Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lotus Village Center For Nursing And Rehabilitatio during CMS and state inspections, most recent first.
A resident with dementia, cognitive impairment, and known elopement risk exited a locked memory care unit unsupervised after removing a screw from her room window, opening the window, and climbing out. Staff last saw her during routine rounds and a med pass, but she was later found walking along a nearby road by an Activity Assistant and returned without injury. Interviews confirmed prior elopement attempts, exit-seeking behavior, and that the resident had gone out seeking cigarettes and fresh air.
Failure to develop comprehensive care plans for multiple residents. A resident with dementia and nicotine dependence had documented smoking needs, exit-seeking behavior, and an elopement alarm order, but these were not included in the care plan. Another resident with dementia, COPD, and functional dependence had documented ADL assistance needs that were not care planned. A third resident with dementia had a wander alarm order and history of wandering/exit seeking, but the care plan did not address wandering or elopement risk.
Medication carts contained multiple opened medications that were not dated when opened, expired medications, and an unlabeled oral gel tube. Staff gave inconsistent accounts of who was responsible for cleaning the carts and removing expired medications, and the DON could not recall the last time she checked the carts.
Failure to obtain informed consent for psychotropic medications: Two residents with dementia, anxiety, and depression received antianxiety, antidepressant, and antipsychotic medications without documentation that they or their Responsible Parties were informed in advance of the risks and benefits or consented to treatment. The MARs showed the medications were administered as ordered, while interviews with the DON, Social Services, Psychiatric NP, and Administrator confirmed the facility was not obtaining or auditing informed consents for psychotropic medications.
Inconsistent code status documentation was found for a resident with severe cognitive impairment. The code status binder contained a DNR form, the care plan and EMR profile listed DNR, and the active physician order listed full code; staff stated the physician order and binder should match, and that the binder would be followed in an emergency.
Late Admission MDS Assessments and Incomplete CAA Documentation: Two residents had admission MDS assessments completed after the required timeframe, with the MDS Coordinator citing staffing absence and an incorrect ARD entry. Two other residents had triggered CAAs for psychotropic drug use and cognitive loss/dementia that lacked a comprehensive analysis of findings, including the underlying causes, contributing factors, and risk factors. The MDS Coordinator acknowledged the CAA documentation was incomplete, and the DON/Administrator stated assessments were expected to be completed within regulatory timeframes and contain a full analysis.
Late Quarterly MDS Assessment: A resident’s quarterly MDS was not completed within the required 14-day window after the ARD. The MDS Coordinator confirmed the delay was an oversight, and the Administrator stated quarterly assessments are expected to be completed and submitted within regulatory timeframes.
The facility inaccurately coded MDS assessments for three residents. One resident with anxiety, depression, and bipolar disorder was coded as not meeting Level II PASRR criteria despite an active PASRR determination letter in the EMR. Two residents were not coded for wander/elopement alarms despite active orders and documentation, and one of those residents was also not coded for current tobacco use despite a smoking screen showing active tobacco use and supervision needs.
Failure to update a resident’s care plan for pressure ulcers was identified. A resident admitted with a stage III coccyx pressure ulcer had a wound note documenting the ulcer and a quarterly MDS that coded unhealed pressure ulcers, pressure-reducing device use, and pressure ulcer care, but the care plan contained no pressure ulcer interventions. The MDS Coordinator said she missed updating the care plan, and the DON and Administrator confirmed the wound should have been care planned.
Failure to provide timely foot care and arrange podiatry services for a resident with severe cognitive impairment and ADL dependence. Staff observed thick, jagged, and overgrown toenails that had been present for some time, but the condition was not identified or reported earlier. The resident had no documented podiatry consult until a provider order was finally obtained after the toenail condition was brought to staff attention.
A resident with an indwelling catheter, MS, neurogenic bladder, and interstitial cystitis had mental status changes and a Psychiatry NP raised concern for a possible UTI. A physician order for a UA with reflex to culture was entered, but the urine sample was not collected during the ordered window because the order dropped off the MAR and was forgotten. Later urine testing showed a possible UTI, and the DON and Medical Director stated staff were expected to follow physician orders.
Failure to address severe pain during wound care: A cognitively intact resident with a Stage 3 pressure ulcer and frequent pain reported stinging pain and later rated the pain 8/10 during wound care. The LPN continued the treatment without responding to the resident’s complaints and gave PRN hydrocodone/acetaminophen only after the care was completed, despite an active PRN pain order and staff leadership stating pain should be assessed and addressed when reported.
Incomplete documentation of resident elopement and return assessment: A resident in the memory care unit was observed walking down the road and was brought back to the facility by an Activity Assistant, but the EMR did not include a nurse assessment or progress note for the event. Nurse #3 and the DON stated a head-to-toe assessment was completed with no injuries found, yet no documentation was entered in the record.
Failure to document influenza and pneumococcal vaccine offerings and education: A resident admitted with COPD and moderately impaired cognition had no record that the flu or pneumococcal vaccines were offered, accepted, refused, or medically contraindicated. The chart also lacked documentation that the resident or RP received education on the benefits and potential side effects, and the DON and QA nurse confirmed the immunization records were incomplete.
Failure to Offer and Document COVID-19 Vaccination: The facility did not assess eligibility or ensure the COVID-19 vaccine was offered and documented for three residents reviewed. One resident was cognitively intact and marked up to date, one was cognitively intact and not up to date with no prior vaccine history, and one was severely cognitively impaired and marked up to date; for all three, the record lacked documentation that the vaccine was offered or that education on benefits and potential side effects was provided. The DON and Regional QA Nurse stated the vaccine was expected on admission and annually, but the follow-through and final check were not completed.
A resident admitted for rehab after an exploratory laparotomy with new colostomy had a hospital discharge order for twice-daily wet-to-dry NS dressings to a 4 cm abdominal wound with seropurulent drainage, but this order was not transcribed onto the physician orders or TAR. The admitting nurse reviewed the discharge summary only for medications, and the DON skimmed the summary and later forgot to recheck for incision care orders, resulting in no wound treatment being set up. Subsequent nurses assessed the incision but did not provide wound care, and the PA later stated that staff should have read the entire discharge summary and contacted him if no incision orders were found.
