Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Homestead Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
Fire sprinkler system was left in-operable for months, with failed pressure tests and missed weekly pump run tests. The LNHA said he was only later aware of the issue and claimed to have reported it by hotline, but there was no record. Staff were conducting fire watch every two hours instead of every 30 minutes, logs were incomplete, and an LPN observed during survey did not enter every room while performing the watch. The DON and LNHA confirmed the LNHA was ultimately responsible for the building and policy implementation.
The facility did not conduct or document annual performance evaluations or competency assessments for CNAs, as confirmed by a review of personnel files and interviews with the DON and LNHA. No policy or supporting documentation was available when requested.
The facility did not provide documentation that any of its CNAs received the required 12 hours of annual in-service training, including dementia care and abuse prevention. When education records were requested, none could be produced, and the DON reported that a change in the education system resulted in the loss of these records. No policies or further information regarding mandatory staff education were available.
Physician progress notes were not completed and signed at the time of visits for multiple residents. Surveyors found draft-only notes with minimal content for residents with complex conditions such as COPD, DM, CHF, dementia, schizophrenia, CKD, and respiratory failure. The DON stated this was unacceptable, and the MD acknowledged he was documenting notes later instead of at the time of service.
RN Staffing Lapse: The facility failed to ensure an RN was present for at least 8 consecutive hours each day, with multiple days showing no RN scheduled for the required coverage. Staffing records confirmed gaps between RN shifts, and the DON, scheduling coordinator, and LNHA acknowledged the staffing shortfalls and the facility’s awareness of the daily RN requirement.
Failure to Offer and Document Evening Snacks: Three alert and oriented residents reported that dinner was served in the late afternoon and breakfast the next morning, but they were not offered evening snacks. The LNHA and DON could not locate documentation showing whether the 8 PM snacks were offered, accepted, or refused. The FSD stated that snacks were sent to the units and should be offered when there is more than a 14-hour gap between meals, while the Director of Recreation said activity staff only passed out morning and afternoon snacks and were not responsible for evening snacks.
Kitchen sanitation and food labeling deficiencies were identified during a surveyor tour. The chef was unable to explain why refrigerated items such as sliced pickles, grated cheese, grape jelly, and sliced American cheese were not properly labeled or discarded by the use-by date. The surveyor also observed a distended bag of biscuit mix, discolored ceiling tiles, and dust-like debris on walk-in freezer fans and a rapid cooling ice container. The FSD stated that kitchen items needed received, opened, and use-by dates and that freezer equipment should be clean and in good repair.
Dumpster Area Not Kept Free of Garbage and Debris: The surveyor observed garbage debris, including food wrappers, containers, cups, gloves, paper products, and medication cups, around the dumpster and surrounding area. The chef said maintenance and dietary should have cleaned it, and the FSD stated the area is shared by kitchen, maintenance, and housekeeping staff. The facility policy also stated these departments monitor garbage removal to ensure the area is clean of debris.
The facility failed to ensure the MD carried out his role in resident care oversight and policy implementation. The MD said he saw about 40 residents, took notes home, and entered visit documentation later when he had time; surveyors found notes from months earlier still missing. He also confirmed he had not reviewed all facility policies, while the DON and LNHA stated the nursing policy binder had not been updated since 2020 and the care plan policy had not been updated since 2014.
QAPI Program Not Implemented to Sustain Prior Deficiency Corrections: The facility failed to show that its QAPI program was being used to sustain correction of prior deficiencies. The LNHA said QAPI concerns came from residents, resident council minutes, employees, and visitor comments, but the survey team identified repeated issues from the prior standard survey, including pressure ulcer prevention, physician visits, pharmacy services, and infection control. The DON’s role included active QAPI participation and coordinating ongoing QAPI activities, but the facility still had the same concerns noted previously.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with severe cognitive impairment and multiple health conditions did not receive all required care plan interventions for skin integrity, specifically the daily skin inspection. Staff confusion over the intervention's implementation and lack of clear documentation resulted in the intervention not being properly carried out, despite facility policy requiring measurable and clear interventions.
Disrepair on 3rd Floor Nursing Unit: Surveyors observed cracked floor tiles, chipped paint, and soiled and cracked ceiling tiles throughout Unit 3, including near the elevator. The DM and LNHA acknowledged the disrepair, and the LNHA stated the unit needed a new roof and that tiles had to be replaced after rain. The LNHA also acknowledged residents should be provided a clean, homelike environment.
A resident with dementia, heart failure, and significant ADL dependence did not receive a shower upon admission or on a scheduled shower day. CNA ADL records showed one refused shower, some completed showers, and one missed shower with no documented reason. The DON confirmed there was no PO for bathing, the resident was only scheduled once weekly, and there was no documentation that bathing occurred within 72 hours of admission.
Infection Control Breaks During Pressure Ulcer Wound Care: An LPN failed to maintain infection control during treatment of a resident’s stage 3 sacral pressure ulcer. The LPN used contaminated gloves while handling Iodoform packing, placed a trash bag on the resident’s bed, returned wound supply containers to the cart, and did not disinfect the over-bed table after care. The LPN also did not assess pain, and a CNA performed improper hand hygiene during the procedure.
An LPN administered a potassium medication using packaging labeled for a higher dose than the resident’s order, and another resident’s seizure medications were given late despite clear PO and EMAR times. The DON, MD, and provider pharmacist gave conflicting statements about borrowing meds from one resident for another, and the facility had a borrowing policy allowing temporary use of another resident’s supply under certain circumstances.
Medical records and FRE documentation were not maintained in accordance with professional standards for a resident with severe cognitive impairment and multiple medical conditions. The resident’s grievance about being unshowered was documented, but the initial FRE provided to surveyors lacked staff witness statements, and CNA bathing records did not match the claim that showers were given twice weekly. The LNHA and DON stated that statements existed and that records were kept across multiple binders, and the facility policy required resident health records to be maintained accurately and accessible.
