Every finding on record at Redbud Village

The facility identified a census of 33 residents, with 15 residents reviewed for misappropriation of property through diversion. Based on record review, observation, and interview, the facility failed to prevent misappropriation of medications for 15 cognitively impaired residents including some controlled substances, which resulted in missed medications for the affected residents. Findings included: The Facility Incident Report, dated 02/13/26, documented on 02/08/26 at 06:30 AM, Laundry Staff U went into the soiled utility room to pick up dirty laundry. When Laundry Staff U was transferring the dirty laundry to the laundry bin, she came across a black trash bag that made a noise when she picked it up. Laundry Staff U opened the bag and saw a bunch of pills. She took the pills to the LN G. LN G notified the facility's administrative staff. Upon investigation by Administrative Nurse D and Administrative Staff A, camera footage revealed, the laundry bin was last emptied at 08:03 PM on 02/07/26. At 08:10 PM Certified Medication Aide (CMA) R removed a black trash bag from the medication cart, carried it down the north hall to the soiled utility room, then left the soiled utility room without the black trash sack. During review of the camera footage, CMA R took out a resident's bubble packed (individually dosed cards of medications) medications, placed the medications into a medication cup, and put some of the medications into the trash bag. Other medications popped from the bubble packs were placed in a medication cup and put in the top left-hand drawer of the medication cart. The controlled substance drawer was unlocked, and pills were placed into the medication cups in the top left drawer. Forty-three pills were identified in the black trash sack belonging to 15 different residents, who were all cognitively impaired. It was determined nine controlled substances or muscle relaxers were popped from the residents' medication cards but were not accounted for. Laundry Staff U's Notarized Witness Statement, dated 02/08/26, documented at 06:30 AM, Laundry Staff U emptied the soiled laundry barrel. When she got to the bottom of the barrel, there was a black trash bag. Laundry Staff U picked up the black trash bag and noticed it made a noise. She looked inside the bag, and noted there were a whole bunch of pills in the bag. Laundry Staff U went and asked the medication aide what to do with them. Laundry Staff U then found Licensed Nurse (LN) G and asked her what to do with the pills. Laundry Staff U showed LN G where she found the pills. Review of Resident (R)1, R3, and R4's records revealed the following outcomes related to misappropriation of their medications: Resident (R) 1's Electronic Medical Record (EMR) documented diagnoses of pain, Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), mood disturbance (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R1's Quarterly Minimum Data Set (MDS), dated 12/12/25, documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS documented R1 had a PHQ-9 (a tool assessing depression severity) of 9, which indicated mild depression. The MDS documented R1 took antipsychotics (a class of medications used to treat major mental conditions, which cause a break from reality), anticonvulsants (a class of medications used to treat seizures and manage epilepsy by regulating abnormal electrical activity in the brain), and opioid (a class of medications used to treat moderate to severe pain) medications. The Care Area Assessment (CAA), dated 09/10/25, documented R1 had a diagnosis of Alzheimer's disease and took psychotropic medications. R1's Care Plan dated 09/02/25, documented R1 had pain and directed staff to administer pain medications as ordered (01/22/26). The plan documented R1 took antipsychotic medications and directed staff to administer the medications as ordered (09/03/25). R1's EMR documented R1 did not receive the following medications the night of 02/07/26: cyclobenzaprine (muscle relaxer), divalproex sodium (anticonvulsant), donepezil (antidementia), Eliquis (anticoagulant), risperidone (antipsychotic), and zaleplon (a hypnotic). The Nurse's Note, dated 02/09/26 at 12:09 PM, documented R1 stated she wanted to leave the facility because she felt disrespected and felt ugly. R1 stated her back hurt too much for her to move. R1 would get up into her chair for short period of time but did not wish to leave her room. On 03/23/26 at 10:00 AM, observation revealed R1 sat in her recliner staring out the window in her room. R3's EMR documented R3 had diagnoses of Alzheimer's Disease, dementia, and anxiety. R3's Significant Change MDS, dated 