A resident admitted after abdominal surgery with a new colostomy had no documented assessments of the colostomy or abdominal incision for the entire stay. Multiple RNs and the DON reported that they assessed the colostomy and incision and that new admissions should have shift-by-shift documentation focused on the reason for admission, but each either forgot to chart or could not confirm their assessments when shown the lack of entries. The Regional Nurse Consultant confirmed the absence of any such documentation, and a PA noted he relies on nursing assessments in the medical record for treatment planning, demonstrating that required clinical assessments were not recorded.
A resident with a neurogenic bladder and chronic indwelling urinary catheter did not have their catheter changed as ordered due to a failure to transcribe the physician's order onto the MAR/TAR. Staff interviews confirmed the omission, and the DON acknowledged that the order was not visible to nursing staff, resulting in the catheter not being changed as scheduled.
A resident with multiple chronic conditions experienced a worsening allergic reaction, including a spreading rash and low-grade fever, after starting an antibiotic. A one-time IM dose of methyl prednisolone was ordered but not administered as scheduled, and nursing staff failed to notify the physician of the delay. The medication was not given until five days later, despite the resident's ongoing symptoms and the nurse practitioner's expectation for timely administration or notification.
A resident with a worsening allergic reaction did not receive a prescribed one-time IM methylprednisolone injection for five days due to nursing staff failing to check the backup medication supply, despite the medication being available. The resident experienced severe itching and rash during this period, and the error was only discovered after the NP followed up on the unadministered order.
A resident's MDS assessment was inaccurately coded in the dental section because the remote MDS Coordinator did not request or ensure a dental assessment was completed during the required period. Nursing documentation confirmed that no dental assessment was performed, and facility leadership expected the dental status to be accurately documented.
A resident with multiple chronic conditions was scheduled for dental extractions, but the facility failed to withhold aspirin as ordered by the NP. The order to hold the antiplatelet medication was documented but not transcribed to the MAR, resulting in continued administration of aspirin and a delay in the dental procedure. Communication lapses among staff contributed to the failure to follow the physician's order, and the resident later required antibiotics and eventually received the extractions.
A resident with severe cognitive impairment was found with Sodium Polyacrylate and solidified fruit punch within reach, posing a potential ingestion hazard. The facility staff, including nurse aides and the DON, were unable to determine how the substance entered the facility. Despite monitoring the resident for gastrointestinal symptoms, no adverse effects were observed.
A cognitively impaired resident in a memory care unit managed to remove a windowpane and exit the facility unsupervised after being denied a smoke break. The resident walked to a nearby gas station before being found and returned by law enforcement. The incident revealed lapses in supervision and security, as the resident had no prior history of elopement and was not considered at risk.
A facility failed to notify the medical provider of an alleged sexual abuse incident involving two residents. Despite staff reporting the incident to the Administrator and DON, the medical provider and family were not informed immediately. The NP was only notified days later, delaying potential medical intervention. The Administrator assumed the notification would be handled the next day, resulting in a deficiency.
A resident with cognitive impairments hit another resident in the eye, believing the victim was viewing inappropriate content on a shared computer. The victim, who had aphasia, avoided the aggressor and the computer for over a week. Staff intervened, and the aggressor was placed under supervision. The facility's computer system was designed to prevent access to inappropriate content.
A facility failed to prevent illegal substances from entering, affecting resident safety. A resident, legally blind, mistakenly ingested methamphetamine left in her room by an unknown individual. Another resident tested positive for THC, linked to a shared vape pen. Drug canines detected scents, but no substances were found. A known drug dealer's visit raised security concerns.
A resident with a history of brain damage, dysphagia, hypertension, and gastrostomy experienced severe septic shock, UTI, and necrotic changes to the left testicle, necessitating its removal. The facility did not recognize the urgency of a Nurse Practitioner's order for a urology appointment following an ultrasound indicating decreased vascular flow. The appointment was scheduled for a later date, resulting in delayed care. Additionally, the facility failed to conduct thorough and ongoing nursing assessments and did not notify the NP or MD when the appointment was not scheduled as ordered, leading to an acute change in the resident's condition.
A facility failed to promptly address decreased vascular flow to a resident's left testicle, despite reports of scrotal swelling and tenderness. Initial assessments led to an ultrasound and antibiotics, but delays in scheduling a urology consultation prolonged necessary medical interventions. The resident's condition worsened, resulting in severe septic shock, a urinary tract infection, and necrotic changes, ultimately necessitating the removal of the testicle. Multiple staff members were aware of the issue, but consistent documentation and follow-up were lacking, and scheduling challenges further delayed care.
A facility experienced a communication breakdown when a urology consult could not be scheduled as ordered by the NP for a resident with a history of anoxic brain injury, persistent vegetative state, and neurogenic bladder. An ultrasound indicated decreased vascular flow to the resident's left testicle, prompting the NP to order an urgent urology consult. The Scheduler faced difficulties in securing the appointment and did not notify the NP or MD, leading to a delay. This delay resulted in the resident developing severe sepsis and requiring an emergency left orchiectomy.
The facility's QAA committee failed to maintain procedures and monitor interventions, leading to repeated deficiencies in Notification of Change, Neglect, and Quality of Care. A resident experienced severe sepsis and an emergency orchiectomy due to delayed medical consultations and inadequate nursing assessments.
