thrive, diabetes, severe cognitive impairment, and a left heel pressure injury initially described as a DTI, the wound condition changed from intact dry eschar to an open wound with drainage. Hospice notes documented that if the heel opened, alginate and a dressing were to be used, and later noted the heel was open with small serosanguineous drainage and that the son and facility agreed with the plan of care. However, the medical record did not show that the recommendation to use alginate was addressed or implemented, and the active physician order remained limited to painting the heel with betadine swab. Nursing documentation showed drainage was present on multiple days, yet no additional wound dressing orders were in place. During observation, the surveyor saw an open red heel wound with granulation tissue and no dressing, and the nurse stated there was no physician order for a dressing. Staff interviews indicated the facility did not notify the provider of the wound opening, drainage, or the hospice wound treatment recommendation for calcium alginate.
Failure to Document and Report Resident’s Nasal Skin Area
Penalty
Summary
The facility failed to provide care in accordance with professional standards for one resident with Alzheimer’s disease and severely impaired cognition. The resident had a weekly skin check order, but the most recent skin assessment did not identify any skin impairment on the nose, and the care plan did not include the nasal area as a skin issue. The resident was observed with a red, raised area on the nose with a dried dark red substance, and the area remained visible days later. The resident stated the area had previously been cancer and believed it was coming back, and later said it was sore and had not been looked at or treated. Record review and staff interviews showed the area on the nose had not been documented on the weekly skin assessment, and there was no physician or NP treatment order for it. The TAR also did not contain a treatment order for the nasal area, and clinical progress notes did not show that the physician was notified of the skin change. A CNA reported the resident had a cut on the nose that was being scratched and had been present for about a week, and a nurse stated she noticed the area but did not notify the MD or NP. The DON acknowledged the area was visible, had been present for some time, and should have been documented and reported; the resident’s daughter later stated the facility had never mentioned the area and reported a history of skin cancer involving the nose.
Failure to Follow Weekly Weight Order for Resident With Significant Weight Gain
Penalty
Summary
The facility failed to ensure that Resident #109 maintained an acceptable nutritional status by not implementing weekly weights as ordered by the physician for a resident at risk for further weight gain. Resident #109 was admitted in December 2023 with hyperlipidemia and morbid obesity due to excess calories, and the MDS indicated severe cognitive impairment with a BIMS score of 2 out of 15. The nutrition care plan identified a nutritional problem related to dietary restriction and risk for further weight gain, and the active physician order directed weekly weights beginning 6/18/25. The weight record showed weights documented on 5/7/25, 5/15/25, 6/4/25, 6/25/25, 7/2/25, 8/1/25, and 9/2/25, but the resident was weighed monthly rather than weekly. The resident experienced a clinically significant weight gain of 8.4% of total body weight over three months, from 167.9 lbs. to 182.0 lbs., and there was no documentation that a reweight was obtained until a month later to confirm the significant gain. The record also did not show that the resident refused weights. Interviews with CNA #4, Nurse #5, the RD, the NP, Physician #2, and the DON confirmed that weekly weights were expected, that the resident had been weighed monthly instead, and that the physician order for weekly weights had not been followed.
Unlicensed admissions director provided incontinence care
Penalty
Summary
The facility failed to ensure incontinence care was provided to one resident by licensed staff. Resident #45 was admitted with diagnoses including a sacrum pressure ulcer, congestive heart failure, stroke, and chronic kidney disease. The most recent MDS indicated the resident had a BIMS score of 5, showing severe cognitive impairment, and that the resident was incontinent of both bowel and bladder and dependent on staff for incontinence care. During observation, the surveyor saw two staff members providing incontinence care to Resident #45, including one person dressed in business casual attire. That staff member identified herself as the admissions director and also said she was a CNA. The Administrator stated she was not licensed as a CNA and should not have been providing direct care. The admissions director later said her CNA license expired in 2022, she had not renewed it, and she had not received facility education on providing incontinence care.
