Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Heritage during CMS and state inspections, most recent first.
A facility failed to protect resident dignity during dining and room entry. A resident’s room was entered multiple times by a CNA without knocking, despite the resident stating she wanted staff to knock and not see her naked. During lunch, one resident was eating while another resident at the same table had not yet received her meal, and the resident stated the table was not served together and she sometimes had to wait last. The RD, ADM, and DON all stated that residents at the same table should be served together and that knocking before entering rooms was important for privacy and respect.
The facility failed to ensure ordered medications and supplements were given as prescribed for three residents. One resident with atrial fibrillation and ASHD had Amiodarone and Midodrine orders that required BP checks, but the MAR lacked BP prompts and no June BP documentation was found. Another resident with rheumatoid arthritis and cerebral palsy missed MiraLAX because staff said it was not in stock, though it was later found in storage. A third resident with parkinsonism and hydrocephalus missed glucosamine-chondroitin because staff said it was unavailable and communication about ordering and supply was inconsistent.
Meals and snacks not provided within required time span. The facility served dinner to hall residents around 4:15 PM and breakfast around 7:00 AM to 7:30 AM, creating more than 14 hours between meals. Two residents reported being hungry at bedtime and said snacks were not routinely offered; snacks were only given if requested and were not available for all residents. The DON and DM acknowledged the meal span and that the kitchen did not have enough snacks for every resident.
Food service staff failed to properly label refrigerated items with use-by dates, discarded soft cucumbers that were no longer servable, and document temperatures for alternate meal items on the temp log. In the kitchen, salsa and ranch dressing were observed without proper date marking, and the RD confirmed that food products should be labeled, unservable produce discarded, and meal temperatures recorded before service.
A medication aide entered a resident’s room under contact precautions without a gown or gloves while administering meds and touching the resident’s bed and water container. In a separate event, two CNAs provided peri-care and positioning to another resident on EBP without gowns, allowing their uniforms to contact the bed during care. Interviews showed staff knew the PPE requirements but did not follow them.
Missing Consent for Sertraline: The facility failed to obtain a signed consent for a resident’s Sertraline order. The resident had intact cognition, mild depression on PHQ-9, and no active depression diagnosis listed, yet received Sertraline 150 mg daily. The DON could not locate a consent form, and the resident stated she refused the medication because she did not need it and no longer wanted to take it.
Call lights were not kept within reach for two residents with moderate cognitive impairment and significant dependence for ADLs. One resident with visual loss and dementia had her call light clipped to the bed and hanging toward the floor, while another resident with hand contractures and prior intracerebral hemorrhage had a soft touch call light hanging under the bed and could not reach it until staff repositioned it on her chest. CNA and leadership stated call lights were the residents' means to communicate with staff and should be within reach.
Inaccurate MDS Weight Loss Assessments: Two residents with dysphagia and other serious diagnoses had quarterly MDS assessments that did not reflect significant recent weight loss, even though their weight histories showed 14.4% and 6.9% losses in the prior month. The MDS nurse and DON acknowledged the assessments were inaccurate and that the weight loss should have been documented.
A resident with left hip pain, osteoarthritis, restless leg syndrome, Brown-Sequard syndrome, and osteoporosis had a baseline care plan that did not include pain even though the admission MDS and pain assessment documented frequent pain. The resident also had an order for oxycodone PRN for pain on admission, but the baseline care plan was coded as no pain and did not reflect the resident’s pain needs or related instructions.
Failure to include MRSA isolation and wound care in care plans: Two residents with severe cognitive impairment had incomplete care plans. One resident had a MRSA-positive urine result and no care plan entry for contact isolation precautions, while another resident had multiple physician-ordered wound treatments but no wound care plan. The MDS Coordinator and DON stated these items should have been included in the care plan.
A resident with chronic respiratory failure, OSA, and supplemental oxygen dependence was ordered oxygen at 3 L/min via nasal cannula every shift, but staff observed the concentrator set at 4 L/min on multiple occasions. An LVN initially believed the setting should be 4 or 5 L/min and stated she would leave it at 5 L/min, then confirmed the order was for 3 L/min and that there was no PRN order to change the flow. The DON also confirmed the concentrator should have been set at 3 L/min per the physician order.
Unlabeled loose medications were found in a nurse cart on the 100 hall, including a yellow capsule, a white pill, and a red pill in the bottom of a drawer. The assigned LVN confirmed the pills were not in pharmacy packaging and were unidentified, and stated they may have popped out of blister packs. The DON stated meds were expected to be stored in pharmacy packaging and carts checked daily, consistent with facility policy.
Missing Immunization Education and Consent Documentation: The facility failed to document education, consent, or refusal details for flu and pneumococcal vaccines for two residents with severe cognitive impairment. One resident had no record that the current flu vaccine was offered or that education was provided, while another resident’s chart showed refusals of both vaccines but no education was given. The DON and ADON/IPC stated the facility relied on verbal consent and did not obtain written consent or provide vaccine risk/benefit education.
Pest control program failed to keep a resident's room free of gnats. A resident with depression and anxiety, and intact cognition, was observed in bed with multiple black flying insects around and on her, and she said they bothered her. Staff reported gnats had been present in the building for some time, while the Maintenance Director said the facility was not being treated for gnats even though the pest control contract included flies/gnats/fruit flies. The most recent pest control visit documented treatment for roaches and ants, but not gnats, and the resident's room again had multiple flying insects during a later observation.
Incomplete Wound Care Documentation: The facility failed to document physician-ordered wound care for two residents. One resident with dementia, muscle weakness, and CKD had missing coccyx wound care entries, and another resident on hospice had missing documentation for daily wound care to multiple wounds. Staff stated the care was provided but was not charted, and the DON confirmed the missing records prevented verification that the ordered treatments were completed.
A resident with a history of cerebral infarction, dysphagia, and gastrostomy status was designated NPO and required enteral nutrition via G-tube, but the care plan was not updated to reflect this status. The plan continued to include interventions for oral intake, such as offering alternate meals and encouraging fluids, despite the resident's NPO order. Staff interviews confirmed the care plan was not revised after a change in condition, and facility policy lacked guidance on ensuring care plan accuracy.