Failure to Supervise Resident with Exit-Seeking Behavior
Penalty
Summary
The facility failed to supervise a resident with dementia and other behavioral disturbance who had known exit-seeking behavior and a prior history of elopement. The resident had been admitted to the locked memory care unit after a hospitalization in which the SNF reported repeated elopement attempts, including an incident where she climbed out of a window. Her care plan identified her as an elopement risk, but the comprehensive care plans reviewed did not address wandering or exit-seeking behaviors, and nursing progress notes for the months reviewed contained no entries related to exit-seeking or elopement. On the day of the incident, staff last observed the resident in her room during routine rounds and medication pass. Shortly afterward, she removed a screw from the bottom of the window frame in her room, opened the window, bent the screen outward, and climbed out wearing a sweatshirt, overalls, and tennis shoes with no jacket in 50-degree weather. The distance from the windowsill to the ground was 5 feet 11 inches. She then walked through the back parking lot and down a hill along a public two-lane residential road with no sidewalks, where she was later seen by an Activity Assistant approximately 1,056 feet from the facility. The resident was found outside the facility without staff knowledge or supervision and was returned without injury. Interviews with staff, the PA, and the Medical Director confirmed that the resident had cognitive impairment, was high functioning physically, and had a history of wanting to leave the facility. The resident stated she had gone out for a walk and wanted cigarettes, and staff confirmed she had climbed out through the window and left the unit unnoticed.
Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop individualized, person-centered care plans that addressed smoking, exit-seeking behaviors, use of an elopement alarm device, and ADL needs for 3 of 28 sampled residents. Resident #58 had diagnoses including personal history of nicotine dependence, dementia with behavioral disturbance, anxiety disorder, and depression, and a Safe Smoking Screen showed current tobacco use, no plan to stop smoking, and a need for supervision while smoking. The resident also had a history of confusion and multiple attempts to elope from a prior SNF, including climbing out of a window, and had an active physician order for an elopement alarm device due to poor safety awareness. Resident #58’s record showed the admission MDS did not code tobacco use or use of a wander/elopement alarm, and the quarterly MDS later coded daily use of a wander/elopement alarm but still did not code current tobacco use. Review of the comprehensive care plans last revised on 02/26/26 showed no care plan addressing smoking, exit-seeking behaviors, or the elopement alarm device. The resident was observed smoking outside with staff and another resident, and the MDS Coordinator stated these were areas she would normally care plan and that it was an oversight. Resident #69 had diagnoses including non-Alzheimer’s dementia, depression, COPD, muscle weakness, and a history of falling, and the quarterly MDS showed severe cognitive impairment, wandering 4 to 6 days, incontinence, and varying levels of assistance needed with toileting hygiene, bathing, dressing, and personal hygiene. His comprehensive care plans last revised on 03/23/26 did not address his ADL needs. Resident #3 had dementia and a physician order for a wander alarm on the left lower leg with monitoring every shift, but the care plan last updated on 3/18/26 did not include wandering or elopement risk. The MDS Coordinator stated she had overlooked the order and did not care plan the resident for wandering or elopement risk, and the Administrator stated the care plan should be accurate and reflect the resident’s needs.
Medication carts contained undated, expired, and unlabeled medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled and stored in accordance with accepted professional principles because multiple medication carts contained opened medications that were not dated when opened, expired medications, and an unlabeled medication. On the 100-hall medication cart, surveyors found an open and undated foil pouch of albuterol sulfate nebulization solution and an open and undated fluticasone-vilanterol inhalation foil tray. On the 200-hall medication cart, surveyors found an open and undated foil pouch of albuterol sulfate nebulizing solution. On the 300-hall medication cart, surveyors found an open and unlabeled tube of oral gel pain medication. On the 400-hall medication cart, surveyors found an open foil pouch of budesonide vials that was not dated when opened and an open and undated fluticasone-vilanterol inhalation foil tray. Facility staff interviews showed inconsistent responsibility for medication cart checks and dating of opened medications. Nurse #2 stated third shift nurses were responsible for cleaning medication carts and removing expired medications, and that the nurse who opened a package should date it so others would know when to discard it. Nurse #1 stated all nurses were responsible for keeping carts clean and orderly, including removing expired medications, and also said the nurse who opened the package should date it. The DON stated third shift nurses were responsible for checking and cleaning the carts, with first shift nurses and herself checking behind them, but she could not recall the last time she checked the medication carts. The DON also stated the nurse who opens the package should date it.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consent and inform residents or their Responsible Parties in advance of the risks and benefits of psychotropic medications before starting or increasing treatment for two residents reviewed. One resident with vascular dementia and anxiety was admitted on buspirone 15 mg twice daily, and the dose was later increased to 15 mg three times daily. The record showed the medication was administered at the increased dose, but there was no documentation that the resident or Responsible Party was informed in advance of the risks and benefits of the increase or consented to it. A second resident with dementia with behavioral disturbance, anxiety disorder, and depression had orders for bupropion 150 mg daily, buspirone 10 mg twice daily, and quetiapine fumarate 25 mg daily. The MAR showed these medications were administered as ordered, but the electronic record contained no documentation that the resident or Responsible Party was informed in advance of the risks and benefits of initiating these medications or consented to treatment. Interviews with the DON, Social Services staff, Psychiatric NP, and Administrator confirmed that the facility was not obtaining informed consent for psychotropic medications and that responsibilities for obtaining or auditing consents were not clearly understood.
Inconsistent code status documentation
Penalty
Summary
The facility failed to ensure Resident #63’s code status information was accurate and consistent across the medical record and the locations used by staff to identify advance directives. Review of the code status binder at the nurses’ station showed a physician-signed DNR form effective 03/27/25 with no expiration date, while the resident’s advance directive care plan revised 03/11/26 identified the resident as full code. The electronic medical record also contained an active physician order dated 03/11/26 for full code, and the profile page listed the resident as DNR. Resident #63 was admitted to the facility on [DATE] and the admission MDS assessed the resident with severe cognitive impairment. During interviews, Nurse #1 stated staff had been told they were responsible for verifying code status with the resident or representative and completing the appropriate advance directive forms, and that there were two places to check code status: the physician order in the electronic record and the code status binder at the nurses’ station. Nurse #1 confirmed the physician order showed full code while the binder contained a DNR form, and stated staff were instructed to follow the advance directive filed in the binder in an emergency. The DON stated the facility used the MOST form and that the physician order and code status binder should match, and the Administrator stated all residents should have a completed MOST form on file and that the physician order and MOST form in the binder should match.