Incomplete ADL Documentation for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to complete daily documentation for one resident out of a sample of 25. The resident was admitted in August 2025 with diagnoses of sacrum pressure ulcer, congestive heart failure, stroke, and chronic kidney disease. The most recent MDS, dated [DATE], showed a BIMS score of 5 out of 15, indicating severe cognitive impairment, and also indicated the resident was incontinent of both bowel and bladder and dependent on staff for incontinence care. Review of the September 2025 ADL documentation showed multiple missing entries for this resident, including 11 of 31 eating opportunities, 6 of 31 bladder care opportunities, 6 of 31 bowel care opportunities, 6 of 31 personal hygiene opportunities, 6 of 31 dressing opportunities, 6 of 31 bed mobility opportunities, 6 of 31 transfers opportunities, 6 of 31 lying to sitting opportunities, 6 of 31 toilet transfer opportunities, 6 of 31 wheelchair opportunities, 6 of 31 walking opportunities, and 5 of 11 shower/bath opportunities. During interviews, the Staff Educator stated staff are expected to document completely upon providing care or task completion, and the DON stated documentation is done on point of care and should be completed as soon as possible, with no holes in the documents because that would lead to an inaccurate medical record.
Failure to Wear Gloves When Handling Soiled Linen
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices when a CNA handled soiled linen with bare hands. During observation on 9/9/25 at 9:36 A.M., the surveyor saw CNA #1 open soiled linen without gloves; the linen included wet used towels, an adult brief with feces, and a heavily soiled bed soaker. The facility policy titled "Personal Protective Equipment-Gloves" dated July 2009 stated that gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin, and that all employees must wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin. During interviews, CNA #1 said she always wears gloves and was not sure why she touched the soiled linen without gloves, CNA #3 said all staff should wear gloves while providing care and handling soiled linen, the Unit Manager said staff should wear gloves while handling dirty linen as part of universal precautions, the DON said the expectation is that staff would wear gloves while handling dirty linen, and the Staff Educator/Infection Prevention Nurse said staff are expected to wear gloves when handling soiled linen and that this expectation is communicated upon hire and with annual competency.
Failure to Follow Care Plan for Resident Transfers
Penalty
Summary
The facility failed to ensure that staff consistently implemented and followed the interventions outlined in the care plan for a resident who required assistance from two staff members for transfers. On a specific evening shift, a Certified Nurse Aide (CNA) transferred the resident back to bed by physically lifting them from their wheelchair without the assistance of another staff member, contrary to the care plan's requirements. This action was inconsistent with the facility's policy for a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's needs. The resident involved was admitted to the facility in October 2020 with diagnoses including Alzheimer's, Failure to Thrive, Atrial Fibrillation, and Aphasia. The resident was severely cognitively impaired and dependent on staff for various activities of daily living, including transfers. The incident led to the resident sustaining a bump above the left eye, bruising, and shoulder redness of unknown origin. The facility's investigation revealed that the CNA did not review the resident's care card and performed the transfer alone, which was against the care plan's directive for two-person assistance.
Deficiencies in Urinary Catheter Care
Penalty
Summary
The facility failed to maintain professional standards in the management and care of urinary catheter devices for four residents. For one resident, the facility did not empty the urinary drainage bag as ordered, resulting in the bag containing 1200 milliliters of urine. The resident, who was cognitively intact, reported that staff did not empty the drainage bag frequently. The facility's policy required the drainage bag to be emptied every eight hours or more often if needed, but this was not adhered to. Another resident, who was moderately cognitively impaired, was observed with a urinary drainage bag lying on the floor and containing 600 milliliters of bloody urine. The facility's policy required the drainage bag to be kept off the floor to prevent contamination and damage. Despite this, the resident's drainage bag was not maintained according to the policy, and the resident was being followed by urology for ongoing hematuria. A third resident, who was cognitively intact, had a urinary drainage bag that was not emptied as ordered, with the bag containing up to 1200 milliliters of urine at times. The resident reported that staff did not empty the catheter, and sometimes a family member would do it. Additionally, the catheter size did not match the physician's orders. Lastly, another resident's urinary catheter drainage bag was observed directly touching the floor without a barrier, contrary to the facility's policy. This resident was physically unable to manage the drainage bag due to dexterity issues, and staff failed to ensure the bag was kept off the floor.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to adhere to accepted professional standards for medication storage and handling, as observed during a survey. Medications were not dated upon opening, leading to expired drugs being used beyond their recommended disposal dates. Specifically, a fluticasone propionate and salmeterol inhaler was used 55 days after opening, exceeding the 30-day guideline. Similarly, a vial of Lantus insulin and atropine drops were undated, despite needing disposal 28 days post-opening. Additionally, medications were prepared in advance and stored improperly, with crushed medications labeled with resident names but not sealed, and an unknown pill stored in an incorrect container. The facility also failed to secure medication carts properly. On multiple occasions, medication carts were left unlocked and unattended in the hallway, allowing unauthorized access. This was observed on the Andover Unit, where nurses admitted to leaving carts unlocked when out of sight. Furthermore, unauthorized personnel accessed medication carts, as seen when the Assistant Director of Nursing (ADON) used a cart without completing the necessary narcotic count or signing out the cart, which is against facility policy. These deficiencies highlight lapses in medication management and security protocols within the facility. The Director of Nursing (DON) confirmed that medications should be dated and discarded according to guidelines, and carts should remain locked when unattended. The DON also stated that only authorized nurses who have completed the narcotic count should access medication carts, emphasizing the importance of adhering to established procedures to ensure resident safety and compliance with professional standards.
