Avir at Bellville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 14 residents (Resident #7) reviewed for care plans. The facility failed to ensure Resident #7's care plan reflected her oxygen status and included a care plan regarding how to take care of the resident's oxygen. This failure could place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: Record review of Resident #7's face sheet, dated 03/21/2025, revealed the resident was an [AGE] year old female, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #16 ) reviewed for incontinence care. When CNA-C was providing incontinent care to Resident #16 on 03/19/2025, the CNA-C did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region). This failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #16's face sheet, dated 03/21/2025, revealed the resident was a [AGE] year old male and admitted to the facility on [DATE] with the diagnoses of cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (high blood pressure),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #26) of one resident reviewed for enteral nutrition. When RN-E administered a medication via gastrostomy tube to Resident #26, RN-E did not check residual by aspiration of gastric content of the resident. This failure could place residents with gastrostomy tube at risk for complications, aspiration, and pneumonia. Findings included: Record review of Resident #26's face sheet, dated 03/21/2025, revealed the resident was a [AGE] year old male and admitted to the facility on [DATE] with the diagnoses of moderate protein-calorie malnutrition (not enough protein and energy to meet nutritional needs), dysphagia (difficulty of swallowing), gastro-esophageal reflux disease (stomach acid repeatedly flows back up), and muscle wasting and atrophy (wasting or thinning of muscle mass). Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 2 of 2 nursing staff (CNA-C and CNA-D) reviewed for competencies. The facility did not perform CNA-C and CNA-D's annual skill check-off. This failure could place the residents at risk for receiving care by staff who do not have the training and competency needed for providing care. The findings included: Record review of CNA-C and CNA-D's employee profiles revealed CNA-C was hired to the facility on [DATE], and CNA-D was hired on 05/25/2023. CNA-C did not have skill check-off for perineal care upon hiring date, and CNA-D did not have skill check-off for perineal care in 2024. Observation on 03/19/2025 at 2:08 p.m. revealed CNA-C opened Resident #16's old and dirty brief and cleaned the resident's penis, and then cleaned the left and right groin area. CNA-C and CNA-D turned the resident to his left side…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 8% based on 2 errors out of 25 opportunities, which involved two residents (Residents #10 and #97) of five residents reviewed for medication errors. 1. Medication aide-B administered fiber laxative calcium polycarbophil 625 mg one tablet for constipation to Resident #10 on 03/19/2025, but the physician order indicated Metamucil (psyllium husk) 0.4-gram one capsule for constipation. 2. Medication aide-B administered Resident #97's Cyclosporine 0.05% eye drop for increasing tear production two drops to the resident's each eye on 03/20/2025. However, the physician order indicated Cyclosporine 0.05% one drop into both eyes. These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications or not receiving them as prescribed, per physician orders. Findings include: Record review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 14 residents (Resident #5) and 1 nursing carts (C-unit nursing cart) out of 2 nursing carts reviewed for storage. 1. Ketoconazole cream for fungal or yeast infection was found on Resident #5's nightstand in the resident's room on [DATE]. 2. The C-unit nursing cart was left open and unattended by RN -E. These failures could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. The findings were: 1. Record review of Resident #5's face sheet, dated [DATE], revealed the resident was an [AGE] year old male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses of cerebral infarction (disrupted blood flow to the brain due to problem with the blood vessels that supply it), type 2 diabetes mellitus (not control blood sugar in the body), muscle wasting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #13) of 14 residents reviewed, in that: Resident #13's personal refrigerator located in her room observed on 03/18/2025, revealed an unknown food wrapped with papers inside the freezer, with no date and no label. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included: Record review of Resident #13's face sheet, dated 03/21/2025, reflected the resident was an [AGE] year old female and was initially admitted to the facility on [DATE] with diagnoses that included: hyperlipidemia (high level of fat), dementia (loss memory or problem solving and other thinking abilities), muscle wasting and atrophy (loss of muscle tissue and strength), and Alzheimer's disease (destroy memory and other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 resident (Residents #16) of 5 residents reviewed for infection control practices. When CNA-C was providing perineal care to Resident #16, the CNA-C touched new and clean brief with old and dirty gloves after cleaning the resident's buttock area. This deficient practice placed residents at risk for cross contamination and infections. The findings included: Record review of