Late Admission MDS Assessments and Incomplete CAA Documentation
Penalty
Summary
The facility failed to complete admission MDS assessments within 14 calendar days of admission for two residents. One resident was admitted to the facility and had an admission MDS that was marked completed after the regulatory timeframe. During interview, the MDS Coordinator verified the assessment was not completed on time and explained she was out of work and got behind on assessments. The Administrator stated admission MDS assessments should be completed within 14 days of admission and that it was her expectation for assessments to be completed and submitted within the regulatory timeframes. A second resident was admitted to the facility and had an admission MDS with an ARD of 03/20/26 that was marked completed on 03/26/26. The MDS Coordinator verified the assessment was not completed within the regulatory timeframe and stated she set the ARD wrong, which caused the MDS assessment to be completed late. The Administrator again stated admission MDS assessments should be completed within 14 days of the resident's admission and that she expected assessments to be completed and submitted within the regulatory timeframes. The facility also failed to complete CAA summaries comprehensively for two residents. For one resident with diagnoses including moderate dementia with other behavioral disturbance, anxiety disorder, and depression, the admission MDS triggered CAAs for Psychotropic Drug Use and Cognitive Loss/Dementia, but the CAA documentation did not describe the nature of the problem, possible causes, contributing factors, or risk factors; it only noted that psychotropic drug use and cognitive loss/dementia would be addressed in the care plan. For another resident with vascular dementia and anxiety, the admission MDS triggered a CAA for Psychotropic Drug Use, but the analysis of findings did not include the underlying cause or contributing factors and only stated the resident was at risk for adverse drug reaction and to proceed to the care plan. The MDS Coordinator acknowledged the CAAs were incomplete, and the Administrator stated it was her expectation that CAAs contain a comprehensive analysis of findings for triggered care areas.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date for Resident #2. Resident #2 was admitted to the facility on [DATE], and the electronic medical record showed a quarterly MDS with an ARD of 04/03/26 that was marked completed on 04/20/26. During interview, the MDS Coordinator verified the quarterly assessment was not completed within the regulatory time frame and stated the late completion was an oversight. The Administrator also confirmed that quarterly assessments should be completed within 14 days of the ARD and stated it was her expectation that MDS assessments be completed and submitted within the required timeframes.
Inaccurate MDS Coding for PASRR, Alarms, and Tobacco Use
Penalty
Summary
The facility failed to accurately code MDS assessments for three residents in the areas of PASRR status, alarms, and current tobacco use. For one resident with anxiety disorder, depression, and bipolar disorder, the admission MDS stated the resident was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, even though the EMR contained a Level II PASRR Determination Notification letter with no expiration date. The MDS Coordinator stated she had overlooked the letter when completing the assessment, and the Administrator stated she expected all MDS assessments to be completed accurately. For another resident admitted with a history of nicotine dependence and dementia with behavioral disturbance, a Safe Smoking Screen showed current tobacco use, no plans to stop smoking, and a need for supervision while smoking, and the TAR showed an order for an elopement alarm device to the right wrist due to poor safety awareness. However, the admission MDS did not code current tobacco use or use of a wander/elopement alarm. For a third resident with dementia, a physician order required a wander alarm on the left lower leg and monitoring every shift, and the MAR showed the alarm was being checked every shift as ordered, but the quarterly MDS did not code the wander/elopement alarm. In both cases, the MDS Coordinator stated she had overlooked the relevant orders or documentation when completing the assessments, and the Administrator stated MDS assessments should be accurate.
Failure to Update Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to revise Resident #70’s care plan to reflect the development of pressure ulcers. Resident #70 was admitted with diagnoses that included a stage III pressure ulcer to the coccyx, and a wound note dated 02/27/26 documented a stage III pressure wound to the coccyx. His quarterly MDS assessment dated 03/31/26 showed he was cognitively intact and coded him as having one or more unhealed pressure ulcers/injuries, including 2 stage II pressure ulcers with one present upon admission, as well as use of a pressure-reducing device for bed and receipt of pressure ulcer care. Review of the care plan last updated on 04/10/26 showed no care plan or interventions for pressure ulcers. During interview, the MDS Coordinator stated she was responsible for updating care plans quarterly or when significant changes occurred and acknowledged that she coded Resident #70’s quarterly MDS as having pressure ulcers/wounds but missed or forgot to update the care plan to reflect those wounds. The DON verified that pressure ulcer/wound care should have been care planned and that the resident’s care plan did not currently include a pressure ulcer/wound care plan. The Administrator also stated the resident’s pressure ulcer/wounds should have been noted on the care plan and that MDS assessments were intended to ensure the care plan was accurate and complete.
Failure to Provide Timely Foot Care and Podiatry Referral
Penalty
Summary
The facility failed to ensure appropriate foot care for a resident with severe cognitive impairment, non-Alzheimer's dementia, depression, COPD, muscle weakness, and a history of falling. The resident required substantial to maximum assistance with toileting hygiene, bathing, footwear, and some dressing and personal hygiene tasks, and his care plan did not address his ADL needs. Review of the medical record showed no podiatry consultation or documentation that he had been seen by a podiatrist from admission through the time the deficiency was identified. An observation showed the resident lying in bed with both feet exposed and his toenails in poor condition. The great toenails on both feet were thick and jagged, and the toenails on the second through fifth toes of both feet were long, extended past the toenail bed, and curved around the toes and toe pads. Staff interviews indicated that the resident’s toenails had been in this condition for some time, that NAs did not trim thick toenails, and that a podiatry referral was needed for a trim. A nurse reported she first learned of the toenail condition when it was brought to her attention and that a provider order for podiatry referral was then obtained. Additional interviews with the NA, DON, Social Services staff, and Administrator confirmed that staff had not identified and reported the toenail condition earlier. The DON stated the condition appeared longstanding and needed trimming, and the Administrator stated staff should have identified the condition on admission, during daily care, or during weekly skin audits. The record showed the podiatry referral order was entered only after the condition was recognized, and the Social Services staff member was still working to enroll the resident for the next facility podiatry clinic.