A resident with a gastrostomy and indwelling catheter did not have Enhanced Barrier Precautions (EBP) properly implemented, as required by their care plan. Staff provided care without donning gowns, EBP signage was missing, and there was no physician's order for EBP in the record. Interviews revealed staff were unaware of the correct EBP process, and the ADON was not aware of the missing order or signage.
A resident's room was found to have a damaged bathroom door, a malfunctioning toilet, and an unsecured sprinkler system access panel. These deficiencies were not reported through the facility's work order system, and the resident occupying the room was unable to be interviewed. The facility's preventative maintenance policy was not followed as required.
Care plans for three residents with dysphagia and physician orders for thickened liquids were not updated to reflect these dietary modifications after comprehensive assessments. The MDS nurse did not review physician orders, resulting in care plans that did not include the required thickened liquid orders, as confirmed by staff interviews and facility policy review.
Surveyors identified multiple deficiencies in kitchen food storage and sanitation, including crumbs and paper wrapping in the fryer, sand-like particles on the dish washing machine, undated packages of corn beef and potatoes in the refrigerator, and unsealed, undated boxes of corn dogs and hamburger patties. The Dietary Manager confirmed these issues and their potential for contamination.
A resident with documented bipolar and schizoaffective disorders was not referred for a required Level I PASARR screen after diagnosis. The MDS coordinator, responsible for PASARR referrals, was unaware of the resident's mental illness due to not reviewing all active diagnoses, resulting in the omission of the screening process as required by facility policy.
Dietary staff prepared pureed foods for a meal without using measuring devices or following recipes, resulting in pureed bread, spinach, and macaroni and cheese that were too thick and sticky, making them difficult to swallow. The required recipes and protocols were not present during preparation, and both the Dietary Manager and Administrator confirmed the improper consistency during testing.
Two CNAs failed to change gloves or perform hand hygiene after touching contaminated surfaces and before providing incontinent care to a resident with complex medical needs and on enhanced barrier precautions. Both staff had received infection control training and passed competency checks, but did not follow facility policy requiring hand hygiene before direct care.
A nurse failed to perform hand hygiene between glove changes while providing wound care to a resident with multiple wounds and complex medical conditions. Despite facility policy and staff expectations requiring hand hygiene between glove changes, the nurse changed gloves multiple times without sanitizing or washing hands, as directly observed by surveyors. Interviews with staff confirmed the expectation for proper hand hygiene, and facility policies supported this requirement.
A resident with multiple pressure ulcers did not receive wound care in accordance with physician orders and professional standards. An LVN failed to clean the inside of wounds before applying dressings, used a wet-to-dry dressing instead of the ordered hydrofera blue on one wound, and did not secure the dressings. Interviews with clinical leadership confirmed these actions did not meet expected standards or facility policy.
A resident with multiple wounds and complex medical conditions received wound care treatments that were not documented in the TAR or LNAR as required by facility policy. Although a nurse performed the treatments, the absence of documentation in the medical records indicated a failure to maintain complete and accurate records in accordance with professional standards.
A resident with severe cognitive impairment was referred for wound care and received a debridement without prior notification to the responsible party. The facility failed to inform the responsible party and hospice of the procedure, despite the resident's inability to consent. Interviews revealed that the responsible party and hospice should have been notified, and the facility's policy emphasized involving the family in care decisions.
A resident was found with eye drops and a nasal spray on her bedside table without a specific written order to self-administer these medications. Despite having no cognitive impairment, the facility's records did not include an order for self-administration, and previous assessments had not confirmed her ability to do so safely. Interviews revealed staff were unaware of the policy on self-administration, and the facility's policy requiring an interdisciplinary team evaluation and a physician's order was not followed.
A medication aide failed to ensure a resident took her medications as required by facility policy, leaving a medication cup with seven medications at the bedside. The resident, with a history of respiratory failure, depression, and paraplegia, was not observed taking her medications, contrary to the facility's policy. The DON confirmed that staff must observe residents taking medications to prevent missed doses.
A resident receiving hospice respite services underwent a surgical wound debridement without the hospice agency's prior authorization or the responsible party's consent. The facility failed to notify the hospice agency and the resident's responsible party, leading to uncoordinated care. The resident had severe cognitive impairment and was admitted with multiple diagnoses, including dementia and depression.
Staff failed to follow infection control protocols for two residents requiring special precautions. In one case, a CNA fed a resident on contact isolation without wearing a gown or gloves, despite posted signage and available PPE. In another case, a CNA provided incontinence care and then handled a clean brief with soiled gloves, without changing gloves or sanitizing hands. Both incidents were observed by other staff and acknowledged as breaches of infection control policy.
Failure to Protect Resident Dignity During Dining and Room Entry
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity during dining and room entry. For one resident reviewed for resident rights, CNA N entered the resident’s room multiple times without knocking. The resident stated staff had entered without knocking and said she would like them to knock before entering, adding, “what if I was naked?” She also stated she did not want anyone to see her naked. CNA N acknowledged she had been trained to knock before entering and said it was important to do so for privacy and general respect. The facility also failed to ensure all residents at one dining table were served their meals before staff moved on to the next table. During lunch observation, one resident at the table had already begun eating while Resident #65 had not yet received her meal. Resident #65 stated the table did not get served together and that sometimes she had to wait to get her meal last, which sometimes bothered her. CNA L stated meals were obtained after the nurse checked them and that meals were sometimes served to separate tables. Resident #65’s record showed diagnoses including anxiety disorder and mild protein-calorie malnutrition, and her quarterly MDS reflected a BIMS score of 7 out of 15, indicating severe cognitive impairment. The RD stated it was important for residents at the same table to be served at the same time so they would not wait for food and so the dining experience would mimic home life. The ADM and DON both stated that serving one table at a time was important to residents’ dignity. The DON also stated staff were expected to knock and announce their position before entering residents’ rooms, and that entering without knocking was a privacy and dignity issue.