The facility failed to maintain an IPCP with all required elements and did not review the IPCP policy annually. The policy lacked surveillance, reporting, and isolation details. The facility also failed to follow infection control procedures for two residents receiving O2 therapy when their NC tubing was observed laying on the floor in their rooms; an LPN stated the tubing should be secured in a bag and/or off the floor.
Missing Handrail Return Portions Exposed Hardware: Surveyors observed two handrails on the 3rd floor low side that were missing the return end pieces, exposing a screw and metal components. An LPN, a CNA, and the MD all acknowledged the condition, and the MD stated a contractor had started work on the handrails but never replaced the return portions.
A resident with severe cognitive impairment and a history of wandering accessed an unsecured room under renovation, became stuck to floor adhesive, and fell, resulting in multiple brain bleeds. The facility did not provide adequate supervision or secure the hazardous area, and failed to complete a thorough investigation or maintain required documentation as per policy.
The facility failed to maintain safe and comfortable room temperatures on the Second and Third Floors, with temperatures ranging from 81.7 to 86.9 degrees Fahrenheit. Several air conditioning units were not functioning properly, leading residents to rely on desk and stand fans for cooling. Despite the high temperatures, residents were not in distress. The Administrator noted that repairs had been attempted but the units continued to fail intermittently.
The facility failed to ensure physicians completed monthly progress notes for residents, affecting 15 out of 16 reviewed. Physicians left placeholder letters in records, intending to complete notes later, which was not done. Residents with various medical conditions lacked adequate documentation, and facility staff could not explain the missing records.
The facility failed to maintain proper kitchen sanitation and food labeling practices, risking foodborne illness. Observations included unlabeled condiment cups, milk containers, and spice containers, as well as soiled ovens and windows. The CDM could not confirm cleaning schedules or clarify labeling dates. The LNHA and DON had no comments on these issues.
A facility failed to ensure their designated Infection Preventionist (IP) had completed the required training and certification. An LPN serving as the IP was a per-diem employee without the necessary qualifications and was also performing other clinical duties. The facility's administration confirmed the LPN's lack of training and experience, violating state guidelines for facilities with 100 or more beds.
Surveyors observed infection control deficiencies in a facility, including improper hand hygiene by LPNs during wound treatment and medication administration, and failure to dispose of sharps containers properly. An LPN did not sanitize hands before applying gloves, and another used a contaminated paper towel and handled a saline solution without washing hands. Overflowing sharps containers were found in utility rooms, with maintenance staff unaware of disposal responsibilities.
Two residents with severely impaired cognition were observed being fed by CNAs who were standing, contrary to proper procedures. The facility's Feeding Policy lacked guidance on appropriate feeding methods, and the administration acknowledged the need for CNAs to be seated while feeding.
Facility staff failed to document a resident's medication refusal and did not consistently record daily weights as per physician orders. An LPN inaccurately documented medication administration, and daily weights were often missing from records, contrary to facility policy. Discussions with the LNHA and DON confirmed these documentation lapses.
A resident with a stage 4 pressure ulcer received wound care that did not follow physician's orders, as an LPN used a wound cleanser instead of normal saline. Additionally, the resident had an undocumented left upper buttock wound, which was not assessed or documented in the medical records. The facility's policies for weekly skin assessments and wound documentation were not adhered to, leading to the identification of this deficiency.
A resident with a history of falls and severe cognitive impairment experienced two falls due to inadequate supervision and lack of proper investigation into the causes. The facility failed to address the resident's involuntary movements in their care plan, and staffing shortages contributed to the incidents. The resident suffered minor and major injuries from the falls, with the second fall requiring hospitalization.
The facility failed to provide proper respiratory care for three residents, including outdated oxygen tubing for a resident with a tracheostomy, incorrect oxygen flow settings for a resident with COPD, and improper storage of oxygen tubing for a resident with asthma. Staff acknowledged these deficiencies, which were contrary to physician orders and facility policies.
A facility failed to ensure accurate signing of the narcotic medication shift-to-shift sign-in sheet, as observed during a State Surveyor's inspection. The sheet had missing nurse signatures on several occasions, contrary to the facility's Narcotics Accountability Policy, which requires outgoing and incoming nurses to count and sign for narcotics at each shift's end. This issue was discussed with the facility's administration, but no additional information was provided.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 11.54%. Errors included administering the wrong multivitamin and not providing food with medications that required it, as observed by a surveyor. The LPN involved misunderstood medication equivalency and did not offer food with medications, despite orders and cautionary labels. The LNHA and DON could not explain the errors.
A facility failed to store medications at the required temperature, with a refrigerator found at 32°F instead of the acceptable 36-46°F range. Medications like insulin pens and lorazepam were affected. The discrepancy was noted despite a log showing a 40°F reading earlier. The issue was discussed with the administration, but no further information was provided.
The facility failed to prepare food to the correct consistency for two residents on mechanical soft diets, leading to a deficiency. Observations revealed that whole fish sticks and vegetables were served, requiring cutting with a knife, contrary to the diet requirements. The CDM and SLP confirmed that mechanical soft diets should be minced and not require cutting. The residents involved had conditions necessitating modified diets, and the facility's diet manual and IDDSI guidelines were not followed.