Missed Urine Testing Order for Resident With Indwelling Catheter
Penalty
Summary
The facility failed to implement an order for a urinalysis with reflex to culture for a resident with an indwelling catheter who had multiple sclerosis, neurogenic bladder, interstitial cystitis, anxiety disorder, and depression. The resident was cognitively intact and had care plan interventions to monitor and report signs and symptoms of a urinary tract infection, including pain, burning, blood-tinged urine, foul-smelling urine, cloudiness, no output, increased heart rate, increased temperature, altered mental status, change in behaviors, and change in eating habits. A Psychiatry NP documented concern that the resident's mental status changes could be related to a possible urinary tract infection and indicated the need to rule out infection. A physician order was entered for urine collection and urinalysis with culture and sensitivity due to confusion, but the urine sample was not collected during the ordered collection window. The DON stated the order dropped off the MAR after the collection time passed and was forgotten, and the nurse assigned to the resident was responsible for collecting the sample. Later lab results from a urine specimen collected on a subsequent date showed a possible urinary tract infection.
Failure to Address Severe Pain During Wound Care
Penalty
Summary
Provide safe, appropriate pain management for a resident who required such services was not met when Resident #2 reported acute, severe pain during wound care for a Stage 3 pressure ulcer. Resident #2 was admitted with diagnoses including obstructive uropathy, cerebrovascular accident, diabetes mellitus, depression, moisture-associated skin damage, and arthritis at multiple sites. The resident was cognitively intact, able to make needs known, had frequent pain that interfered with sleep, physical therapy, and day-to-day activities, and had an active PRN order for hydrocodone/acetaminophen 10/325 mg every 6 hours for breakthrough pain. During observed wound care, Nurse #2 cleansed the wound and the resident gasped and complained of stinging pain. The nurse continued the treatment without responding to the complaint, applied calcium alginate and silver sulfadiazine, covered the wound, and continued care after the resident again stated, "That hurts me." At the end of the treatment, the resident rated the pain as 8 out of 10 and requested PRN pain medication. The medication was then given about 40 minutes later. Nurse #2 stated she usually gave PRN pain medication after completing wound care, while the DON, PA, Medical Director, and Administrator stated that when a resident reports pain during care, the nurse should stop, assess the pain, and provide PRN pain medication if available before continuing.
Incomplete Documentation of Resident Elopement and Return Assessment
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident in the locked memory care unit by not documenting an elopement from the facility and not documenting a nurse assessment after the resident returned. Resident #58 was admitted to the memory care unit on 11/12/25. On 01/08/26, an Activity Assistant observed the resident walking down the road near a food pantry and thrift store, stopped to speak with her, and then drove her back to the facility. The resident complied with the request to go back inside and was assisted to the memory care unit by the Activity Assistant. A statement from Nurse #3 indicated the resident was later found in bed during a medication pass and that a skin assessment showed no open areas or injuries, but the resident’s electronic medical record did not contain a nurse assessment or progress note for the elopement event. Review of the January 2026 nursing progress notes showed no entry related to the elopement, and the only documented nurse assessment on that date was a later note tied to a fall in the shower. During interviews, Nurse #3 stated she completed a head-to-toe assessment when the resident returned and that she should have documented it, while the DON and Administrator both confirmed there was no nurse assessment or progress note in the record related to the elopement.
Failure to Document Influenza and Pneumococcal Vaccine Offerings and Education
Penalty
Summary
The facility failed to document that Resident #58, who was admitted with chronic obstructive pulmonary disease and had moderately impaired cognition on the quarterly MDS, was offered the influenza and pneumococcal immunizations, or that the resident or responsible party received education about the benefits and potential side effects of those vaccines. The resident’s MDS indicated the influenza vaccine was not received because it was not offered, and the pneumococcal vaccination was not up to date and also was not offered. Review of the electronic health record found no signed consent, no record of vaccine administration, and no refusal documentation for either the influenza or pneumococcal vaccines. The record also contained no documentation of education provided regarding the benefits or potential side effects of the vaccines. During interview, the Interim DON stated she could not find any information showing the vaccines were offered, declined, or discussed, and said someone should have followed up after admission. The Regional QA Nurse stated the expectation was that nurses obtain the information on admission, that the DON should have followed up with residents already in house, and that the final check to ensure the process was completed had not been done for a while.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to assess residents for eligibility and ensure the COVID-19 vaccine was offered to 3 of 5 residents reviewed for immunizations. Record review showed that Resident #2 was cognitively intact and documented as up to date on COVID-19 immunization, but the last vaccine recorded in the medical record was given before admission, and there was no documentation that the vaccine had been offered or that education on benefits and potential side effects had been provided. Resident #6 was cognitively intact, documented as not up to date on COVID-19 immunization, had no history of COVID-19 vaccination, and also had no documentation that the vaccine had been offered or that education had been provided. Resident #9 was severely cognitively impaired and documented as up to date on COVID-19 immunization, but the last vaccine recorded in the medical record was given before admission, with no documentation that the vaccine had been offered or that education on benefits and potential side effects had been provided. During interview, the interim DON stated the latest COVID-19 vaccination should be offered on admission and annually, with education on risks and benefits documented in the resident's medical record, and said the system failure was that no one continued to follow up to ensure vaccines were offered and given at admission and annually. The Regional QA Nurse stated the nurses were expected to obtain the information on admission, the DON should have followed up on residents already in house, and the final check had not been done for a while.