Missed Medication Administration and Missing Blood Pressure Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services to meet resident needs by not ensuring medications and supplements were administered as ordered for three residents. The report states that the facility did not ensure accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for Resident #22, Resident #9, and Resident #117. The deficiencies involved missed doses of ordered medications, missing stock, and missing blood pressure prompts in the electronic record. For Resident #117, a female with atrial fibrillation and atherosclerotic heart disease, the physician ordered Amiodarone 200 mg daily with instructions to hold if systolic blood pressure (SBP) was less than 110, and Midodrine 5 mg three times daily with instructions to hold if SBP was greater than 130. The resident’s care plan included monitoring vital signs for altered cardiovascular status. The June MAR did not show blood pressure readings documented for these medications, and the last blood pressure noted in the summary was on 05/28/2026. Staff interviews revealed the MAR lacked a prompt for nurses to record blood pressure before administration, and the DON stated the orders were updated that day because the prompt was missing. The DON and staff also stated blood pressure was being checked, but it was not documented in the electronic record. For Resident #22, a female with rheumatoid arthritis, cerebral palsy, and generalized weakness, the physician ordered polyethylene glycol 3350 (MiraLAX) 17 grams by mouth twice daily for constipation. During observation, the medication aide administered the morning medications but omitted MiraLAX and stated the facility did not have it in stock. The aide said she had not notified the nurse. A nurse later stated the medication was found in storage and there was plenty available, but the medication aides had to ask for it. For Resident #9, a male with parkinsonism and hydrocephalus and severe cognitive impairment, the physician ordered glucosamine-chondroitin twice daily. During observation, the medication aide omitted the supplement and stated it was not available. The aide said he had told several nurses but could not remember who, while nursing staff and DON gave differing accounts of who was responsible for ordering and obtaining the supplement.
Meals and snacks not provided within required time span
Penalty
Summary
The facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, and it did not provide a nourishing bedtime snack when the meal span exceeded 14 hours. The kitchen posted meal times as breakfast at 7:00 AM, lunch at 12:00 PM, and dinner at 5:00 PM, but observations showed dinner trays for residents who ate in their rooms were being passed as early as about 4:15 PM to 4:40 PM, while breakfast trays were being passed around 7:00 AM to 7:30 AM. Staff interviews confirmed that dinner for the halls usually started around 4:15 PM and breakfast around 7:15 AM to 7:30 AM, creating a span of more than 14 hours between dinner and breakfast. Record review and interviews showed that three residents were affected by this practice. One resident had rheumatoid arthritis, GERD, and anemia, another had muscle wasting, unspecified dementia, hypertension, and type 2 diabetes, and a third had COPD, muscle wasting, and unspecified dementia. Their orders included regular diets, and one resident had mechanically altered texture, but none had an order for evening snacks. Weekly weight records showed no recent weight loss for these residents. During a resident council interview, two residents stated dinner was served before 4:30 PM and breakfast about 7:30 AM, and that they got hungry before bedtime. The residents stated they were not routinely offered a bedtime snack. One resident said she received a snack only when she asked, usually a banana, graham crackers, or sometimes a sandwich. Another resident said staff would look for extras when she asked for a snack. Staff members stated snacks were available for some residents or those with orders, but not enough were provided for all residents. The DON and Dietary Manager both acknowledged that dinner and breakfast were served more than 14 hours apart and that the kitchen did not provide enough snacks for every resident. The facility policy stated meals are to be scheduled at regular times to assure each resident receives at least three meals per day, and mealtimes are to be posted in common areas.
Food Labeling, Storage, and Temperature Documentation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During an observation in the reach-in refrigerator in the food preparation area, salsa was found dated 6/9 with no use-by date, and the CDM stated the date needed to be updated because it had been made the day before. Ranch dressing was also observed in the same refrigerator dated 06-15-2026 with no use-by date. The CDM stated that correct dates were important so food would not expire and be given to residents, and noted that kitchen staff had been told during a prior visit to put discard dates on food products and knew to throw food out after 3 days. In the walk-in refrigerator, cucumbers were observed exposed to air. The CDM stated it was acceptable that they were not covered, but they needed to be thrown out because they had become soft and could not be served to residents. During meal service review, there was no place on the temperature log to document temperatures for alternate foods for lunch, and staff stated temperatures were supposed to be taken and documented to ensure they were appropriate. The RD confirmed that food products should be labeled with use-by or expiration dates, mushy cucumbers should be discarded, and food temperatures should be documented on the temperature log. The facility policy required refrigerated and frozen foods to be covered, labeled, and dated, and required food temperatures to be taken and properly recorded prior to service of each meal.
Failure to Use Required Isolation and EBP PPE During Resident Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for two residents by not following required isolation precautions during direct care. One resident had diagnoses including parkinsonism and hydrocephalus, a BIMS score of 7 indicating severe cognitive impairment, and was dependent on staff for all care. His record showed a positive urine test for MRSA, and his room had contact isolation signage with gown and glove PPE available outside the door. During observation, a medication aide entered the room without a gown or gloves, touched the resident’s bed and uniform, assisted with positioning, administered medication, and handled a water thermos in the room without using the required PPE. A second resident had diagnoses including cerebral infarction, gastrostomy status, and generalized muscle weakness, with a BIMS score of 12 indicating moderate cognitive impairment and total dependence on staff for ADL care and movement. Her care plan called for enhanced barrier precautions with gown and glove use during high-contact care activities such as hygiene and changing briefs. During observation, two CNAs provided peri-care and positioning while neither wore a gown, and their uniforms touched the sides of the resident’s bed during care. Interviews confirmed the missed precautions. The medication aide stated he did not wear PPE for the resident on contact precautions and said he was in a hurry and did not see the signs. One CNA stated she did not wear a gown because she was called to assist and was not looking at the sign, and the other CNA stated she knew she was supposed to wear a gown but did not do so. The Infection Preventionist and DON stated staff should wear gown and gloves for contact precautions and for EBP during direct care, and the facility policy required gown and glove use for contact precautions and targeted gown and glove use for EBP during high-contact resident care activities.