02/02/26, documented a BIMS of 0, which indicated severely impaired cognition. The MDS documented R3 took antianxiety medications and opioid medications. CAA's, dated 02/02/26, documented R3 had diagnoses of Alzheimer's disease and dementia. R3 had a BIMS of 0. R3 took psychotropic medications. R3's Care Plan, dated 01/22/26, documented R3 took psychotropic medications, antianxiety medications, antidepressant medications, and pain medications and directed staff to administer the medications as ordered (01/22/26). R3's EMR indicated R3 did not receive the following medications on the night of 02/07/26: tramadol (opioid pain medication), lorazepam (antianxiety medication), melatonin (medication to help regulate sleep), and gabapentin. The Nurse's Note, dated 02/08/26 at 02:30 AM, documented R3 was very restless through the night and up to the bathroom multiple times. R3 was unavailable for observation. R4's EMR documented R4 had diagnoses of major depressive disorder (major mood disorder which causes persistent feelings of sadness), psychosis (any major mental disorder characterized by a gross impairment and perception), and anxiety. The Quarterly MDS, dated 01/08/26, documented R4 had a BIMS score of four, which indicated severe cognitive impairment. The MDS documented R4 took antipsychotic medications, antidepressant medications, and anticonvulsant medications. CAA's, dated 07/16/25, documented R4 had impaired cognitive abilities with a BIMS score of six. R4 displayed disorganized thinking and inattention. The CAA documented R4 took psychotropic medications. R4's Care Plan, dated 11/25/25, documented R4 had agitated behaviors, impaired cognition, and hallucinations. The care plan directed staff to administer R4's antipsychotic, antidepressant, and pain medications as ordered. The EMR indicated R4 did not receive the following medications on the night of 02/07/26: cephalexin (an antibiotic for a urinary tract infection), duloxetine (an antidepressant), Seroquel (an antipsychotic), and gabapentin (for nerve pain). The Nurse's Note, dated 02/07/26, documented R4 came out of her room and stated she had been held captive at the facility for three years, her daughter was getting married, and she had to get out to go and get her a dress. R4 stated she was all packed, the police knew, and she would leave at midnight. On 03/23/26 at 10:30 AM, observation revealed R4 in her wheelchair pedaling up and down the hall. R2, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, and R15 did not receive multiple other medications the night of 02/07/26, such as stool softeners, pain medications, cholesterol medications, and sleep medications. On 03/23/26 at 11:30 AM, Administrative Nurse D stated she went through the black trash sack and sorted all of the medications that were in the bag. Administrative Nurse D stated none of the controlled substances that were supposed to be given to the fifteen residents who were cognitively impaired were located. Administrative Nurse D stated she thought CMA R had specifically chosen those residents to target because they would not remember if they took medications or not. Administrative Nurse D stated CMA R did not administer any of the medications to the fifteen residents. Administrative Nurse D stated law enforcement was notified, CMA R refused to take a drug test, and quit. Administrative Nurse D stated all of the residents who were affected were assessed that day and for the next seventy-two hours. On 03/23/26 at 01:00 PM, Administrative Staff A, during the exit interview, stated education on drug diversion and misappropriation of property had been presented to all the staff on 03/04/26, which was verified through appropriate documentation of the in-service. The facility's Abuse, Neglect, and Exploitation Policy, dated 02/12/26, documents that each resident in the community has the right to be free from abuse, neglect, and misappropriation of their property. The community will enforce the policies and procedures that protect each resident from abuse, neglect, and misappropriation of property by employees of the community, other residents, consultants, volunteers, employees of other agencies, family members, legal guardians, friends, or other individuals. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility completed all corrective actions on 03/04/26, prior to the onsite survey therefore the deficient practice was deemed past noncompliance and remained at the scope and severity of a G to represent actual harm using the reasonable person concept. This was applied due to inability of the cognitively impaired residents to verbalize the impact of their increased discomfort and pain.