Resident #16's face sheet, dated 03/21/2025, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] with diagnoses of cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (high blood pressure), hypokalemia (low potassium in the blood), muscle weakness, type 2 diabetes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 3 air filters (B-hall air filter) reviewed for environmental concerns. The air filter located B-hall, observed on 03/19/2025, was very dirty with gray colored thickened dust. It was last changed on 04/02/2024. This failure could place residents at risk of a diminished quality of life and respiratory status due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: Observation on 03/18/2025 at 3:16 p.m. revealed there was an air filter on B-hall. The air filter was very dirty with gray colored thickened dust. Further observation revealed the air filter was dated 04/02/2024. Interview on 03/19/2025 at 3:26 p.m., Maintenance stated the air filter located B-hall was observed to be very dirty with gray colored thickened dust, and was last changed on 04/02/2024. Maintenance said he was responsible for changing air filters and was supposed to change them every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide mandatory effective training on communications training for 2 of 20 employees (Housekeeper G and LVN K) reviewed for training, in that: The facility failed to ensure effective communication training was provided to Housekeeper G and LVN K annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for the Housekeeper G revealed a hire date of 06/15/2022. Further review of a training log from the previous 12 months for Housekeeper G, provided by the Administrator revealed no evidence of communication training being provided annually. Record review of the personnel records for LVN K revealed a hire date of 06/01/2022. Further review of a training log from the previous 12 months for LNV K, provided by the Administrator revealed no evidence of communication training being provided annually. Interview with the Administrator, on 03/21/2025 at 4:25 PM revealed communication trainings were available to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program for 1 of 20 employees (RN E) reviewed for training, in that: The facility failed to ensure standards, policies, and procedures for an infection prevention and control program training was provided RN E annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for RN E revealed a hire date of 04/24/2023. Further review of a training log from the previous 12 months for RN E, provided by the Administrator revealed no evidence of Infection control training being provided annually. Interview with the Administrator, on 03/21/2025 at 4:25 PM revealed annual Infection prevention trainings were available to employees via CEU360 and assigned by corporate. The Administrator stated new employees received training in house from the BOM prior to working the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide mandatory effective in-service training for nurse aides on dementia for 1 of 5 nurse aides (CNA H) reviewed for training, in that: The facility failed to ensure dementia training was provided CNA H annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for CNA H revealed a hire date of 07/13/2023. Further review of a training log from the previous 12 months for CNA H, provided by the Administrator revealed no evidence of Dementia training being provided annually. Interview with the Administrator, on 03/21/2025 at 4:25 PM revealed annual trainings were available to employees via CEU360 and assigned by corporate. The Administrator stated new employees received training in house from the BOM prior to working the floor. The Administrator stated current employees received emails informing them of assigned dementia trainings that are due to be completed. The Administrator stated it is the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day 7 days a week from 11/1/2023 to 11/30/2023 for a total of 30 days, 12/1/2023 to 12/31/2023 for a total of 31 days and 1/1/2024 to 1/23/2024 for a total of 23 days, reviewed for RN coverage. The facility had no DON from 7/25/2023 to 9/26/2023 and from 12/26/2023 to 1/26/2024. These failures placed the residents at risk for not having decisions made that would have required and RN to make in the management of the resident's healthcare needs and in managing and monitoring of the direct care staff. The findings included: Record review of employee files r evealed employment dates of the two previous DON's as: DON A 8/31/2022 to 7/25/2023 DON B 9/6/2023 to 12/26/2023 Record review of facility time stamps revealed facility had no RN coverage: 11/1/2023 to 11/30/2023. 12/1/2023 to 12/31/2023. 1/1/2024 to 1/23/2024. Record review on 1/26/2024 revealed facility census was 38 . In an interview on 1/26/2024 at 8:30am with the Regional Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure bulk foods were stored in a manner to prevent contamination. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators. The facility failed to ensure refrigerators maintained a temperature at or below 41 degrees Fahrenheit. These failures could place residents at risk for food contamination and foodborne illness. Findings included: 1/23/24 Entered kitchen for initial observation. 8:55 Am Refrigerator #1 had a temperature of 51 degrees. 8:55 AM Refrigerator #2 had no thermometer. 9:02 AM observation of Freezer #2 revealed it contained: 1 cardboard box of food not labeled, sealed, or dated;. 