Fire Sprinkler System Left Inoperable and Fire Watch Not Performed Correctly
Penalty
Summary
The facility failed to maintain its fire sprinkler system in an operable condition and failed to ensure staff and administration followed the facility’s fire watch and reporting procedures when the system was impaired. The report states the sprinkler system had been partially operable and then in-operable for approximately 3 to 5 months, with the maintenance director reporting that the facility had failed the pressure test on the past two quarterly fire protection equipment inspections. The maintenance director also stated the weekly fire pump run tests had not been conducted for at least 5 to 6 months because the pump was in-operable. The licensed nursing home administrator stated he was only made aware of the in-operable sprinkler system on a later date and said he called the NJDOH hotline twice, but there was no record of the calls and he did not speak to anyone. The fire marshal stated the facility should have immediately notified the local fire department and that, since the system had been in-operable, there would have been no fire protection if a fire occurred. The fire marshal also stated the facility had been in an imminent hazard status and that the fire watch needed to be conducted at least every 30 minutes with a designated person going into each room. Surveyors observed the fire watch being performed inaccurately. One LPN assigned to fire watch took 12 minutes to inspect the four floors and did not go into every room. The fire watch log contained only one entry for a fire watch at midnight, and other pages were pre-filled with blank dates, two-hour time increments, and the area listed as the entire building. Staff interviews showed the fire watch was being done every two hours, not every 30 minutes, and staff described walking hallways and stairwells rather than entering rooms. The DON and LNHA both confirmed the LNHA was ultimately responsible for the building and for ensuring facility policies and procedures were implemented.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to evaluate the job performance of all Certified Nursing Assistants (CNAs) on an annual basis, as required. During a review of personnel files for five CNAs, it was found that none had recent employee evaluations completed. Additionally, the Director of Nursing (DON) confirmed that the facility does not have competency assessments for CNAs and was unable to provide any employee evaluations or competency documentation when requested. The DON also stated that there was no policy available regarding CNA evaluations, and no further relevant information was provided by facility leadership.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nurse Assistants (CNAs) received the required 12 hours of mandatory in-service training, including education in dementia care and abuse prevention, for all five CNAs whose education records were reviewed. During the survey, the personnel education files for these CNAs were requested, but no records of education were provided for any of them. The Director of Nursing (DON) stated that the facility had changed its staff education program and was unable to retrieve the education records, and no copies were saved in the employee files. When further documentation and policies regarding mandatory staff education were requested, the facility was unable to provide them.
Physician Progress Notes Left in Draft for Months
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising resident care completed monthly progress notes and signed them at the time of the visit. Surveyors found that multiple residents had physician progress notes left in draft status for months, with the notes containing only a letter "Z" and no other documented clinical information. Residents reviewed included individuals with diagnoses such as severe protein-calorie malnutrition, COPD, hypothyroidism, hypertension, Parkinson’s disease, asthma, diabetes, vertebral fracture, sepsis, pneumonia, respiratory failure, metabolic encephalopathy, cystitis, hydronephrosis, ESRD, CHF, MI, schizophrenia, depression, CKD, GERD, and dementia. Record review showed that the physician progress notes for several residents remained incomplete over extended periods. For example, notes for one resident were held in draft from April through June 2025, another from March through July 2025, and another from January through July 2025. For a closed record, the physician’s draft notes were documented only as "Z" entries on multiple dates in February and March 2025. The surveyor also reviewed the facility’s medical staff bylaws, which stated that a progress note is written and signed by the attending physician at the time of each visit and that the physician signs all orders. During interviews, the DON stated that the physician, who also served as Medical Director, should be writing complete and signed progress notes at the time of the visit and that leaving notes in draft for months was unacceptable. The physician acknowledged that progress notes should be completed and signed at the time of service, but stated he did not do so and instead entered notes later when he had time. He further stated he was at the facility about twice per week and that residents should be seen monthly, and he confirmed that some notes from February 2025 were still not written at the time of the interview.
RN Staffing Lapse
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) worked seven days a week for at least 8 consecutive hours a day for 5 of 14 days reviewed. Review of the Nurse Staffing Report sheets showed no RN on 7/4/25, 7/5/25, 7/6/25, 7/9/25, and 7/10/25, with the last RN scheduled on 7/3/25 for the first three dates and on 7/8/25 for the last two dates. The corresponding nursing staff sheets confirmed that an RN was scheduled on the prior shifts, but the next RN was not scheduled until the later dates noted in the report. During interviews, the DON stated she was aware the facility required an RN to be present daily and that an RN was needed for critical care and assessments. The scheduling coordinator stated she knew the facility needed an RN in the building for 8 hours in a 24-hour period and said the facility had more LPNs than RNs and did the best she could to staff the facility. The LNHA, in the presence of the DON, acknowledged that there were days when no RNs were scheduled for eight consecutive hours.
Failure to Offer and Document Evening Snacks
Penalty
Summary
The facility failed to serve and document evening snacks for residents when there was more than a 14-hour gap between dinner and breakfast. During a resident council meeting, three alert and oriented residents stated that dinner was served between 5:00 PM and 5:30 PM and breakfast arrived between 8:00 AM and 8:30 AM, but they were not offered or given snacks in the evening. The survey team discussed these concerns with the LNHA and DON, and the LNHA stated he would investigate the process for evening snacks. The LNHA later stated he could not locate the accountability book for the 8 PM snacks, and the DON confirmed that recreation staff passed out the snacks but also could not find documentation showing whether residents received or refused them. The FSD stated that dietary staff sent extra snacks to the units, including sandwiches, cookies, beverages, and yogurt, and that activities staff and CNAs were responsible for delivering them. The FSD also stated that if there were more than a 14-hour gap between meals, snacks needed to be offered to all residents. The Director of Recreation stated that activity staff only distributed the morning and afternoon snacks and were not responsible for the evening snacks, and the DON stated she had not been aware that evening snacks were not being passed out until it was discussed at the resident council meeting.
Kitchen sanitation and food labeling deficiencies
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices in accordance with professional standards. During a kitchen tour with the chef, the surveyor observed 10 two-ounce cups of sliced pickles dated 7/7/25 through 7/12/25 and 12 two-ounce cups of grated cheese with a use-by date of 7/15/25 in a 3-door standing refrigerator. The chef was unable to explain why the items had not been discarded by the use-by date. In a 6-door standing refrigerator, the surveyor observed a round container of grape jelly covered with plastic wrap and labeled opened on 7/11/25, but without a use-by date; the chef stated it should have been discarded three days after opening. The surveyor also observed an open package of sliced American cheese without a label, and the chef was unable to state when it had been opened or why a use-by label had not been placed. In the dry storage area, the surveyor observed a 5 lb bag of B'gan brand biscuit mix that was distended, while other bags of biscuit mix were not distended. Multiple ceiling tiles were also observed to be discolored. The chef discarded the biscuit mix and stated maintenance would be informed about the ceiling tiles. In the walk-in freezer, the circulating fans had dust-like debris and a rapid cooling ice container had dust-like debris on the handle. The chef stated maintenance was responsible for cleaning the fans and that the cooling container would be cleaned immediately. The FSD later stated that all kitchen items needed received, opened, and use-by dates, that items should be discarded by the use-by date, and that the freezer fans and rapid cooling container should always be clean and in good repair.