Failure to Transcribe and Provide Ordered Surgical Wound Care on Admission
Penalty
Summary
The deficiency involves the facility’s failure to transcribe and implement a physician’s order for surgical wound care upon admission, resulting in the absence of ordered treatment for a resident’s abdominal incision. The resident was admitted following an exploratory laparotomy with creation of a colostomy related to diverticulitis with perforation. The hospital discharge summary documented that on the day of discharge the physician opened a 4 cm portion of the wound below the umbilicus due to seropurulent drainage and ordered wet-to-dry dressing changes with normal saline twice daily. Review of the admission physician orders and the Treatment Administration Record for the admission and following day showed no orders for wet-to-dry dressings or any surgical wound care. The resident’s discharge MDS later documented discharge to home/community with return not anticipated. Nurse #1, who admitted the resident, stated she reviewed the hospital discharge summary only for medication orders and did not read the entire summary, resulting in failure to transcribe the wound care order to the TAR. She reported having a very busy day and acknowledged that between herself and the DON, the treatment order should have been entered. The DON confirmed she assisted with the admission, entered medication orders, assessed the incision, and skimmed the discharge summary, recognizing later that she had not seen incision care orders and then forgot to recheck the summary. Nurse #2 and Nurse #3, who cared for the resident on subsequent shifts, recalled the resident and his new colostomy but indicated they would need to review the record to identify any treatment orders; Nurse #3 confirmed she assessed the incision but did not provide treatment. The Physician Assistant stated nurses are expected to read the entire discharge summary for all discharge orders and that, in the absence of incision care orders, the facility should have contacted him for interim orders.
Failure to Document Assessments for New Colostomy and Abdominal Incision
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident admitted after an exploratory laparotomy with creation of a new colostomy. From admission to discharge, the resident’s chart contained no documented assessments of the abdominal incision or the new colostomy. Multiple nurses, the DON, and the Regional Nurse Consultant all acknowledged that assessments should be documented every shift for new admissions, particularly related to the reason for admission, yet no such documentation existed for this resident during the entire stay. Nurse #1 reported assessing the resident’s new colostomy and abdominal incision, describing a damp gauze packed in the bottom of the incision with a dry gauze over it, but admitted she did not document her assessment, intending to do so later and then forgetting after the resident was discharged. Nurse #2 stated that assessments should be documented every shift and recalled the resident had a colostomy, but when informed there was no assessment documented, she could not confirm whether she had assessed the colostomy or incision and said she would need to refer to the record. Nurse #3 stated she assessed the colostomy, which was almost full with a good seal, and also assessed the abdominal incision, but when shown there was no documentation, she acknowledged she must have forgotten to chart it. The DON stated she also looked at the resident’s colostomy and incision but did not document her assessment and did not follow up with nurses when she later noted the absence of documentation. The Regional Nurse Consultant confirmed there were no documented assessments of the colostomy or incision, and the Physician Assistant stated he relies on nurses’ assessments in the medical record for treatment planning, underscoring the absence of required documentation.
Failure to Change Indwelling Urinary Catheter as Ordered
Penalty
Summary
A resident with a history of neurogenic bladder and a chronic indwelling urinary catheter was admitted to the facility with physician orders specifying that the catheter should be changed on a particular date. The order for the catheter change was transcribed into the resident's medical record by a nurse, but it was not entered into the Medication Administration Record (MAR) or Treatment Administration Record (TAR). As a result, the scheduled catheter change was not performed as ordered. Interviews with facility staff, including the nurse responsible for the admission and the Director of Nursing (DON), confirmed that the omission occurred because the order was not properly processed to appear on the MAR or TAR. The DON acknowledged that without the order on these records, nursing staff would not be aware of the need to change the catheter. The Nurse Practitioner (NP) and Administrator both stated that their expectation was for the catheter to be changed as ordered, but this did not occur during the resident's stay.
Failure to Notify Physician of Missed Steroid Dose for Allergic Reaction
Penalty
Summary
The facility failed to notify the physician when a one-time dose of methyl prednisolone, ordered for the treatment of an allergic reaction, was not administered as prescribed. Nursing staff documented that the medication was on order but did not inform the physician of the delay or request further instructions. The medication, intended to address a worsening rash, increased redness, hives, itching, and a low-grade fever, was not given until five days after it was ordered. The nurse initialed the Medication Administration Record (MAR) and noted the medication was on order, but did not communicate the missed dose to the physician as expected. The resident involved had a history of heart failure, hypertension, and chronic pain, and developed a severe rash after starting an antibiotic. The rash worsened over several days, spreading and causing significant discomfort, including intense itching and skin peeling. Despite the resident's deteriorating condition and the nurse practitioner's expectation for prompt administration or notification if the medication could not be given, the physician was not notified of the delay, resulting in a significant lapse in care.
Failure to Administer Ordered Steroid Injection Resulting in Significant Medication Error
Penalty
Summary
A deficiency occurred when the facility failed to ensure a one-time dose of methylprednisolone (a steroid) intramuscular injection, prescribed for the treatment of an allergic reaction, was administered as ordered. The resident, who had a history of heart failure and chronic pain, developed an itchy, erythematous rash with hives and a low-grade fever after being treated with clindamycin for a gum abscess. The nurse practitioner (NP) discontinued clindamycin and prescribed alternative medications, including oral and topical treatments, but as the rash worsened, the NP ordered a one-time intramuscular injection of methylprednisolone. Despite the order, the injection was not administered for five days. Nurse #1, who was responsible for giving the injection, did not find the medication on the cart and was incorrectly informed by another nurse that it was not available in the backup medication supply. Although the backup supply did contain the medication, Nurse #1 did not access it and instead passed the responsibility to the oncoming nurse, assuming the medication would be administered once delivered by pharmacy. The medication remained unadministered until the NP discovered the omission during a subsequent visit and directed that the injection be given. Interviews with facility staff, including the Director of Pharmacy Operations, confirmed that the medication was available in the backup supply and had not been removed or administered as ordered. The Director of Nursing and Administrator acknowledged that the nurse should have checked the backup supply and administered the medication as ordered. The resident continued to experience significant discomfort, including widespread rash and severe itching, during the delay in administration.
Inaccurate MDS Dental Assessment Due to Lack of Coordination
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of dental for one resident. The resident was admitted to the facility and had a significant change MDS assessment completed, which indicated that the dental status was unable to be examined. The MDS Coordinator responsible for this assessment was working remotely at the time and was no longer employed by the company, making them unavailable for follow-up. Interviews with the Administrator and Director of Nursing (DON) revealed that the remote MDS Coordinator did not reach out to nursing staff or the DON to request a dental assessment during the lookback period, and a review of nursing documentation confirmed that no dental assessment was completed at that time. Both the Administrator and DON stated that they expected the dental status to be accurately completed on the MDS assessment.