1 plastic bag of bacon not labeled, sealed, or dated;. 1 plastic bag of tomato-based sauce not labeled or dated;. 1 plastic bag of chicken strips not labeled or dated. 9:57 AM observation of Refrigerator #1 revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the environment was free of accidents hazards for 4 (Resident #20, Resident #25, Resident #26, Resident #30 ) of 5 residents, reviewed for accidents hazards This failure placed residents at risk of injury for accidents or hazard. Findings included: Record review of Resident #25's orders revealed Resident #25 was admitted [DATE] with diagnoses of chronic obstructive pulmonary disease (chronic shortness of breath and cough), muscle wasting and atrophy (loss of muscle), cough, unsteadiness on feet, colostomy status (opening for the large intestine in the stomach). Record review of Resident # 25's MDS dated [DATE] revealed a BIMS score of 13 out of 15 indicating the resident was cognitively intact. Resident #25 required supervision with eating, oral hygiene, and showering/bathing. Resident #25 was independent with upper body dressing, lower body dressing, personal hygiene, and used a wheelchair and walker for ambulating. Record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 4 of 4 dietary support staff Dietary Aide W, [NAME] S, [NAME] R, and Dietary Aide T reviewed for competencies. The facility failed to ensure [NAME] S, [NAME] R, Dietary Aide T, and Dietary Aide W had a current Food Handling Certificate while working in the facility kitchen. This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. The findings included: Record review of Dietary Aide W's personnel file information revealed Dietary Aide W was a part-time aide, with a hire date of 12/23/23. No documentation of a food handler's certificate was found in Dietary Aide W's personnel information provided to surveyor. Observation on 1/23/2023 at 11:30 AM revealed [NAME] S was ladling food onto plates and placing the plates on trays with the assistance of [NAME] R. Dietary Aide T was pouring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 3 of 13 Residents (Resident #27, #22 and #20) reviewed for environment. The facility failed to properly clean/maintain resident #27, #22 and #20's rooms in a sanitary manner. This failure could place residents at risk of unsanitary conditions, psychosocial decline, spread infections which could result in a decline in health. Findings included: Record review of resident #27's face sheet dated 1/25/2024 revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included heart failure, chronic kidney disease, dementia, Cellulitis (infection involving the skin of the lower limbs) and history of diarrhea. Record review of Resident #27's quarterly MDS dated [DATE] revealed he had a BIMS score of 1 out of 15 indicating severe cognitive impairment. He required partial/moderate assistance with toileting, and he was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of five residents (Resident #28) reviewed for care plans The facility failed to ensure Resident #28's comprehensive care plan addressed the residents individual need for the use of a CPAP (a non-invasive ventilation therapy used to facilitate breathing). This failure could place residents at risk of receiving inadequate or unnecessary interventions not individualized to their health care needs. Record review of Resident #28's face sheet dated 01/23/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included a stroke, allergy, aphasia (a comprehension and communication disorder), acute respiratory disease, pneumonia, shortness of breath,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 residents (Resident #28) reviewed for Quality of Care in that: -Nurse Aide F provided services outside the scope of practice of a NA by administering a topical medication to Resident #28's wound. -the ADON delegated outside the scope of nursing practice by allowing Nurse Aide F to administer a topical medication to Resident #28's wound. This failure could place residents at risk of inappropriate medication administration, infection and decline in health. Record review of Resident #28's face sheet dated 01/23/2024 revealed a [AGE] year-old male admitted [DATE]. His diagnoses included stroke, need for assistance with personal care, difficulty with speech, acute respiratory disease, Pneumonia (inflammatory condition of the lung), urinary tract infection, shortness of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure that a resident who needs respiratory care for 1 of 6 residents (Residents #28) reviewed for care consistent with professional standards, in that: The facility failed to clean Resident #28's CPAP (a machine used to keep breathing airway open) mask, nasal pillow and tubing daily. The facility failed to change Resident #28's CPAP tubing monthly. These failures could place residents at risk of respiratory infection, decline in health and hospitalization. Findings include: Record review of Resident #28's face sheet dated 01/23/2024 revealed a [AGE] year-old male admitted [DATE]. His diagnoses included stroke, need for assistance with personal care, difficulty with speech, acute respiratory disease, Pneumonia (inflammatory condition of the lung), urinary tract infection, shortness of breath (difficulty breathing), COPD, hemiplegia (paralysis to one side of the body), obesity, diabetes, HTN and osteoarthritis (a type of joint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.