Dumpster Area Not Kept Free of Garbage and Debris
Penalty
Summary
The facility failed to provide a sanitary environment for residents, staff, and the public by not keeping the dumpster and surrounding area free of garbage and debris. During a kitchen and garbage area tour with the chef, the surveyor observed garbage debris around the dumpster, including food wrappers, food containers, cups, gloves, paper products, and medication cups. The chef stated that the maintenance and dietary departments should have cleaned the area. The Food Service Director later stated that the garbage areas are a shared area and that the kitchen, maintenance, and housekeeping departments are all responsible for cleaning that area. The facility policy titled Dumpster Sanitation Policy stated that Dietary, Housekeeping, and Maintenance Departments will monitor when taking out garbage that the areas are clean of debris and other items.
Medical Director Failed to Timely Document Visits and Review Policies
Penalty
Summary
The facility failed to ensure the Medical Director implemented resident care policies and procedures related to physician visits and the timely documentation of those visits in the medical record. During a telephone interview, the Medical Director stated he had served in that role for 8 to 9 years, saw about 40 residents, and was at the facility twice a week. He said he took personal notes home and entered them into the electronic medical record later when he had time, and he confirmed that notes from February 2025 were still not written at the time of the survey. He also stated he did not know whether documenting months later was allowed and acknowledged that he had previously been told during an earlier survey about not documenting at the time of the physician visit. The surveyor also found that the Medical Director had not reviewed all facility policies and procedures. He stated he reviewed policies only if there were changes and confirmed he had not reviewed all of them. The DON and LNHA stated the facility had a binder of nursing policies and procedures that had not been updated since 2020, and the DON said the care plan policy had not been updated since 2014. The Medical Director stated policies should be reviewed at least annually and updated as needed. The facility census report showed the Medical Director saw 38 residents, while the other two physicians saw 20 residents combined.
QAPI Program Not Implemented to Sustain Prior Deficiency Corrections
Penalty
Summary
The facility failed to ensure that its QAPI program was implemented to sustain correction of previously cited deficiencies. During the entrance conference, the surveyor requested the facility’s QAPI program plan, quarterly sign-in sheets for 2024 and 2025, and the QAPI notebook. The facility had been cited on the prior standard survey for concerns involving treatment and services to prevent pressure ulcers, physician visits, pharmacy services, food storage and sanitation, and infection control, with references to F686, F711, F755, and F880. During interviews, the LNHA stated the facility used information from residents, resident council minutes, employees, and visitors’ comments for QAPI concerns. The survey team informed the facility that the same concerns from the prior standard survey remained, including treatment and services to prevent pressure ulcers, physician visits, pharmacy services, and infection control. The LNHA acknowledged awareness of the prior deficiencies and stated that staff had been educated and reports completed. The DON job description identified responsibilities related to active participation in QAPI, coordinating ongoing QAPI activities, compiling findings for the QA committee, and participating in the preparation of the plan of correction and follow-up QAPI for nursing allegations.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Implement Care Plan Interventions for Skin Integrity
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including dementia, heart failure, and major depressive disorder, was not provided with all the care plan interventions necessary to maintain skin integrity. The resident, who had severely impaired cognition and required partial assistance with activities of daily living, had an individualized comprehensive care plan (ICCP) that included interventions such as keeping the skin clean and dry, daily skin inspection, notifying the physician of any skin breakdown, turning and repositioning every two hours, and monitoring for changes in circulation. Despite these interventions being documented, the facility failed to ensure that the daily skin inspection was implemented as required. The issue came to light after the resident's representative reported multiple complaints about the resident's skin condition, including irritations, upon discharge. Interviews with the DON and MDS Coordinator revealed confusion regarding the implementation of the daily skin inspection intervention, with staff believing it was either an automated entry or should be performed visually during care without specific documentation. The facility's policy required interventions to be clear, concise, and measurable, but the lack of clarity and proper implementation led to the deficiency.
Disrepair on 3rd Floor Nursing Unit
Penalty
Summary
The facility failed to maintain the residents’ living environment in a clean, sanitary, and homelike manner on Unit 3. During a tour of the 3rd floor nursing unit, the surveyor observed cracked floor tiles and chipped paint throughout the unit on both the low and high sides, along with soiled and cracked ceiling tiles on the low side near the elevator. The Director of Maintenance acknowledged that the floor, paint, and ceiling tiles were all in disrepair. The LNHA also stated he was aware of the cracked flooring, chipped paint, and soiled ceiling tiles on the 3rd floor nursing unit, and explained that the last contractor had been in the middle of repairs and left abruptly. He further stated that the facility needed a new roof and that the tiles needed to be replaced every time it rained, and acknowledged that residents should be provided a clean homelike environment.
Failure to Provide Scheduled Bathing and Admission Shower
Penalty
Summary
The facility failed to ensure a resident who required assistance with bathing received a shower upon admission and on the resident’s scheduled shower day. Resident #67 was admitted with diagnoses including unspecified dementia, heart failure, need for assistance with personal care, and major depressive disorder. The resident’s MDS showed a BIMS score of 4 out of 15, indicating severely impaired cognition, and the care plan identified increased assistance with ADLs due to debility, impaired mobility, cognitive deficit with poor safety awareness, and medication changes. Facility records showed the resident refused a shower on one occasion, received showers on some later dates, but did not receive a shower on 2/20/25 and there was no documentation explaining why. CNA documentation indicated the resident was scheduled for bathing once weekly on Thursdays, and the DON confirmed there was no physician order for bathing and no documentation that the resident received a shower within 72 hours of admission. Interviews with CNAs and the DON confirmed the shower schedule was tracked in the ADL system, that missed showers should be documented, and that the resident should have been showered within 72 hours of admission and at least twice a week, but the record did not show that occurred.