Food Safety and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed by surveyors. Specifically, the facility did not ensure that food items in the unit kitchenette refrigerators were properly labeled and dated. Observations included undated and unlabeled water bottles filled with a green liquid, a white plastic bag containing undated food containers, and several undated plastic pitchers of various juices. Additionally, two undated containers of resident food were found in another unit's kitchenette refrigerator. These findings indicate a lack of compliance with the facility's policy, which requires all food to be dated and discarded after three days. Furthermore, the facility did not properly handle dented cans, which pose a risk for botulism. A significantly dented can of pumpkin and a dented can of mandarin oranges were found on the can rack in the kitchen, contrary to the facility's policy that dented cans should be set aside in a separate labeled area to avoid use. Interviews with the cook and the Food Service Director confirmed that dented cans should not be placed on the can rack and should be returned to the vendor. These deficiencies highlight lapses in food safety practices and adherence to established policies within the facility.
Failure to Provide Privacy Bags for Urinary Catheter Drainage
Penalty
Summary
The facility failed to maintain a dignified existence for two residents by not providing privacy bags for their urinary catheter drainage bags. Resident #471, who was admitted with diagnoses including benign prostatic hyperplasia, brain cancer, and hemiplegia, was observed multiple times without a privacy bag on their urinary catheter drainage bag. The resident expressed interest in having a privacy cover, but it was not provided. The facility's policy and the resident's care plan did not indicate any refusal of care or privacy bag, and staff interviews confirmed that privacy bags should always be used. Similarly, Resident #117, admitted with Parkinson's disease and benign prostatic hyperplasia, was also observed without a privacy bag on their urinary catheter drainage bag. The resident, who was cognitively intact, stated that staff did not offer a privacy cover, although they would be interested in having one. The resident's care plan did not document any refusal of a privacy bag, and staff interviews reiterated the expectation that urinary catheter drainage bags should have privacy covers to prevent urine from being visible to others.
Failure to Assess Appropriateness of Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that the interdisciplinary team was involved in determining whether the self-administration of medications was clinically appropriate for a resident. Specifically, the facility did not assess if it was clinically appropriate for a resident to self-administer an injection prior to the resident doing so. The facility's policy requires that criteria be met to determine if a resident is both mentally and physically capable of self-administering medication, and that staff and practitioners assess each resident's abilities. However, there was no record of such an assessment for the resident in question. The resident, who was admitted with diagnoses including diabetes and hyperlipidemia, was observed self-administering a Trulicity injection without any documented assessment of their mental and physical abilities or a completed consent for self-administration. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. Despite this, the facility's records did not reflect any evaluation or consent process, and the Assistant Director of Nursing confirmed that these steps should have been completed but were not.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically neglecting to implement weekly weight monitoring as care planned and to develop a care plan for the resident's history of suicide attempts. The resident, who was admitted with diagnoses including heart failure, renal insufficiency, anxiety disorder, depression, and PTSD, had a care plan that required weekly weight checks due to risks associated with CHF and hypertension. However, the facility did not obtain weekly weights for several weeks, resulting in a significant weight gain of 39.4 lbs, which was 26.2% of the resident's total body weight in one month. Interviews with facility staff, including a nurse, registered dietitian, nurse practitioner, and the director of nursing, revealed that the expectation was for residents at risk for fluid retention to be weighed weekly. The failure to adhere to this care plan was acknowledged by the staff, who indicated that weights should be recorded in the electronic health record according to the care plan's frequency. The resident's medical record did not indicate any refusal to be weighed, and the oversight led to the resident being placed on diuretic therapy due to increased edema. Additionally, the facility did not develop a care plan addressing the resident's history of suicide attempts, despite the resident having a documented history of severe depression and two suicide attempts. Interviews with the nurse and social worker assigned to the resident revealed that they were unaware of the resident's history of suicide attempts and expected a care plan to be in place to address this issue. The director of nursing also confirmed that a care plan should have been developed for the resident's history of suicide attempts.