The facility identified a census of 33 residents, with three residents reviewed for falls and supervision. Based on record review and interview, the facility failed to provide the care planned supervision for cognitively impaired Resident (R) 1 (who had a history of falls, dizziness, and weakness) to prevent a fall with major injury. On 01/08/26 at 08:57 PM, Licensed Nurse (LN) G assisted R1 to the north patio smoking area, placed a smoking apron on R1, and lit R1's cigarette. LN G left R1 outside on the patio and went back inside the facility, which left R1 without direct supervision. While inside, LN G stepped away for a moment and heard R1 yell for help at 09:05 PM. LN G went outside and discovered R1 on the ground on his left side. R1 required emergency medical transport to a local hospital and surgery to repair his broken left hip. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of paroxysmal (a sudden, intense, recurring onset of symptoms) atrial fibrillation (rapid, irregular heartbeat), orthostatic hypotension (blood pressure dropping with change of position), dizziness (lightheadedness, spinning, or imbalance), and tobacco use. The Significant Change Minimum Data Set (MDS) dated 12/03/25 documented R1's Brief Interview for Mental Status (BIMS) score was four, which indicated severely impaired cognition. The MDS documented R1 required moderate staff assistance for sit-to-stand and transfer, required maximum staff assistance with toileting, dressing, and personal hygiene, and was dependent on staff for bathing. The MDS documented R1 had two or more injury falls (not major) since 10/08/25. The Care Area Assessment (CAAs) dated 12/03/25 documented R1 was a fall risk and had two or more falls with minor injury since the last assessment. R1's Care Plan, initiated 08/09/22, documented R1 had a history of syncopal episodes (a temporary loss of consciousness caused by a sudden drop in blood flow to the brain) and was at risk for falls. The care plan directed staff to encourage R1 to call for staff assist if he felt weak, dizzy, or unsteady before attempting to transfer or ambulate. The care plan directed staff to observe/monitor R1 for changes in gait or balance when/after R1 smoked, as R1 had been noted to become dizzy at times after he smoked (08/10/22). The care plan directed staff to provide R1 with a safe environment (08/09/22). The care plan directed staff to monitor R1 while smoking and light R1's cigarette (11/25/25). The Smoking Safety Evaluation dated 11/17/25 documented R1 had problems with balance while sitting or standing, had previously burned his skin, clothing, furniture, or other items, and dropped ashes on himself. The evaluation indicated the staff were to light R1's cigarette and monitor R1 while the resident smoked. The Morse Fall Scale dated 12/08/25 documented a fall risk score of 70, which indicated R1 was a high risk for falls. The Communication with Physician Note dated 11/20/25 documented at 06:35 AM, staff were called to R1's room. R1 lay on the floor on his back with his knees bent. R1 verbalized he was going out of his room to get coffee and then felt weak and dizzy. R1 verbalized he hit his head and had pain in his neck. The Communication with Physician Note dated 11/21/25 documented the staff notified R1's primary care physician (PCP) regarding R1's increasing weakness and received an order for physical therapy. The Incident Note dated 11/23/25 documented a Certified Nurse Aide (CNA) found R1 on the floor. R1 reported he was dizzy, he hit his head, he felt weak and confused to his surroundings. The note documented orders received to send R1 to the emergency room (ER) for increased weakness and confusion. The Nurses Note dated 11/25/25 documented R1 was weak, displayed difficulty getting up off his bed and into his wheelchair, and displayed difficulty moving his feet at times. The Plan of Care Note dated 11/26/25 documented R1's health status had declined, and R1 required more assistance with activities of daily living (ADL). R1 required one to two staff members' assistance as needed. The Communication with Physician Note dated 12/23/25 documented R1 was found on the ground outside. The nurse observed R1 sitting outside on the concrete, on his buttocks, with bilateral legs outstretched in front of him. R1 attempted to transfer himself from his wheelchair into the lawn furniture and slipped from the cushion of the lawn chair and onto the ground. R1 educated on requesting assistance when transferring self. The Health Status Note dated 12/28/25 documented R1 was not eating, was drinking very little, and getting weaker as the day went on. The ER was called, and a new order was given to obtain a urine specimen. The