Infection Control Breaks During Pressure Ulcer Wound Care
Penalty
Summary
The facility failed to maintain infection control standards and procedures during wound care treatment for a resident with a stage 3 sacral pressure ulcer. The resident had diagnoses including Parkinson’s disease and diabetes mellitus, and the quarterly MDS dated 6/22/25 documented severe cognitive impairment with a BIMS score of 2 of 15 and one stage 3 pressure ulcer. The physician’s order directed cleansing the sacrum with saline, packing with Iodoform, packing the tunnel, and applying a protective dressing daily and as needed. During observation of the wound treatment, the LPN/WN initially brought the wrong packing strips into the room, then left and returned with the Iodoform packing strips. The LPN/WN placed a plastic bag on the resident’s bed to collect soiled dressing and used supplies, removed the soiled dressing, discarded it into the bag, and then continued the treatment using the same gloves after they had been contaminated. The LPN/WN opened and handled the Iodoform packing strips with contaminated gloves, used the wooden end of a Q-tip to pack the wound, touched the packing strip while measuring it, cut the strip, taped the end of the packing strip to the resident’s compromised skin, and used the same gloves to put the lid back on the packing strips. The LPN/WN also brought the packing strip containers out of the room and returned them to the treatment cart, and did not disinfect the over-bed table after the treatment was completed. The surveyor also observed that the LPN/WN did not assess the resident for pain during the treatment and confirmed he had not checked whether pain medication had been given beforehand. The CNA assisting with positioning performed hand hygiene incorrectly by washing her hands under running water for 8 seconds without first lathering and applying friction outside the stream of water. The CNA acknowledged she should have washed her hands for 20 seconds outside the water stream, and the LPN/WN confirmed the handwashing was unacceptable. The facility’s wound care and hand washing policies were reviewed during the investigation.
Medication Administration and Borrowing Practices Not Followed
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and acceptable standards of practice, and failed to maintain a system for the accurate acquiring, receiving, and dispensing of medications. During a medication pass, an LPN prepared Potassium chloride for a resident with hypokalemia, vitamin deficiency, and major depressive disorder. The resident’s physician order and EMAR called for Potassium chloride ER 10 mEq, one tablet daily with food, but the medication packaging was labeled for two tablets, equal to 20 mEq. The LPN stated the label was confusing and could have caused a medication error. A later inspection of the medication card still showed instructions for two tablets, and another LPN stated the label remained confusing and could lead to a medication error. The facility also failed to administer seizure medications at the ordered times for another resident with epilepsy, Alzheimer’s disease, and major depressive disorder. The resident’s orders included Dilantin 30 mg every 12 hours and Phenytoin 50 mg chewable tablets three times daily. During observation, the medications were administered late, and the LPN acknowledged that both Dilantin orders should have been given no later than 9 AM. The LPN also acknowledged that medications ordered more than once daily should be administered at the appropriate time. In addition, the facility had a borrowing medication practice that was not consistent among staff and leadership. The DON stated that staff could borrow medication from one resident for another resident using a form and replacement process, while the Medical Director stated that residents’ medications could not be borrowed because they were the resident’s property and the facility had an emergency back-up supply. The Provider Pharmacist also stated that borrowing medication from one resident for another was not acceptable and was outside the pharmacist’s dispensing role. The facility’s borrowing policy stated that nursing staff may temporarily borrow prescribed medication from another resident’s supply under certain circumstances.
Medical records and FRE documentation were incomplete and not maintained in an accessible manner
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards for a resident with unspecified dementia, heart failure, need for assistance with personal care, and major depressive disorder. The resident’s MDS reflected a BIMS score of 4 out of 15, indicating severely impaired cognition, and the care plan identified increased assistance needs related to debility, impaired mobility, cognitive deficit with poor safety awareness, and medication changes. During review of the closed record, the surveyor requested the complete Facility Reportable Event (FRE) for the resident, including witness statements, but the initial FRE provided did not include any staff witness statements. The FRE and grievance documentation stated that the resident’s representative complained that the resident smelled and was not showered, and the grievance form indicated documentation was reviewed and showers were given twice a week with CNA compliance confirmed. However, CNA bathing documentation did not corroborate that the resident received showers twice weekly, showing a refused shower, one shower received, one day without a shower, and two additional showers on other dates. The DON stated that statements were gathered from staff during investigations and that she had statements from CNAs who cared for the resident, but those statements were not initially provided when requested. The LNHA stated the facility had 17 binders to search through and acknowledged that medical records should be maintained accurately and accessible. The facility’s medical records policy stated records are to be maintained on all residents in accordance with professional standards of practice and filed in the nursing units.
IPCP Policy Deficiencies and Improper O2 Tubing Handling
Penalty
Summary
The facility failed to develop and maintain an infection prevention and control program (IPCP) that included all required elements, and the IPCP policy was not reviewed on an annual basis. The surveyor reviewed the facility’s IPCP policy and found that it did not include a system of surveillance designed to identify possible infections before they spread to other residents, did not identify who possible infections should be reported to, and did not document the requirements for isolating a resident. The policy showed a last review date of January 2024, and the DON acknowledged during interview that it should have been reviewed annually by January 2025. The facility also failed to follow infection control procedures for two residents receiving O2 therapy. Resident #8 was observed awake in bed with O2 via NC at 2.0 LPM, and the O2 tubing was laying directly on the floor of the room; the resident had diagnoses including severe protein-calorie malnutrition, COPD, hypothyroidism, and hypertension, and the MDS showed severe cognitive impairment and continuous O2 therapy. Resident #4 was observed in bed, lethargic, on O2 at 1.5 L/min with O2 tubing on the floor; the resident had diagnoses including sepsis, pneumonia, COPD, and acute and chronic respiratory failure with hypoxia, and the MDS showed moderate cognitive impairment and continuous O2 therapy. In both rooms, an LPN stated the tubing should be secured in a bag and/or off the floor.