Failure to Implement Physician Orders and Arrange Follow-Up Care
Penalty
Summary
The facility failed to provide services that met professional standards of quality for two residents. For Resident #473, who was admitted with diagnoses including diabetes and soft tissue disorder, the facility did not implement the physician-ordered treatment for skin graft wounds. The physician's order specified cleansing the wounds with soap and water, applying triple-antibiotic cream, and covering with xeroform. However, during a dressing change, Nurse #2 used normal saline instead of soap and water and omitted the triple-antibiotic cream. This deviation from the prescribed treatment was acknowledged by both Nurse #2 and the Director of Nursing (DON). For Resident #14, who was admitted with neuromuscular dysfunction of the bladder and other conditions, the facility failed to arrange a follow-up urology appointment after a hospital discharge in March 2024. The discharge paperwork indicated the need for outpatient follow-up with urology for management of neurogenic bladder and chronic Foley catheter. The clinical record did not show any evidence of an arranged appointment until five months later, when the DON confirmed an appointment had been made. This delay in arranging necessary follow-up care was identified during the survey.
Failure to Maintain Treatment Orders for Skin Tear
Penalty
Summary
The facility failed to provide quality care according to physician orders and professional standards for a resident with a skin tear. The resident, who was moderately cognitively impaired and had diagnoses including muscle wasting and end-stage renal disease, was observed with a saturated, undated dressing on their left elbow. The resident reported acquiring the skin tear during transportation from an outside hospital. Upon further observation, the dressing was found to be undated and covering a xeroform gauze with bloody drainage, indicating the wound was still open. A review of the medical record revealed no treatment orders were in place for the skin tear, despite a nurse progress note indicating that the wound doctor had resolved the issue and discontinued dressing orders. The care plan, however, included interventions to apply treatment as ordered by a physician and to position the left arm on a pillow. Interviews with Nurse #3 and the Assistant Director of Nursing confirmed that treatment orders should have been maintained, as the wound was still open and required dressing treatments with physician orders.
Failure to Document Physician's Order for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide necessary treatment to promote the healing of a pressure ulcer for Resident #39. Resident #39, who was admitted with anoxic brain damage and was at risk for pressure ulcers, had a stage two pressure ulcer on the left hip. Despite the wound physician's evaluations and recommendations for treatment, there was no physician's order for the wound care documented in the resident's records. The Treatment Administration Record from 9/1/24 to 9/19/24 did not include any treatment for the pressure ulcer, indicating a lack of formal documentation and physician authorization for the care being provided. Observations and interviews revealed that Nurse #5 was performing wound care based on the wound physician's recommendations without a confirmed physician's order. The Director of Nursing acknowledged that recommendations from the wound physician should be confirmed with the attending physician and transcribed into the electronic health record as an official order. This oversight in obtaining and documenting a physician's order for the pressure ulcer treatment led to the deficiency identified by the surveyors.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident with severe cognitive impairment, who had a history of multiple falls. The resident, admitted with diagnoses of cancer and malnutrition, scored a 5 out of 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. Despite the resident's history of falls while attempting to self-transfer, the facility did not implement the care plan intervention of keeping the resident's walker within reach while in bed. This intervention was initiated on April 30, 2024, but was not observed to be in place during multiple observations by the surveyor on September 18 and 19, 2024. Interviews with facility staff, including a CNA, two nurses, and the Director of Nursing, confirmed that the resident was at risk for falls and had a history of falling while attempting to self-transfer. The staff members acknowledged that they would expect the care plan interventions for fall prevention to be implemented. However, during the surveyor's observations, the resident's walker was consistently found folded and out of reach, indicating a failure to adhere to the prescribed fall prevention measures.