Missing Consent for Sertraline
Penalty
Summary
The facility failed to ensure Resident #74 was informed of and consented to treatment with Sertraline, an antidepressant psychotropic medication. Record review showed the resident was a [AGE]-year-old female with cognitive communication deficit, intact cognition with a BIMS score of 15 out of 15, and a PHQ-9 score of 8 indicating mild depression. Her face sheet did not list depression as an active diagnosis and did not identify a responsible party. Her care plan included a focus on antidepressant medication use and an intervention to educate the resident/family/caregivers about the risks, benefits, side effects, and toxic symptoms of antidepressants. The order summary showed Sertraline HCl 150 mg daily for depression with a start date of 06/01/2026, and the June MAR showed the resident received the medication from 06/01/2026 through 06/19/2026 except for one refusal. During interview, the DON stated she could not find a consent form for the Sertraline and said it was important for the facility to have a signed consent so the resident was informed of possible adverse effects, side effects, and had the right to refuse. The resident stated she refused the pill for depression because she did not need it and said a family member had previously told the facility to give it to her, but she no longer wanted to take it. The facility’s resident rights policy stated residents have the right to be informed of and participate in their care planning and treatment, and the requested medication consent form was not provided.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure residents received services with reasonable accommodation of resident needs for 2 of 8 residents observed for call light placement. Resident #59, who had diagnoses including unqualified visual loss in both eyes, unspecified dementia, anxiety disorder, muscle wasting and atrophy, and overactive bladder, had a BIMS score of 09 indicating moderate cognitive impairment. Her annual MDS also showed she was dependent for toileting hygiene, bathing, dressing, personal hygiene, eating, and oral hygiene. Her care plan identified that she was at risk for falls and included the intervention to anticipate and meet needs and keep the call bed within reach as indicated. During observation, Resident #59 was resting in bed and her call light was clipped to the top left corner of the bed and hung down toward the floor. She stated staff mostly came and checked on her as she attempted to locate the call light by feeling around for it on the right upper side of the pillow, but could not locate it. Resident #114, who had diagnoses including contracture of the left hand, nontraumatic intracerebral hemorrhage, lack of coordination, contracture of the right hand, muscle wasting and atrophy, and epilepsy, had a BIMS score of 10 indicating moderate cognitive impairment. Her functional assessment showed she was dependent for eating, oral hygiene, toileting hygiene, bathing, dressing, and personal hygiene, and the record review noted she did not have a comprehensive care plan. When observed, Resident #114 was lying in bed with her soft touch call light hanging down from between the side rail and the top of the mattress on the floor under her bed. She stated staff usually put the call light on her stomach and indicated it had probably fallen. CNA B stated both residents' call lights were out of reach and they would not be able to use them where they were, and that the call lights should have been placed within reach. CNA B then repositioned both call lights, but Resident #114 still could not reach the soft touch pad until it was placed on her chest. The DON and Administrator stated the call light was the resident's way to communicate with staff and that it was everyone's responsibility to ensure call lights were within reach.
Inaccurate MDS Weight Loss Assessments
Penalty
Summary
The facility failed to ensure that quarterly MDS assessments accurately reflected significant weight loss for two residents. Resident #9, an older male with dysphagia, muscle wasting and atrophy, and protein-calorie malnutrition, had a quarterly MDS dated 06/02/2026 that indicated no weight loss of 5% or more in the last month or 10% or more in the last 6 months. However, the resident’s weight history showed a 14.4% weight loss in the last month, and the care plan identified nutritional problems and potential for weight loss related to a mechanically altered diet, dysphagia, and meal refusal at times. Resident #29, an older female with Huntington’s disease, dysphagia, and muscle wasting and atrophy, had a quarterly MDS dated 05/26/2026 that also indicated no significant weight loss. Her weight history showed a 6.9% weight loss in the last month. The MDS nurse stated both residents had significant weight loss that should have been reflected in their MDS assessments, and the DON stated she had been told the assessments did not document the significant weight loss and that it needed to be updated so intake and weight loss could be monitored.
Baseline Care Plan Missing Pain Instructions for Newly Admitted Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #129 within 48 hours of admission that included the instructions needed to provide effective, person-centered care and meet professional standards of quality care. Resident #129 was admitted with diagnoses including unilateral primary osteoarthritis of the left hip, pain in the left hip, restless leg syndrome, Brown-Sequard syndrome, unspecified osteoarthritis, and age-related osteoporosis without current pathological fracture. The admission MDS assessment showed a BIMS score of 9, indicating moderate cognitive impairment, and documented pain presence and frequent pain over the last 5 days. Record review showed the baseline care plan dated 06/10/2026 did not include a pain care plan and was coded no for presence of pain, despite the resident’s pain assessment indicating pain had been present and occurred frequently. The physician order summary included an order for Oxycodone HCl 5 mg every 4 hours as needed for pain starting on admission. During interviews, the ADON stated the baseline care plan was completed within the initial 24 to 48 hours and was based on assessment and conversation with the resident, while the DON stated the plan was based on what the resident said at the time and that if the resident expressed no pain, that would be documented in the baseline care plan.
Failure to Include MRSA Isolation and Wound Care in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for 2 of 8 residents reviewed. Resident #9, an older male admitted with diagnoses including parkinsonism and hydrocephalus, had a quarterly MDS showing a BIMS score of 7 and was dependent on staff for all care. His urinalysis dated 6/8/2026 was positive for MRSA staphylococcus aureus, but his care plan dated 2/26/2026 did not include information about the MRSA-positive urinary tract infection or the need for contact isolation precautions. Resident #1, an older male admitted with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, and chronic kidney disease, had a 5-day admission MDS with a BIMS score of 5 indicating severe cognitive impairment. His care plan dated 6/04/2026 did not include a plan for wounds or wound care, even though physician orders dated 6/09/2026 and 6/12/2026 directed treatment for wounds on the left buttock, right ankle, right shin, and nose. During interview, the MDS Coordinator stated both residents should have had these issues included in their care plans, and the DON stated the care plan was the guide to caring for the resident and staff go by what is documented in it.