Missing Handrail Return Portions Exposed Hardware
Penalty
Summary
The facility failed to ensure handrails were secure and intact on 1 of 2 resident units, specifically on the 3rd floor nursing unit. During observation on 07/21/25, the surveyor saw two handrails on the 3rd floor low side, next to two resident rooms, that were missing the return part at the end of the handrail. The missing return portion exposed a screw and metal components that attached the handrail to the wall. On 07/22/25, the surveyor interviewed an LPN and a CNA, both of whom observed the missing return portions and stated that the condition was a potential hazard to residents. The Maintenance Director acknowledged that the two handrails were missing the return portion and stated that a contractor had been working on the handrails, stopped, and never put the return portion back on. The Maintenance Director also acknowledged that the condition was a potential hazard to residents using the handrails.
Failure to Prevent Resident Access to Hazardous Area and Incomplete Incident Investigation
Penalty
Summary
A deficiency occurred when a cognitively impaired, ambulatory, and wandering resident with multiple diagnoses, including Alzheimer's disease and vascular dementia, accessed an unsecured room undergoing floor renovation. The resident, who was dependent on staff for activities of daily living and had a history of wandering and fall risk, entered the room where the floor was being redone and became stuck to the adhesive on the floor. While attempting to free themselves, the resident fell backwards, struck their head, and began vomiting, necessitating transfer to an emergency department. Subsequent hospital evaluation revealed three brain bleeds. The facility's documentation showed that the resident's care plan identified risks for elopement, wandering, and falls, and described behaviors such as pacing, entering other residents' rooms, and rummaging. Despite these known risks, the resident was able to access a hazardous area that should have been secured, indicating a failure to provide adequate supervision and a safe environment as required for residents with such vulnerabilities. Additionally, the facility failed to follow its own policy regarding the thorough investigation of accidents and incidents. When requested, the facility's new administration was unable to provide the full incident/accident report or staff statements related to the event, only producing a brief incident summary. This lack of complete documentation and investigation did not meet the facility's stated policy requirements for reporting, reviewing, and investigating all accidents and incidents involving residents.
Failure to Maintain Safe Room Temperatures
Penalty
Summary
The facility failed to maintain safe and comfortable room temperature levels for residents in two of its three nursing units, specifically on the Second and Third Floors. On the Second Floor, room temperatures ranged from 82.2 to 86.9 degrees Fahrenheit, with several air conditioning units either not working or providing low air output. Despite the high temperatures, residents were not in distress, although some required additional cooling measures such as desk fans. The surveyor also noted that the air conditioning units in the hallways were not functioning and were leaking water. On the Third Floor, room temperatures ranged from 81.7 to 84.0 degrees Fahrenheit, with similar issues of air conditioning units not working or providing insufficient cooling. Residents were observed using stand fans to mitigate the heat, and none were reported to be in distress. The facility's Administrator acknowledged the issue, stating that the air conditioning units had been repaired the previous day but were experiencing intermittent failures. The deficiency was identified during a survey conducted on June 20, 2024.
Deficiency in Physician Documentation of Resident Care
Penalty
Summary
The facility failed to ensure that the physicians responsible for supervising the care of residents completed monthly progress notes. This deficiency was observed over several months and affected 15 out of 16 residents reviewed. The survey revealed that the progress notes for these residents were either missing or held in draft form without any substantial information. The physicians, particularly Physician #1, were found to have left placeholder letters in the electronic medical records, indicating an intention to complete the notes later, which was not done. The surveyor's review of the medical records showed that residents with various medical conditions, such as systemic lupus erythematosus, sepsis, major depressive disorder, and atherosclerotic heart disease, did not have their care adequately documented. For instance, Resident #18's progress notes from February to March were incomplete, and similar issues were found with other residents, including those with chronic kidney disease, heart failure, and dementia. The facility's policy required that each resident be seen by their attending physician at least once every thirty days, with a progress note written and signed at the time of each visit, which was not adhered to. Interviews with facility staff, including the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), revealed that they were unable to provide explanations for the missing documentation. Physician #1 admitted to visiting residents but acknowledged that the progress notes were not completed in a timely manner. The facility's failure to ensure proper documentation of physician visits and progress notes was a significant oversight, as it compromised the continuity and quality of care provided to the residents.
Deficient Kitchen Sanitation and Food Labeling Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices and did not store, label, and discard potentially hazardous foods correctly, which could lead to foodborne illness. During a kitchen inspection, several issues were observed, including condiment cups with parmesan cheese and milk containers without open or use-by labels. The Certified Dietary Manager (CDM) acknowledged that all products should have these labels. Additionally, black-colored baked-on debris was found inside the dual ovens, and the CDM could not explain why the debris was present or when the ovens were last cleaned. Further observations included open spice containers with unclear labeling, soiled windows, and a shelf with various containers lacking proper labeling. The CDM was unable to clarify the dates on these containers. The inspection also revealed a small bowl of scrambled eggs with an incorrect date and a walk-in refrigerator and freezer with dust-like debris and ice accumulation. The CDM stated that the maintenance department was responsible for cleaning these areas but could not confirm when they were last cleaned. The facility's policies on labeling, dating, and cleaning were reviewed, but the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) had no comments regarding the kitchen issues.
Inadequate Infection Preventionist Qualifications
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) had completed specialized training in infection prevention and control, as required by CMS and New Jersey State guidelines. During an interview, the surveyor found that the Licensed Practical Nurse (LPN) serving as the facility's IP was a per-diem employee who had not completed the necessary certification or training. The LPN stated that her work hours varied and that she sometimes performed clinical duties, such as administering medications and conducting wound rounds, which indicated that infection prevention was not her sole responsibility. The facility's Licensed Nursing Home Administrator and Director of Nursing confirmed that the LPN had not completed any infection control training or certification and did not have the required five years of experience as an IP. This deficiency was in violation of the State of New Jersey Department of Health Executive Directive, which mandates that facilities with 100 or more beds must employ a full-time IP with no other responsibilities. The survey team discussed these findings with the facility's administration, highlighting the LPN's lack of qualifications and the facility's non-compliance with the directive.