Health Status Note dated 01/02/26 documented R1's health status had declined recently from independent to requiring one to two staff members for ADLs. R1's appetite decreased, and R1 did not want to eat or drink despite education on the importance of nutrition and hydration. R1 was more fatigued throughout the day, his overall health status declined the past several months, and worsened over the past week. The Nurse's Note dated 01/02/26 documented R1 was weak that evening and R1 displayed difficulty ambulating. The Incident Note dated 01/08/26 documented R1 went outside to the smoke patio about 08:57 PM, noting staff let him out as R1 had missed the original smoke time. R1 sat in a chair, and staff (LN G) went inside for a few minutes. At 09:05 PM, staff (LN G) heard R1 yell and went to check on R1. LN G found R1 on the ground, lying on his left side. R1 denied hitting his head. R1's right slipper was noted to be off. R1 was alert and oriented and moved his legs. LN G asked R1 if he was in pain, and R1 stated no more than usual. R1 recently started on round-the-clock tramadol (pain medication) due to severe pain. Staff assisted R1 to try to push off the ground to sit up, and R1 moved about five degrees, but immediately grabbed his right hip and said it hurt badly. Staff assisted R1 back to the ground and called the ambulance to transfer R1 to the ER for severe hip pain. R1 told the paramedics his left hip also hurt, and the left hip was noted to have some rotation. It was noted R1 had a skin tear to the top of his left hand and blood on his shirt to the left elbow. The paramedics and LN assisted R1 in removing his coat, as it was soaked in water, and R1 was very cold. R1 stated his left shoulder hurt. The Radiology Report dated 01/08/26 documented R1 had sustained a non-displaced subcapital hip fracture at the junction where the femoral (thigh bone) head meets the femoral neck and a mid-left femoral neck fracture. The Incident Note dated 01/09/26 documented R1 left via ambulance at 09:15 PM for the local hospital. LN G called the local hospital and was informed R1 broke his left hip. The Plan of Care Note dated 01/13/26 documented R1 had returned from the hospital and was non-weight-bearing due to his hip fracture. The facility's Incident Report dated 01/14/26 documented on 01/08/26 at 08:57 PM, R1 went outside to smoke a cigarette. R1 walked outside wearing a coat and using his walker, and then sat in his favorite chair on the smoking patio. LN G placed a smoking apron on R1 and lit R1's cigarette. LN G went inside the door to monitor through the windows while at the nurses' cart, until R1 finished smoking. At 09:05 PM, R1 yelled for help. LN G went outside and found R1 lying on the ground on his left side. R1 denied hitting his head. It was noted R1's right slipper was off his foot on the ground next to him. R1 reported he lost his balance as he stood up, and his slipper came off, which then caused him to fall onto the ground. R1 was alert and oriented times two and staff performed a full body assessment in the same place to avoid injuries, with no major injuries or concerns at that time. The staff obtained R1's vital signs: temperature 97.8 degrees Fahrenheit (F), blood pressure 150/87 millimeters of Mercury (mmHg), heart rate 87 beats per minute, respiration 16 per minute, and oxygen saturation 93% on room air. LN G asked R1 if he had any pain, and he replied no more than usual. R1 recently started on tramadol to help with pain. Additional staff arrived and assisted LN G with getting R1 up from the ground. LN G instructed R1 to push off the ground to sit up. R1 moved about five degrees when he immediately grabbed his right hip and said it hurt badly. Staff assisted R1 back to a lying position, where it was not painful. The staff immediately called for an ambulance to transfer R1 to the local hospital ER. Once EMS arrived, the paramedics talked more with R1, and he stated his left hip also hurt. LN G noted minimal right hip rotation when R1 moved inside with light. It was also noted R1 had a skin tear to the top of his left hand, and when his coat was taken off, staff noted blood coming through his shirt by his left elbow. While the paramedics and LN G assisted R1 with removing his coat, R1 complained of left shoulder pain, but continued to move his arm freely to finish taking off his coat. Blankets were placed over R1 while on the gurney, and R1 was transferred to the local hospital ER for further evaluation. While in the ER, R1 stated he had left hip pain and wounds and that he had hit his head when he fell. Lab work and imaging obtained. Computed tomography (CT scan- a test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) of the head