Oxygen concentrator set above ordered flow rate
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident who had chronic respiratory failure with hypoxia, obstructive sleep apnea, and dependence on supplemental oxygen. Resident #105’s care plan included oxygen as ordered/indicated, and the physician order summary directed oxygen at 3 liters per minute via nasal cannula every shift. However, during observations on 06/16/2026 and 06/18/2026, the resident was seen resting in bed with the head of the bed elevated and wearing a nasal cannula while the oxygen concentrator was set at 4 liters per minute instead of the ordered 3 liters per minute. The resident stated he had been using oxygen since admission and that he used 3 liters per minute. During interview and observation, LVN B stated the resident’s oxygen concentrator was supposed to be set at 4 or 5 liters per minute and that she would leave it at 5 liters per minute, then checked the setting and confirmed it was at 4 liters per minute. After reviewing the EMR, LVN B stated the physician order was for 3 liters per minute and that there was no PRN order to change the oxygen liters as needed. The DON also reviewed the orders and stated the concentrator should have been set at 3 liters per minute because that was the physician’s order. The facility policy on oxygen administration required verifying a physician order and adjusting the oxygen delivery device so the proper flow of oxygen was being administered.
Unlabeled Loose Medications Found in Nurse Cart
Penalty
Summary
Drugs and biologicals were not stored in accordance with facility policy when an observation of the nurse cart on the 100 hall revealed three loose, unidentified pills in the bottom of the second drawer: one small yellow capsule, one small round white pill, and one small round red pill. The medications were not in pharmacy packaging and were not labeled with identifying marks. LVN C, who was assigned to the cart at the time, stated the loose pills may have popped out of blister packs and confirmed they were unlabeled and unidentified. LVN C stated it was the responsibility of the nurse or Med Aide assigned to the cart to keep the cart clean and store medications correctly, and that carts were to be cleaned daily. She also stated the loose pills could have affected the medication count and could have caused medications to run out before refills were delivered. The DON stated the expectation was that medication carts and nurse carts were clean and medications were stored in pharmacy packaging, and that staff should check carts at least once a day. Facility policy stated medications and biologicals are to be stored in the packaging, containers, or dispensing systems in which they are received, and nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Missing Immunization Education and Consent Documentation
Penalty
Summary
The facility failed to develop and implement policies and procedures for flu and pneumococcal vaccinations to ensure residents’ medical records included documentation that education was provided regarding the benefits and potential side effects of the vaccines and that the vaccines were either received or refused due to medical contraindication or refusal. This deficiency was identified for 2 of 5 residents reviewed for immunizations, including Resident #1 and Resident #12. Resident #12 was a 76-year-old female with diagnoses including Parkinson’s disease, type 2 diabetes mellitus, and moderate dementia with behavioral disturbance. Her annual MDS showed a BIMS score of 3, indicating severe cognitive impairment. The record showed her last flu vaccine was given on 10/02/2024, but there were no signed consents for acceptance or refusal of the flu vaccine, no indication that the 2025/2026 flu vaccine was offered, and no documentation that education was provided. An attempt to contact her RP on 6/19/2026 was unsuccessful, and no return call was received. Resident #1 was a male with metabolic encephalopathy, type 2 diabetes mellitus, and chronic kidney disease. His 5-day admission MDS showed a BIMS score of 5, indicating severe cognitive impairment, and it documented that he was offered and declined both the influenza vaccine and the pneumococcal vaccine. The medical record showed the pneumovax was refused and the influenza vaccine was refused on 6/02/2026, but the ADON/Infection Preventionist documented that no education was provided for either vaccine. During interview, the ADON/Infection Preventionist stated she was not obtaining written consent or providing education about the risks or benefits of vaccination and was only documenting verbal yes or no responses. The DON stated the facility used verbal consent and did not have a written consent form with risks and benefits for immunizations.
Pest Control Program Failed to Eliminate Gnats in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to keep Resident #117's room free of pests and rodents. Resident #117 was a female with diagnoses including depression and anxiety, and her admission MDS reflected a BIMS score of 14 out of 15, indicating intact cognition. During an observation, she was lying in bed with a towel covering her face while at least 5 black flying living things were flying around her and landing on her and her bed. She stated the gnats bothered her and said she had told someone about them, though she could not recall who or when. Staff interviews showed the issue had been ongoing. A PTA stated that since he had been working at the facility, there had been gnats in the building. The Maintenance Director stated there had been an issue with gnats since he had been working there for about a year and described them as a seasonal issue. He also stated the pest control company offered gnat treatment services, but the facility was not being treated for gnats at that time. He further stated the facility used a pest sightings book for staff to document insects or pests and that the pest control technician reviewed it during visits. Record review of the most recent pest control visit showed treatment for roaches, ants, and common areas, but no documentation or mention of treatment for flies or gnats. The pest control contract did include flies, gnats, and fruit flies among the pests covered, and the facility policy stated it maintained an ongoing pest control program to keep the building free of insects and rodents. During a later observation, Resident #117's bed again had approximately 6 black flying living things on the bed and flying around her. The Maintenance Director stated gnats had been an issue in the room for a couple of days and that the family had expressed concerns about them.