Failure to Implement Dietitian's Nutritional Recommendations
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident diagnosed with protein calorie malnutrition, diabetes, and chronic kidney disease. The resident, who was cognitively intact, experienced significant weight loss and was receiving more than half of their calories through tube feeding. However, the resident began eating by mouth and refused tube feeding. The dietitian recommended increasing the frequency of a nutritional supplement, Nepro, to three times a day, which was approved by the physician. Despite this, the order was not entered, and the resident's medication administration record did not reflect the increased frequency. The dietitian acknowledged forgetting to input the physician's order for the increased supplement frequency. The Director of Nursing confirmed that the dietitian was responsible for entering the physician's order, which was not done. This oversight resulted in the resident not receiving the recommended nutritional support, as evidenced by the weight fluctuations recorded in the resident's weight summary report.
Failure to Maintain and Monitor Peripheral IV Catheter
Penalty
Summary
The facility failed to provide proper care and maintenance of a peripherally inserted IV catheter for a resident, identified as Resident #70, who was admitted with diagnoses including heart failure and hypertension. The deficiency was observed when the facility did not consistently flush the peripheral IV catheter and failed to monitor the IV site for complications. The facility's policy required specific physician's orders for flushing the catheter, which were not documented in Resident #70's medical records. The resident reported that the IV catheter had not been flushed since the IV fluids were discontinued. Nurse #4 confirmed that there should have been a physician's order to monitor the IV site for complications and to flush the catheter to maintain patency, but these orders were not in place. The Director of Nursing also stated that orders should have been in place to monitor the IV site and to flush the catheter at least twice daily when not infusing fluids. The lack of these orders and actions led to the deficiency in care for Resident #70.
Failure to Maintain Clean Oxygen Filter for Resident with COPD
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident diagnosed with chronic obstructive pulmonary disease (COPD) with hypoxia and hypercapnia, who was dependent on oxygen. The deficiency was identified when a surveyor observed the resident using a nasal oxygen cannula connected to an oxygen concentrator with a visibly dirty filter, covered with a thick layer of dust. This observation was made despite the facility's policy and the physician's order requiring the oxygen filter to be cleaned regularly. The resident, who was cognitively intact, was being weaned off oxygen, with the concentrator set at a flow rate of 1.5 liters per minute. The physician's order specified that the oxygen filter should be rinsed, patted dry, and replaced weekly, and the Director of Nursing confirmed that this was the expected practice. However, the failure to clean the oxygen filter as ordered was confirmed through interviews with the nursing staff, indicating a lapse in following the prescribed respiratory care protocol.
Failure to Ensure Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to ensure proper dialysis care and services for residents requiring such treatment. Specifically, the facility did not obtain physician orders for dialysis treatment and post-dialysis weights for one resident, and failed to obtain post-dialysis weights for two other residents. This deficiency was identified during a review of the facility's Dialysis Management policy and interviews with staff members. Resident #77, admitted with acute kidney failure and type 2 diabetes, did not have active physician orders for dialysis treatment or post-dialysis weights. The resident was weighed inconsistently, with only two recorded weights in August and three in September. Interviews with Nurse #3 and the Director of Nursing revealed a lack of awareness regarding the absence of physician orders and the failure to obtain weights for this resident. Resident #117, readmitted with dependence on renal dialysis and type 2 diabetes, also experienced issues with weight documentation. Despite having physician orders for pre and post-dialysis weights, the resident was weighed only four times in August and twice in September. The dialysis communication binder for this resident was found to be blank, indicating a possible misplacement of previous records. Similarly, Resident #372, admitted with end-stage renal disease, had discrepancies in recorded post-dialysis weights between the Medication Administration Record and the dialysis communication book, highlighting inaccuracies in weight documentation.