was negative for abnormalities. CT of the cervical spine showed no abnormalities. Left hip x-ray showed a non-displaced subcapital hip fracture that occurs at the junction where the femoral (thigh bone) head meets the femoral neck and mid left femoral neck fracture. R1 transferred to a higher level of care orthopedic unit. R1 received surgery to repair his hip fracture on the morning of 01/09/26. While in the hospital, R1 let occupational therapy work with him, but would not allow physical therapy to work with him. R1 returned to the facility on [DATE], and was non-weight bearing on his left leg, requiring a pivot transfer or Hoyer (total body mechanical lift) lift transfer. Education provided to R1 on the importance of wearing proper footwear when walking outside to smoke. R1 knew he needed to wear tennis shoes or other appropriate footwear rather than slippers when he ambulated outside to smoke. R1 was unavailable for observation or interview. On 01/26/26 at 11:30 AM, Administrative Nurse D stated LN G stated she had monitored R1 out the windows by the patio when another staff member had come up to her informing her of another resident having pain. LN G stated she stepped away from the window to go to the nurse's office to look at the resident's medication administration record to see if they could have pain medication when she heard R1 yell. Administrative Nurse D stated LN G told her she was gone from the window for no more than ten seconds when she heard R1 yell. Administrative Nurse D stated she considered watching R1 from the window to be direct supervision, and LN G could not stay outside with R1 because it was cold, the smoke bothered LN G, and LN G had precancer. Administrative Nurse D stated lack of supervision did not contribute to R1's fall with injury, but allowing R1 to walk outside on the concrete to smoke in his slippers had been the cause of R1's fall. Administrative Nurse D stated R1's slippers were at least two sizes too big, but he preferred the slippers. Administrative Nurse D stated staff should have had R1 wear tennis shoes to go out to smoke. Administrative Nurse D stated R1's BIMS score was low, but he was actually a good historian with short-term items, and she believed R1 when he said he tripped over his slipper. Administrative Nurse D stated LN G was unavailable for the interview, as she was a nursing instructor and was in class. Administrative Nurse D stated she would have LN G call this surveyor for an interview. LN G did not call the surveyor for an interview. The facility's Smoking Policy, revised July 2017, documented the policy establishes safe and consistent guidelines for smoking within the facility to protect the health and safety of all residents while maintaining a smoke-free environment for staff, visitors, and residents. The staff shall consult with the physician and/or director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Smoking and Safety Evaluation. Any smoking-related privileges, restrictions, and concerns would be noted on the care plan, and all personnel caring for the resident would be alerted to these issues. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer at all times while smoking. The facility's Fall Risk Assessment, revised March 2018, documented the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, would seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on assessment information. Assessment data would be used to identify underlying medical conditions that may increase the risk of injury from falls. The staff would evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, ADL capabilities, and cognition. Staff would collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to disinfect a glucometer (blood sugar reading machine) between resident use and sort soiled laundry in a sanitary manner. This placed the residents at risk for infectious disease processes. Findings included: - On 03/11/25 at 07:31 AM, Licensed Nurse (LN) G obtained a blood sugar reading for Resident (R) 6 by using a multiuse glucometer. LN G then placed the glucometer on top of the treatment cart. LN G then left the glucometer on the top of the cart and went on to perform other nursing tasks. On 03/11/25 at 07:52 AM, LN G returned to the treatment cart and retrieved the glucometer to obtain another resident's blood sugar level. LN G then took the unsanitized glucometer into another resident's room to obtain a blood sugar reading. LN G stated she had not sanitized the glucometer between resident use. On 03/11/25 at 10:01 AM, Administrative Nurse D verified the glucometer should be cleaned with appropriate sanitizing wipes between each resident use. The facility's Shared Glucometer Cleaning Protocol dated 