Incomplete Wound Care Documentation
Penalty
Summary
The facility failed to ensure complete and accurate wound care documentation for 2 residents. For one resident, an 86-year-old female admitted on 05/21/2026 with muscle weakness, unspecified dementia without behavioral disturbance, and hypertensive chronic kidney disease, the record showed a physician order for coccyx wound care beginning 05/22/2026. The TAR for May 2026 did not document completion of the coccyx wound care on 05/22/2026 or 05/23/2026. During interview, the wound care nurse stated she completed the wound care and then signs, but said she probably forgot to document it and did not remember the omission. For the second resident, a male receiving hospice services, physician orders dated 05/25/2026 included daily wound care for multiple areas, including the coccyx and left heel. The TAR for May 2026 did not document completion of the scheduled wound care on 05/31/2026, and there was no documentation that the resident refused the treatment. At the time of observation on 06/03/2026, the resident was lying in bed sleeping, appeared clean, and the bed was clean and dry; the wounds were not observed and the wound care nurse was not present. During interviews, Nurse A stated the resident slept frequently, had shaking and seizures when stimulated, and required extensive assistance with care. The DON stated treatment refusals were expected to be documented and reported according to facility policy and confirmed that the missing documentation prevented verification that the physician-ordered wound care had been completed as ordered. Nurse A later stated hospice staff had performed the wound care for the resident on 05/31/2026 and acknowledged that it should have been documented. Facility policies required documentation of all services provided, including the date and time, the name and title of the person providing care, assessment findings, resident response, refusals, and signatures.
Failure to Update Care Plan for NPO Resident Receiving Enteral Nutrition
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that accurately reflected a resident's current medical needs. Specifically, a male resident with diagnoses including cerebral infarction, dysphagia, and gastrostomy status was admitted and assessed as requiring enteral nutrition via a G-tube and was designated as NPO (nothing by mouth) due to swallowing difficulties. Despite this, the resident's care plan included interventions for encouraging oral intake, such as offering alternate meals or supplements if less than 50% of food was consumed and encouraging or assisting with oral fluid intake. These interventions were not appropriate for a resident with NPO status and were not updated following a recent hospitalization and change in condition. Observations confirmed the resident was receiving enteral nutrition via a feeding pump, and interviews with facility staff, including the MDS Nurse and DON, revealed that the care plan had not been revised to remove oral intake interventions after the resident was made NPO. The staff acknowledged the oversight and the importance of ensuring care plans reflect current orders and resident needs. Review of facility policy did not provide specific guidance on ensuring the accuracy of care plan content.
Failure to Implement Enhanced Barrier Precautions for Resident with Infection Risks
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with significant infection risks, including a gastrostomy and an indwelling urinary catheter. The resident's care plan indicated the need for Enhanced Barrier Precautions (EBP), but there was no physician's order for EBP in the medical record, and EBP signage was not present at the entrance or inside the resident's room. During observation, a nurse provided direct care to the resident using gloves but did not don a gown as required by EBP protocols. The nurse left the facility before a follow-up interview could be conducted. Interviews with staff revealed a lack of awareness and understanding regarding the implementation of EBP for the resident. The primary nurse was unsure if EBP was required and could not locate the necessary signage or physician's order. The Assistant Director of Nursing, responsible for the infection prevention program, was unaware that the EBP order was missing and could not explain the absence of signage. The facility's policy required targeted gown and glove use and the posting of precaution signs, but these measures were not followed for the resident in question.
Failure to Maintain Safe and Functional Resident Room Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in one of four resident rooms reviewed for environmental concerns. Specifically, in the identified room, there was a hole measuring approximately 3 inches by 2 inches in the bathroom door, a toilet that continuously ran water and would not flush, and an unsecured sprinkler system access panel on the bathroom wall measuring about 1.5 feet by 1.5 feet. These issues were directly observed during a walkthrough with the Administrator and Maintenance Director. Interviews revealed that the room was occupied by a single resident who was unable to be interviewed. The Maintenance Director stated that repairs are typically reported through the TELS work order system, but no work order had been received for this room. He also mentioned that resident rooms are checked weekly as needed for repairs. The facility's policy on physical environment, dated 01/2023, indicates a preventative maintenance program is in place to ensure all essential equipment is in safe operating condition.
Failure to Update Care Plans for Thickened Liquids
Penalty
Summary
The facility failed to review and revise care plans for three residents after their comprehensive assessments, specifically neglecting to update the care plans to reflect physician orders for thickened liquids. For each of the three residents, medical records indicated diagnoses including dysphagia and orders for thickened liquids, as documented in their quarterly MDS assessments and monthly physician orders. However, the care plans for these residents were not updated to include these dietary modifications. Interviews with facility staff confirmed that the MDS nurse had not updated the care plans due to not reviewing the residents' physician orders. The DON also acknowledged that the care plans should have been updated to reflect the thickened liquids orders. Facility policy requires care plans to be reviewed and updated at least quarterly and with significant changes in condition, but this was not done for the affected residents.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen related to food storage, preparation, and sanitation. Crumbs and paper food wrapping were found inside the fryer, and sand-like particles were present on top of the dish washing machine, particularly at the opening. The Dietary Manager confirmed both the presence of these contaminants and acknowledged their potential to contaminate food and clean dishes. Additionally, three packages of corn beef and a box of raw potatoes were found undated in the refrigerator, and the Dietary Manager stated these items had recently been placed there. Further observations revealed that a box of corn dogs and a box of hamburger patties were stored in unsealed and undated packaging in the refrigerator and freezer, respectively. The Dietary Manager confirmed that these unsealed foods were subject to contamination and, in the case of the hamburger patties, also to freezer burn. Review of the facility's Kitchen Sanitation policy indicated that all Nutrition and Foodservice employees are required to maintain clean, sanitary kitchen facilities to prevent food-borne illness, but these standards were not met during the survey.
Failure to Coordinate PASARR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident with newly evident or possible severe mental disorder. Specifically, a male resident with diagnoses of bipolar disorder and schizoaffective disorder was not referred for a Level I PASARR screen after being diagnosed with a mental disorder. Record reviews showed that the resident had active diagnoses of psychiatric mood disorder, bipolar disorder, and schizoaffective disorder, and was receiving medication for hallucinations and paranoia. Despite these documented mental health conditions, there was no evidence that the required PASARR screening was completed. Interviews with facility staff revealed that the MDS coordinator, who was responsible for referring and screening residents for Level I PASARR, was unaware of the resident's mental illness due to not having reviewed all residents' active diagnoses. The DON confirmed that the MDS coordinator should have referred the resident for evaluation in accordance with facility policy. Facility policy required PASARR screening for all individuals with mental illness, but this process was not followed for the resident in question.