Failure to Withhold Antiplatelet Medication Prior to Dental Procedure
Penalty
Summary
The facility failed to withhold an antiplatelet medication, specifically aspirin, as ordered by the Nurse Practitioner prior to a scheduled dental extraction for a resident with diagnoses including heart failure, hypertension, and chronic pain. The physician's order to hold aspirin for three days before the dental procedure was documented on the dental consent form but was not transcribed to the Medication Administration Record (MAR). As a result, nursing staff continued to administer aspirin to the resident from 11/1/24 through 11/6/24, contrary to the order. This oversight led to the cancellation of the scheduled dental extractions, as the dental provider could not proceed while the resident was still taking aspirin. Interviews with facility staff revealed a breakdown in communication and process regarding the handling and transcription of physician orders related to dental procedures. The DON and Administrator stated that the expected process was for the signed dental form to be given to the Unit Manager and then to the assigned nurse for transcription to the MAR, but this did not occur. The Unit Manager reported not receiving the relevant dental notes or forms. The resident did not report pain at the time of the missed extraction, but later developed a gum abscess requiring antibiotics and eventually underwent extractions after the medication issue was resolved.
Potential Hazard from Sodium Polyacrylate in Resident's Room
Penalty
Summary
The facility failed to maintain an environment free from potential hazards when Sodium Polyacrylate, a super-absorbent powder, and a glass of solidified fruit punch were left within reach of a resident with severe cognitive impairment. The resident, who required extensive assistance for daily activities and was on a dysphagia mechanical diet, was found with these items on his bedside table. The presence of these items posed a risk of ingestion, which could lead to gastrointestinal obstruction, as noted by Poison Control. The incident was discovered by a nurse aide who found the bottle of Sodium Polyacrylate and the solidified fruit punch during her shift. She reported the findings to the nurse, who then contacted Poison Control for guidance. Despite the uncertainty of whether the resident ingested the substance, the facility's staff monitored the resident for any signs of gastrointestinal distress as advised by Poison Control. The resident showed no symptoms and was stable throughout the monitoring period. Interviews with various staff members, including the Dietary Manager, Nurse Aides, and the Director of Nursing, revealed that the source of the Sodium Polyacrylate was unknown, and it was not a substance typically used or ordered by the facility. A search of the facility did not uncover any additional Sodium Polyacrylate, and the maintenance and supply staff confirmed that they had not ordered or used the substance. The facility was unable to determine how the Sodium Polyacrylate ended up in the resident's room, highlighting a lapse in ensuring a safe environment for residents.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately supervise a cognitively impaired resident, leading to the resident exiting the locked memory care unit unsupervised. The resident, who had Alzheimer's disease, dementia, and other conditions, was able to remove a windowpane and exit through a window. This incident occurred after the resident requested to go outside to smoke and was told by staff that it would be a while before they could take him out. The resident returned to his room, and staff continued with their duties, unaware of his subsequent actions. The resident managed to exit through a window in an adjoining room, which was 79 inches from the ground, and walked approximately 2/10 mile to a convenience store. The staff discovered the resident missing during routine rounds and initiated a search. The resident was found by a staff member at a nearby gas station and was returned to the facility by law enforcement. The incident highlighted a significant lapse in supervision and security measures, as the resident was able to remove a heavy glass windowpane and leave the facility unnoticed. Interviews with staff and law enforcement revealed that the resident had no prior history of elopement and was not considered at risk for such behavior. The facility's maintenance staff had previously conducted audits to ensure windows could not open more than 7 inches, but the resident was still able to remove the windowpane. The incident raised concerns about the facility's ability to prevent similar occurrences, given the resident's cognitive impairments and the potential for serious harm.
Failure to Notify Medical Provider of Alleged Abuse
Penalty
Summary
The facility failed to notify the medical provider of an alleged sexual abuse incident involving Resident #2. On the night of the incident, Nurse Aides reported to Nurse #4 that Resident #1 had confessed to being sexually inappropriate with Resident #2. Nurse #4, who was not directly responsible for either resident, informed Nurse #5, the supervisor, about the allegation. Both nurses then contacted the facility Administrator and Director of Nursing (DON) for further instructions. However, neither the medical provider nor the family of Resident #2 was notified immediately, as the Administrator assumed the notification would be handled the following day. The Nurse Practitioner (NP) was not informed of the alleged abuse until several days later, which delayed any potential medical examination or intervention. Upon learning of the incident, the NP conducted a vaginal examination on Resident #2, which showed no signs of trauma. The DON expected that the medical provider and family would be notified, but this did not occur. The Administrator acknowledged that the notification was not completed as expected, leading to a deficiency in the facility's response to the alleged abuse.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when one resident hit another resident in the left eye with a closed fist. This incident occurred after the aggressor believed the victim was looking at inappropriate pictures on a shared facility computer. The victim, who had a red area under his left eye, avoided the aggressor and the use of the shared computer for approximately a week and a half following the incident. The victim, identified as Resident #4, was admitted to the facility with diagnoses including aphasia, which affected his ability to communicate verbally. His care plan emphasized the importance of engaging in meaningful daily routines, including using the computer. Despite being moderately cognitively impaired, Resident #4 was usually able to make himself understood and had no prior behaviors. The aggressor, identified as Resident #7, was admitted with diagnoses including schizophrenia and generalized anxiety. He was also moderately cognitively impaired and exhibited signs of delirium and delusions. On the day of the incident, staff members, including nurses and nurse aides, responded to the altercation. Resident #7 was placed on one-on-one supervision following the event. Interviews with staff and residents revealed that Resident #7 was confused and had difficulty being redirected, while Resident #4 was known to spend significant time on the computer without accessing inappropriate content. The facility's computer system was designed for the elderly population, making it unlikely for inappropriate content to be accessed.