03/21/22 documented that glucometers shared by multiple residents will be thoroughly wiped with Sani-Cloths and allowed to air dry for two minutes after every use and between residents. The facility failed to ensure the multiuse glucometer was sanitized between resident use, which placed the residents at risk for infectious disease processes. - On 03/11/25 at 10:27 AM, Housekeeping/Laundry Staff V reported wearing only gloves as personal protective equipment (PPE - gowns, face shields and/or eyeglasses/goggles, and gloves) while sorting soiled laundry. Housekeeping/Laundry Staff V stated he was new to the position and had not been informed he was to use a gown and gloves to sort soiled laundry. On 03/11/25 at 11:26 AM, Housekeeping/Laundry Supervisor U stated Housekeeper/Laundry Staff V should wear a gown and gloves while sorting soiled laundry. She stated she had gotten busy with other tasks and forgotten to replenish the supply of gowns for sorting of soiled laundry. The facility's undated Soiled [NAME] and Bedding policy documented that soiled laundry/bedding shall be handled, transported, and processed according to the best practice for infection prevention and control. All used laundry is handled as potentially contaminated using standard precautions (e.g., gloves and gowns when sorting). Hand hygiene products, as well as appropriate PPE (i.e. gloves and gowns), are available and used while sorting and handling contaminated linens. The facility failed to sort soiled laundry by using appropriate PPE, which placed the residents at risk for infectious disease processes.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to meet professional standards of quality when administering insulin (a hormone that lowers the level of glucose in the blood) with an insulin pen (an injection device used to deliver preloaded insulin). This placed the seven residents who received insulin at risk of receiving an inaccurate dose. Findings included: - On 03/11/25 at 08:00 AM, Licensed Nurse (LN) G administered Lantus and Aspart (manufacturer named) insulin subcutaneously (beneath the skin) without priming the insulin pen to Resident (R) 11. LN G verified she had not primed the insulin prior to administration of the insulin and was unaware of the manufacturer or facility policy to do so. On 03/11/25 at 09:59 AM, Administrative Nurse D stated she was unaware of the need to prime the insulin pens prior to dialing the ordered units of insulin. The facility's Insulin Administration policy, dated 09/2014, documented that the nursing staff will have access to specific instructions (from the manufacturer, if appropriate) on all forms of insulin delivery system (s) prior to their use. The policy lacked instructions regarding the need to prime insulin pens prior to giving the dose. The manufacturer's instructions of use for Lantus and Aspart insulin pens direct the user to prime the insulin pens with two units of waste insulin prior to dialing the physician ordered dose. The facility failed to ensure professional standards of quality when preparing and administering insulin, using insulin pens, which placed the residents at risk of receiving inaccurate doses of insulin.

The facility had a census of 31 residents. The sample included 12 residents, with five residents reviewed for immunizations. Residents (R) 11 and R13 lacked the pneumococcal vaccination (helps protect against serious illnesses like pneumonia). Based on record review, and interview, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) to administer a pneumococcal vaccine following written consent. This deficient practice placed the R11 and R13 at risk of acquiring, spreading, and experiencing complications from the pneumococcal disease. Findings included: - A review of immunization records revealed R11 and R13 lacked the CDC recommended pneumococcal immunizations. On 09/03/24 R11 and 08/27/24 R13 had signed consent on the Consent Form for Flu and Pneumonia Vaccine to receive the pneumonia vaccine. Both R11 and R13 lacked documentation of having received the CDC recommended pneumococcal immunizations. Administrative Nurse D was unable to provide documentation R11 and R13 had received the appropriate pneumococcal vaccinations. On 03/12/25 at 12:19 PM, Administrative Nurse D reported the local medical clinic had obtained the consents and would have administered immunizations. The facility's Pneumococcal Vaccine policy, dated 10/2019, documented that administration of pneumococcal vaccinations or revaccination will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. This deficient practice placed the R11 and R13 at risk of acquiring, spreading, and experiencing complications from the pneumococcal disease.