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by an incident involving one resident out of four observed. During a medication pass observation, Nurse #1 made two errors out of 32 opportunities, resulting in a medication error rate of 6.25%. Specifically, Nurse #1 administered the incorrect form of aspirin and the incorrect dose of calcium plus vitamin D3 to Resident #89. The facility's policy on medication administration requires that the correct medication be administered by verifying the physician's order and the medication label. Resident #89, who was admitted to the facility with diagnoses including heart failure and hypertension, was observed receiving medications that did not match the physician's orders. The resident's orders specified an aspirin 81 mg chewable tablet and a calcium 600 mg/5 mcg vitamin D3 tablet. However, Nurse #1 administered an enteric-coated aspirin and a calcium 600 mg/10 mcg vitamin D3 tablet. During interviews, Nurse #1 admitted to being unaware that medications needed to be in the form ordered by the physician, and the Director of Nursing confirmed that the medication form and dose should match the physician's order.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control program, specifically in the area of hand hygiene during wound care. Observations revealed that Nurse #2 and CNA #4 did not perform hand hygiene after removing gloves while attending to a resident with multiple wounds on the left leg. The resident's wounds had a significant amount of bloody drainage, and during the care process, both staff members repeatedly changed gloves without washing or sanitizing their hands in between. This included instances where Nurse #2 removed soiled gloves to handle an electronic tablet and to open dressing packages, and CNA #4 removed gloves to assist with taking photographs, all without performing hand hygiene. Interviews with the staff involved confirmed the oversight, with both Nurse #2 and CNA #4 acknowledging the failure to perform hand hygiene as required by the facility's policy. Nurse #2 admitted forgetting to bring sanitizer into the room, which contributed to the lapse. The Director of Nursing also confirmed that hand hygiene should be performed every time gloves are removed and before new gloves are applied during wound care, highlighting a clear deviation from the established protocol.
Failure to Transmit MDS Discharge Assessments Timely
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) discharge assessments to the Centers for Medicare and Medicaid Services (CMS) System within the required timeframe for two residents. According to the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, MDS discharge assessments must be transmitted within 14 days after completion. However, for Resident #18, who was admitted with diagnoses including low back pain and repeated falls, the MDS discharge assessment was completed on 5/14/24 but was never transmitted. Similarly, for Resident #99, admitted with diagnoses including adult failure to thrive and repeated falls, the MDS discharge assessment was completed on 5/16/24 but was also never transmitted. Interviews with facility staff revealed that the Director of Nursing (DON) acknowledged that all MDS assessments should be transmitted timely by an MDS Nurse as per RAI guidelines. MDS Nurse #1 confirmed that the MDS discharge assessments for both residents were completed but not transmitted as required. This oversight resulted in a failure to comply with the mandated timeline for transmitting MDS data, as outlined in the CMS guidelines.
Inaccurate MDS Coding for Resident's Cognitive Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, leading to a deficiency in the assessment process. The resident, admitted in April 2023 with a diagnosis of traumatic subdural hemorrhage, was inaccurately coded as comatose or in a persistent vegetative state in the MDS assessment dated September 6, 2024. This coding error resulted in the resident's hearing, speech, vision, cognitive patterns, mood, activity preferences, and pain not being assessed. Observations and interviews conducted by the surveyor revealed that the resident was able to answer questions, follow commands, and engage with electronic devices, indicating a level of awareness and interaction inconsistent with the MDS coding. Interviews with facility staff, including a nurse practitioner, a nurse, a certified nursing aide, and the Director of Nursing, confirmed that the resident had shown improvement since admission and was able to communicate effectively. The MDS nurse acknowledged the discrepancy, noting that the MDS coding was based on the nursing clinical evaluation assessment, which should reflect the resident's current status. The Director of Nursing also confirmed that the resident was not in a vegetative state and that the MDS should accurately represent the resident's condition.
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 1,284 citations issued within 25 miles in the last 12 months — including the 4 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 Wilmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Care One At Wilmington | 0.6 mi | ★★★★★ | 0 | 0 |
| Oc Reading Center Llc | 2.1 mi | ★★★★★ | 19 | 0 |
| Bear Hill Healthcare And Rehabilitation Center | 3.4 mi | ★★★★★ | 7 | 0 |
| Woburn Rehabilitation And Nursing Center | 3.9 mi | ★★★★★ | 0 | 0 |
| Royal Meadow View Center | 3.9 mi | ★★★★★ | 4 | 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.