Failure to Prepare Pureed Foods to Required Consistency and Recipe Standards
Penalty
Summary
The facility failed to prepare pureed foods according to required consistency and recipe standards for residents on pureed diets during a lunch meal. Dietary staff prepared pureed bread and spinach by adding chicken broth and thickener without using measuring devices, relying instead on visual assessment of consistency. Recipes for the pureed items were not present during preparation, and the staff did not follow the specified measurements outlined in the corporate recipe for pureed bread. Observations showed that the pureed macaroni and cheese and bread were not at the required pudding or mashed potato consistency, instead being thick, sticky, and difficult to move in the mouth. During testing, both the Dietary Manager and the Administrator noted that the pureed items were too thick and could be difficult for residents to swallow or remove from the roof of their mouths. Record review confirmed that the facility's policy required residents to receive diets as ordered by their physicians, including pureed diets, but the policy or protocol for pureeing food was not provided at the time of the survey. This failure to follow proper preparation methods and recipes for pureed foods was observed for one meal and could affect residents requiring pureed diets.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to follow proper infection prevention and control protocols while providing incontinent care to a resident with multiple medical conditions, including schizophrenia, PTSD, type 2 diabetes, gastrostomy status, hypertension, and Parkinson's disease. The resident required total assistance with activities of daily living and was always incontinent of bowel and bladder. During care, one CNA touched the bed remote and another touched the privacy curtain with gloved hands, both of which are considered contaminated surfaces. Neither CNA changed gloves or performed hand hygiene before proceeding with direct care for the resident, who was on enhanced barrier precautions due to gastrostomy status. Interviews with the CNAs revealed they were aware that the bed remote and privacy curtain were considered dirty and acknowledged they should have changed gloves and sanitized their hands, but did not realize this was required before starting care. Both CNAs had received infection control training and passed competency checks on hand hygiene. The Director of Nursing confirmed that staff are expected to change gloves and sanitize hands prior to providing care to prevent cross-contamination and infection, and that infection control training and skills checks are conducted at least annually. Facility policy also requires hand hygiene before and after direct resident contact and when moving from contaminated to clean procedures.
Failure to Follow Hand Hygiene Protocols During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during wound care for one resident. The resident in question had significant medical conditions, including quadriplegia, morbid obesity, type 2 diabetes, neurogenic bowel, and was always incontinent of bowel. The resident also had multiple wounds, including pressure ulcers and surgical wounds, requiring regular wound care and dressing changes as per physician orders and care plan interventions. On three observed occasions, an LVN performed wound care for the resident and failed to follow proper infection control protocols. Specifically, the LVN removed contaminated dressings, changed gloves multiple times, and performed wound cleansing and dressing application without performing hand hygiene between glove changes. The LVN stated she believed hand hygiene was only necessary after patient care or when hands were visibly soiled, and was unaware of the facility's specific policy regarding hand hygiene between glove changes. Interviews with the treatment nurse, ADNS, DNS, and the administrator confirmed that facility policy and expectations required hand hygiene to be performed between glove changes, either by washing with soap and water or using hand sanitizer, unless hands were visibly soiled. Review of the facility's policies on wound care and hand hygiene further supported these requirements, stating that hand hygiene is the primary means to prevent the spread of infection and must be performed between glove changes. The failure to follow these protocols was directly observed and acknowledged by staff, constituting a deficiency in the facility's infection control program.
Failure to Provide Pressure Ulcer Care per Professional Standards and Physician Orders
Penalty
Summary
A resident with multiple medical conditions, including quadriplegia, morbid obesity, and type 2 diabetes, was readmitted to the facility with existing pressure ulcers. The resident's care plan and physician orders specified wound care protocols, including cleansing wounds with wound cleanser and applying specific dressings such as hydrofera blue for the right glute and wet-to-dry dressings for the left ischium if the wound vac was dislodged or malfunctioned. The facility's wound care policy and competency checklist also required wound cleansing and securing dressings as part of standard practice. On the observed date, an LVN performed wound care on the resident's left ischium and right glute. The LVN did not clean the inside of the wounds prior to applying dressings, only cleaning the peri-wound areas. Additionally, the LVN applied a wet-to-dry dressing to both wounds, contrary to the physician's order for the right glute, which required a hydrofera blue dressing. The LVN also failed to secure the dressings after application, leaving them unfastened. The LVN stated she followed instructions from the DNS and checked the orders, but misapplied the treatment and did not follow the facility's wound care policy or the specific physician orders. Interviews with the treatment nurse, ADNS, DNS, and NP confirmed that the expected standard of care was not met. All agreed that wounds should be cleansed prior to dressing application, dressings should be secured, and orders should be followed precisely. The facility's policy and competency checklist further supported these expectations, indicating that the LVN's actions were inconsistent with both professional standards and facility protocols.
Failure to Document Wound Care Treatments in Medical Records
Penalty
Summary
The facility failed to ensure that medical records were maintained in accordance with professional standards and were complete and accurately documented for one resident. Specifically, on two occasions, wound care treatments provided to a resident with quadriplegia, morbid obesity, type 2 diabetes, neurogenic bowel, and multiple wounds were not documented in the Treatment Administration Record (TAR) or Licensed Nurse Administration Record (LNAR) as required by facility policy. The resident's care plan included interventions for fragile skin and actual wounds, with physician orders for specific wound care treatments. However, review of the April TAR and LNAR revealed blanks for the required wound care treatments on the specified date, and there was no documentation in the progress notes for those treatments. Observation confirmed that a nurse performed the required wound care treatments, but interviews with nursing staff and administration revealed that documentation was expected to be completed immediately after treatment. The nurse involved stated she had documented the treatments, but the records did not reflect this. Facility policy required documentation of wound care in the TAR, and the absence of such documentation indicated non-compliance with professional standards and facility policy.