Infection Control Deficiencies in Hand Hygiene and Sharps Disposal
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound treatment and medication administration, as observed by surveyors. An LPN was seen performing wound treatment on a resident without following the facility's hand hygiene policy. The LPN did not sanitize her hands before applying gloves and did not lather her hands for the required 20 seconds during handwashing. The LPN acknowledged the oversight when informed by the surveyor. The facility's hand hygiene policy mandates washing hands before and after resident contact and procedures, with specific instructions on handwashing techniques. During a medication pass, another LPN was observed using a previously used paper towel to dry her hands and clean around the sink, which compromised hand hygiene. The LPN also handled a contaminated saline solution bottle without washing or sanitizing her hands before administering medication. The DON confirmed that the pitchers should be cleaned daily and that the LPN should have washed her hands after handling the contaminated bottle. These actions were not in line with the facility's infection control protocols. Additionally, the facility failed to properly dispose of sharps containers filled with contaminated needles. Surveyors found several overflowing sharps containers in the soiled utility rooms on two floors. The maintenance staff member responsible for disposal was unaware of this duty, as it was not communicated to him. The facility's policy states that Environmental Services personnel are responsible for disposing of full sharps containers. The lack of proper disposal practices poses a risk of infection spread within the facility.
Failure to Maintain Dignity During Mealtime
Penalty
Summary
The facility failed to maintain dignity during mealtime for two residents who required assistance with eating. On the specified date, a surveyor observed a hospice CNA feeding a resident in a Broda chair by standing behind and reaching over the resident's right side. The hospice CNA acknowledged that staff should be seated at eye level while feeding residents, indicating awareness of the proper procedure. The resident had been admitted with diagnoses including Aphasia, Cerebral Infarction, and Atrial Fibrillation, and had a severely impaired cognition score, requiring partial/moderate assistance for eating. Similarly, another resident was observed being fed by a CNA who was standing over them. The CNA admitted awareness that staff should be seated next to residents during feeding. This resident had been admitted with diagnoses of Vascular Dementia, Alzheimer's Disease, and Abnormal weight loss, and also had a severely impaired cognition score, requiring supervision or touching assistance for eating. The facility's Feeding Policy lacked specific guidance on the appropriate way to feed residents, and the administration acknowledged the need for CNAs to be seated while feeding residents.
Documentation Failures in Medication and Weight Monitoring
Penalty
Summary
The facility staff failed to adhere to professional standards of clinical practice by not accurately documenting a resident's refusal of medication and not adequately recording daily weights as per physician's orders. During a medication pass, a resident identified and returned a medication they had not taken the previous night, despite the electronic medication administration record (eMAR) indicating it had been administered. This discrepancy was discussed with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), who acknowledged that the administering nurse should document accurately whether the medication was swallowed or refused. Additionally, the facility did not consistently document daily weights for residents as required by physician orders. A review of the Resident Medication Administration Record (RMAR) for January and February 2024 showed numerous instances where weights were not recorded, despite a standing order to weigh residents daily before breakfast. The Registered Nurse (RN) responsible for one of the residents could not explain the missing documentation. The facility's policy mandates that all weights be documented in the electronic medical record or designated form, but this was not followed, as confirmed in discussions with the LNHA and Interim DON.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident with a pressure ulcer. The deficiency was identified during a survey when a resident with a stage 4 pressure ulcer was observed receiving wound care that did not adhere to the physician's orders. Specifically, the Licensed Practical Nurse (LPN) used a wound cleanser instead of normal saline as prescribed, and there was a lack of proper documentation and assessment of the resident's wounds. The resident, who was cognitively intact, had a sacral wound and an additional wound on the left upper buttock, which was not documented in the medical records. The facility's records only included treatment orders for the sacral wound and right buttock, with no mention of the left buttock wound. The Director of Nursing (DON) later confirmed the presence of the left buttock wound, but there was no previous documentation or assessment of this wound in the resident's medical records. The facility's policies required weekly skin assessments and documentation of wounds, including their location, size, and treatment effectiveness. However, the survey revealed that these policies were not followed, as there was no documentation of the left buttock wound, and the wound treatment did not comply with the physician's orders. The lack of proper documentation and adherence to treatment protocols led to the identification of this deficiency during the survey.
Failure to Investigate and Prevent Falls for a Resident
Penalty
Summary
The facility failed to ensure that a resident at risk for falls was adequately supervised and that the causes of their falls were properly investigated. The resident, who had a history of falls and was diagnosed with conditions such as unspecified convulsions and hemiplegia, experienced two falls on 11/11/23 and 11/13/23. The investigation reports for these incidents did not include possible causes or root causes of the falls, nor were appropriate interventions evaluated or implemented. The resident's care plan did not address their specific needs, including involuntary jerking movements that contributed to the falls. The first fall on 11/11/23 was witnessed and resulted in minor injuries, while the second fall on 11/13/23 was unwitnessed and resulted in a major injury requiring hospitalization. The facility was also found to be deficient in CNA staffing on the day of the second fall. Additionally, the resident was left unattended in a dining room with their Broda chair in an upright position, contrary to the recommended reclined position. The facility's Director of Nursing acknowledged that the investigations were not thoroughly assessed to determine the causes of the falls.