Failure to Prevent Illegal Substances in Facility
Penalty
Summary
The facility failed to prevent illegal substances from entering the premises, affecting the safety and supervision of residents. Resident #3, who is legally blind and has a history of methamphetamine use, reported that an unknown individual in a wheelchair entered her room and left a substance on her table, which she mistakenly identified as candy. Upon tasting it, she recognized it as methamphetamine laced with fentanyl. The resident's family member, a Sheriff's Deputy, confirmed the substance's identity after testing it at the police department. Despite the resident's inability to identify the individual, the incident raised concerns about the facility's security measures and supervision protocols. Resident #1, who is cognitively intact, was involved in a separate incident where he tested positive for THC after being transferred to the hospital. During a police investigation, drug canines detected a scent at Resident #1's room, although no illegal substances were found. Resident #1 initially claimed to have received marijuana from another resident but later admitted to sharing a vape pen containing marijuana with his girlfriend, Resident #6. The vape pen was reportedly stolen from a staff member, although the staff member denied owning it. The facility's administrator was informed of these incidents and requested a search of the facility using drug canines. The investigation revealed that a known drug dealer had visited the facility earlier, raising further concerns about the facility's ability to control access and prevent illegal substances from entering. The administrator's efforts to address the situation included interviewing staff and residents, but the incidents highlighted significant lapses in the facility's supervision and security protocols.
Delayed Urology Appointment Leads to Severe Medical Complications
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect when they did not identify the seriousness of a left swollen testicle for Resident #1. Despite a Nurse Practitioner's order for a urology appointment due to decreased vascular flow noted in an ultrasound, the facility scheduled the appointment for a later date, leading to a delay in care. Resident #1 experienced a serious adverse outcome with severe septic shock, urinary tract infection, and necrotic changes to the left testicle, ultimately requiring its removal. Immediate Jeopardy was identified when the facility did not recognize the urgency of the situation, resulting in a delay in necessary medical intervention. The deficiency was further highlighted by the failure to complete thorough and ongoing nursing assessments of the testicle and to notify the Nurse Practitioner or Medical Doctor when the urology appointment was not scheduled as ordered. This lack of timely action led to Resident #1's acute change in condition, requiring emergency care and eventual orchiectomy. The deficiency was exacerbated by the facility's failure to promptly address the medical concerns for Resident #1, who had a history of brain damage, dysphagia, hypertension, and gastrostomy upon admission. The delay in scheduling the urology appointment, inadequate assessments, and lack of communication regarding the testicle's condition culminated in a serious medical emergency for Resident #1, underscoring the facility's failure to protect the resident from neglect.
Delayed Urology Consultation and Inadequate Documentation of Vascular Flow Issues
Penalty
Summary
The deficiency identified in the report pertains to the facility's failure to recognize and address the seriousness of decreased vascular flow to Resident #1's left testicle. Despite reports of scrotal swelling and tenderness, thorough and ongoing nursing assessments of the left testicle were not documented. The Nurse Practitioner (NP) ordered an ultrasound and antibiotics upon initial assessment of the swelling, but delays in scheduling a urology consultation prolonged the Resident's access to necessary medical interventions. The Resident's condition deteriorated, leading to a diagnosis of severe septic shock, urinary tract infection, and necrotic changes in the left testicle, ultimately resulting in the removal of the testicle. Multiple staff members, including Nurse Practitioners, Wound Physicians, and Nurse Aides, were aware of the Resident's scrotal swelling but there was a lack of consistent documentation and follow-up on the issue. The facility's Scheduler faced challenges in scheduling a timely urology consultation, leading to significant delays in the Resident receiving appropriate care. Despite concerns raised by the Resident's family member and healthcare providers, the urgency of the situation was not fully recognized or acted upon promptly, contributing to the Resident's worsening condition.
Communication Breakdown in Scheduling Urology Consult Leads to Acute Condition
Penalty
Summary
The facility failed to notify the Nurse Practitioner or the Medical Doctor when a Urology Consult was not able to be scheduled per the Nurse Practitioner's order for Resident #1, who had a history of anoxic brain injury, persistent vegetative state, and neurogenic bladder. The Nurse Practitioner ordered a urology consult as soon as possible after an ultrasound showed decreased vascular flow to Resident #1's left testicle on 02/19/24. However, the Scheduler encountered difficulties in scheduling the appointment promptly, leading to a delay in Resident #1 receiving the necessary urology consultation. This delay resulted in Resident #1 experiencing an acute change in condition on 03/11/24, leading to a diagnosis of severe sepsis and necessitating an emergency left orchiectomy. Despite the Nurse Practitioner's order for an urgent urology consult, the Scheduler faced challenges in promptly securing an appointment for Resident #1. The Nurse Practitioner was unaware of these difficulties and assumed the appointment had been made, highlighting a breakdown in communication within the facility. This lack of notification to the medical providers about the scheduling issues prevented timely intervention that could have potentially averted the adverse outcome experienced by Resident #1.
Repeated Failures in Quality Assessment and Assurance
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions following previous surveys. This failure resulted in repeat deficiencies in the areas of Notification of Change, Neglect, and Quality of Care. Specifically, the facility did not notify the Nurse Practitioner or Medical Doctor when a Urology Consult could not be scheduled for a resident with decreased vascular flow to the left testicle, leading to severe sepsis and an emergency orchiectomy. Additionally, the facility failed to identify the seriousness of the resident's condition, complete thorough nursing assessments, and schedule timely medical consultations, resulting in delayed care and treatment. The deficiencies were observed in multiple instances, including a failure to notify the Medical Director during an acute change in condition, neglecting to seek medical assistance, and not performing necessary skin assessments and treatments. These repeated failures indicate a pattern of the facility's inability to sustain an effective QAA program. The deficiencies affected the quality of care provided to residents, leading to serious adverse outcomes, including severe septic shock and the need for emergency medical interventions.
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 11 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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 Sparta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grayson Health And Rehabilitation | 8 mi | ★★★★★ | 1 | 0 |
| Waddell Nursing And Rehab Center | 15.2 mi | ★★★★★ | 4 | 0 |
| Galax Health And Rehab | 16.9 mi | ★★★★★ | 0 | 0 |
| Margate Health And Rehabilitation, Llc | 19.2 mi | ★★★★★ | 3 | 0 |
| Chatham Nursing & Rehabilitation | 21.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.