Failure to Inform Responsible Party of Treatment Options
Penalty
Summary
The facility failed to ensure that a resident's responsible party was informed in advance of the risks and benefits of proposed care, treatment alternatives, or treatment options. This deficiency was identified for a resident who was referred to a Wound Care Physician for an evaluation and subsequently received a wound debridement without prior notification to the responsible party. The resident, who was admitted for hospice respite services, had severe cognitive impairment and was unable to consent to the procedure herself. The resident's medical records indicated that she had an unstageable wound on her coccyx, which was covered in necrotic tissue. A surgical excisional debridement was performed to remove the necrotic tissue and establish the margins of viable tissue. The facility's records showed that the treatment options, risks, and benefits were explained to the resident, who indicated agreement to proceed. However, the responsible party was not informed of the procedure until several days later, and it was unclear if the hospice was ever notified. Interviews with the facility's physician, the wound care physician, and the Director of Nursing (DON) revealed that the responsible party and hospice should have been notified and consent obtained before the procedure. The DON stated that the previous wound LVN, who was responsible for contacting hospice and notifying the responsible party, had not worked at the facility since January 2025. The facility's policy on end-of-life care emphasized the importance of involving the resident and family in developing the plan of care, which was not adhered to in this case.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined whether a resident could safely self-administer medications. This deficiency was identified for one resident who was observed with eye drops and a nasal spray on her bedside table without a specific written order to self-administer these medications. The resident, who had a BIMS score indicating no cognitive impairment, was using the eye drops multiple times a day for dry eyes and self-administered the nasal spray once a day. However, the facility's records did not include an order for the resident to self-administer these medications, and previous assessments had not confirmed her ability to do so safely. Interviews with facility staff revealed a lack of awareness regarding the policy on self-administration of medications. The medication aide responsible for the resident was unaware of any residents allowed to self-administer medications and did not know the facility's policy on the matter. The Director of Nursing confirmed that residents must be assessed for safe self-administration and have an order to do so, which was not initially in place for the resident in question. The facility's policy requires an interdisciplinary team evaluation and a physician's order for residents to self-administer medications, which was not adhered to in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the accurate administration of medications for one resident, leading to a deficiency in medication administration. On the morning of March 18, 2025, a medication aide (MA A) was responsible for administering medications to a resident. However, the resident was later observed with a medication cup containing seven medications on her bedside table, indicating that the medications were not taken as intended. The resident confirmed that the medications were given to her by a male medication aide and that she placed the medication cup on the overbed table while other staff members performed a mechanical lift transfer. The medication aide left the room before the resident finished taking her medications, contrary to the facility's policy that requires staff to observe residents taking all medications before leaving the room. The resident involved was a female with a history of acute or chronic respiratory failure, depression, and paraplegia, and had a BIMS score of 15, indicating no cognitive impairment. Despite this, her comprehensive care plan noted impaired cognitive function or thought process. The facility's Director of Nursing (DON) confirmed that the policy for medication administration mandates that no medications should be left at the bedside and that staff must observe residents taking their medications. The failure to adhere to this policy could result in residents missing medications and not receiving the necessary therapeutic benefits.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to ensure proper coordination of care with the hospice agency for a resident receiving hospice services. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including cerebral atherosclerosis, dementia, and depression, was admitted for hospice respite services. During her stay, she underwent a surgical wound debridement without the hospice agency being notified or giving prior authorization, as required by the hospice's interdisciplinary plan of care. The resident had an unstageable wound on her coccyx, which was evaluated and treated by a wound care physician without the knowledge or consent of the hospice agency or the resident's responsible party. The facility's physician did not recall referring the resident to the wound care physician and stated that the hospice team should have been the referring entity. The wound care physician also noted that there was no documentation indicating the resident was on hospice, which would have prompted further consultation before proceeding with the debridement. Interviews with the hospice director, facility physician, and wound care physician revealed that the facility failed to notify the hospice agency and the resident's responsible party about the evaluation and procedure. The Director of Nursing (DON) indicated that the previous wound LVN, who was responsible for such referrals, should have contacted hospice for approval. The facility's policy on end-of-life care emphasizes the importance of obtaining physician orders and involving the resident and family in the care plan, which was not adhered to in this case.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents identified as requiring such measures. In the first instance, a cognitively intact female resident with quadriplegia, urinary tract infection, and hematuria was placed on contact isolation due to a vancomycin-resistant infection. Despite clear signage and a fully stocked PPE cart outside the resident's room, a CNA who was new to the facility entered the room and fed the resident without wearing the required gown and gloves. The CNA stated she was distracted by the timing of the meal tray and did not notice the isolation precautions, although she acknowledged understanding the importance of PPE use for infection control. In the second instance, a male resident with paraplegia, muscle wasting, neurogenic bowel, and an indwelling urinary catheter required regular incontinence care. During observed care, a CNA cleaned the resident's bowel movement but then touched a new, clean brief with the same soiled gloves, failing to change gloves or sanitize hands between tasks. The CNA admitted to forgetting to change gloves due to nervousness, despite having received in-service training on infection control practices. Both incidents were observed and confirmed by other staff members, including a medication aide and an LVN, who recognized these actions as breaches of infection control policy. Facility policy requires staff to follow procedures to prevent cross-contamination, including proper hand hygiene and glove changes after providing personal care. The failures observed could contribute to the development and transmission of communicable diseases within the facility.
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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.
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Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windcrest Nursing And Rehabilitation | 1.8 mi | ★★★★★ | 0 | 0 |
| Crestway Nursing & Rehabilitation | 1.9 mi | ★★★★★ | 2 | 0 |
| Army Residence Community | 2 mi | ★★★★★ | 0 | 0 |
| Avir At Converse | 2.8 mi | ★★★★★ | 12 | 0 |
| Northeast Rehabilitation And Healthcare Center | 3.4 mi | ★★★★★ | 23 | 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 October 2026) and official state health department websites.