Deficient Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to ensure proper respiratory care for three residents, as evidenced by inappropriate storage and administration of oxygen equipment. For Resident #11, the oxygen tubing connected to the tracheostomy was dated 2/7/24, indicating it had not been changed weekly as per the physician's order and facility policy. The resident, in a vegetative state, was observed with the outdated tubing, and the assigned RN confirmed the tubing was overdue for a change. Resident #12 was observed receiving oxygen via a nasal cannula with a humidified bottle dated 2/15/24, and the oxygen concentrator was set at 4 LPM instead of the ordered 2 LPM. The LPN responsible for the resident's care admitted to not checking the oxygen setting that morning and acknowledged the humidified bottle should have been changed. The resident, with moderate cognitive impairment, was admitted with COPD and acute respiratory failure, and the physician's order specified a lower oxygen flow rate. Resident #58's oxygen nasal tubing was found improperly stored in a nightstand drawer without a protective bag, contrary to facility policy. The resident, with moderate cognitive impairment and medical diagnoses including asthma and pneumonitis, had a care plan requiring oxygen equipment to be checked and stored correctly. The LPN confirmed the improper storage and acknowledged the tubing should have been bagged to prevent contamination.
Narcotic Medication Sign-In Sheet Not Accurately Signed
Penalty
Summary
The facility failed to ensure that the narcotic medication shift-to-shift sign-in and out sheet was accurately signed, as observed during a State Surveyor's inspection of the 2nd floor medication Cart A. The inspection revealed that the Narcotic Count shift-to-shift sign-in sheet had empty areas where nurse signatures were missing. Specifically, the sheet lacked signatures from the outgoing nurse on 3/1/24 at 11:00 PM, the incoming nurse on 3/3/24 at 3:00 PM, and the outgoing nurse on 3/4/24 at 11:00 PM. This was confirmed by an interview with a registered nurse who stated that the sheet should be signed by every incoming and outgoing nurse on each shift. The facility's Narcotics Accountability Policy, reviewed on 5/16/23, mandates that all narcotics must be counted daily by two nurses and documented in the log. The policy specifies that outgoing and incoming nurses must count narcotics at the end of each shift and sign the narcotic count form. The discrepancy was discussed with the Licensed Nursing Home Administrator and the Director of Nursing, but no further information was provided.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.54%. During a medication pass, a surveyor observed two nurses administer 26 doses of medication to three residents, with three errors identified. The first error involved the administration of Multi-Vitamin with Minerals instead of the prescribed Multivitamin 50 Plus to a resident. The Licensed Practical Nurse (LPN) incorrectly assumed these were the same, despite the Physician's Order specifying Multivitamin 50 Plus. The second and third errors involved the administration of medications without food, contrary to the Physician's Orders. Potassium Chloride Extended Release and Decadron were both administered without food, despite orders and cautionary labels indicating they should be taken with food to prevent stomach discomfort. The LPN stated that food was only offered upon request, and breakfast was served later. The Licensed Nursing Home Administrator and Director of Nursing were unable to explain the reasons for these errors when discussed with the surveyor.
Improper Medication Refrigeration
Penalty
Summary
The facility failed to properly store and refrigerate medication at the required temperature, as observed during an inspection of the 2nd floor locked medication refrigerator. The State Surveyor, accompanied by an RN, found the refrigerator's thermometer reading at 32 degrees Fahrenheit, which is below the documented acceptable range of 36 to 46 degrees Fahrenheit. This discrepancy was noted despite the Daily Freezer/Refrigerator Temperature Log indicating a recorded temperature of 40 degrees Fahrenheit earlier that day. The medications stored in the refrigerator included insulin pens, calcitonin salmon nasal spray, latanoprost ophthalmic solution, tuberculin purified protein derivative, and lorazepam intensil oral concentrate. The facility's Medication Storage Policy, revised in May 2023, requires medications to be stored in a manner that maintains their integrity and safety, in accordance with state Department of Health guidelines. The policy specifies that medications requiring refrigeration should be kept between 36 and 46 degrees Fahrenheit. The surveyor discussed the temperature discrepancy with the Licensed Nursing Home Administrator and the Director of Nursing, but no further information was provided. This deficiency was observed in one of the two facility units inspected during the initial facility unit inspection.
Failure to Prepare Food to Correct Consistency for Residents on Modified Diets
Penalty
Summary
The facility failed to prepare vegetables in the proper consistency for two residents on a modified diet, leading to a deficiency. During a survey, it was observed that the lunch tray for residents on a mechanical soft diet included whole fish sticks and regular mixed vegetables, which were not prepared to the required minced consistency. The Certified Dietary Manager (CDM) explained that the food was considered fork mashable, but acknowledged that mechanical soft consistency should be minced. This inconsistency was confirmed by the Speech Language Pathologist (SLP), who stated that foods needing to be cut with a knife should be prepared in the kitchen to ensure the correct size. Resident #5, who had severe cognitive impairment and was on a mechanical soft diet, was observed eating whole fish sticks and vegetables. The resident's care plan indicated a need for a mechanical soft diet due to conditions like Down syndrome and protein-calorie malnutrition. Despite the resident's need for 1:1 feeding assistance, the food was not prepared to the appropriate consistency, requiring the CNA to cut the vegetables with a knife. Similarly, Resident #36, who had diagnoses including epilepsy and dysphagia, received a lunch tray with intact fish sticks and vegetables, which also required cutting with a knife, contrary to the mechanical soft diet requirements. The facility's diet manual and the International Dysphagia Diet Standardization Initiative (IDDSI) guidelines were not adhered to, as they specify that mechanical soft diets should not require cutting with a knife and should be prepared to minimize chewing. The Director of Therapy and the CDM both acknowledged the discrepancy in food preparation, and the Licensed Nursing Home Administrator (LNHA) confirmed that food should be prepared in the kitchen to the correct size for residents on mechanical soft diets.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Newton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Barn Hill | 4.6 mi | ★★★★★ | 12 | 0 |
| Valley View Rehabilitation And Healthcare Ctr | 4.6 mi | ★★★★★ | 0 | 0 |
| United Methodist Communities At Bristol Glen | 5.4 mi | ★★★★★ | 10 | 0 |
| Mohawk Meadows | 6.2 mi | ★★★★★ | 3 | 0 |
| Milford Rehabilitation And Healthcare Center | 14.2 mi | ★★★★★ | 14 | 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.