Alhambra Healthcare & Wellness Centre, LP

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 61), was provided Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting performed daily) care. On 6/24/2025, Resident 61 was observed in bed with brown residue on right inner thigh and brown smear on the outside and top of the incontinent brief (a disposable diaper used for adults). This failure had the potential for Resident 61 to experience skin breakdown and/or discomfort. Findings: During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness one side of the body), dementia (a progressive state of decline in mental abilities) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and…

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 follow the fluid restriction (a dietary change that limits the amount of liquid a person can consume in a day) as indicated on the physician order for one (1) of two (2) sampled residents (Resident 12), who was receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/s have failed) treatment. This deficient practice has the potential for fluid overload (a condition where there is too much fluid in the body which could result in swelling, particularly in the ankles and legs, and shortness of breath and health complications) for Resident 12. Findings: During a review of Resident 12's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of end stage renal disease (irreversible kidney failure) and generalized edema (swollen throughout the body due to fluid…

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 administer a scheduled medication on time for one (1) of 21 sampled residents (Resident 35) per physician's order, in accordance with the facility's Medication Administration policy and procedure (P&P). This deficient practice had the potential to cause Resident 35's medical condition to worsen. Findings: During a review of Resident 35's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included paraplegia (paralysis of the legs and lower body) and dizziness (a sensation of unsteadiness, lightheadedness, or spinning). During a review of Resident 35's Minimum Data Set (MDS, resident assessment tool) dated 4/16/2025, the MDS indicated the resident was assessed to have intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making and was assessed to require substantial/maximal assistance (helper does more than half…

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 of the facility menu, the facility failed to ensure one (1) of two sampled residents (Resident 17) was provided with a therapeutic (food that does not require much chewing and are soft on the mouth) diet (dysphagia [difficulty swallowing] mechanical soft diet) as ordered by the physician. This deficient practice had the potential for Resident 17 not to receive proper nutrition and experience weight loss. Findings: During a review of Resident 17's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of protein-calorie malnutrition (serious condition that occurs when a resident's diet does not contain the right amount of nutrients) and hyperlipidemia (high cholesterol). During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool), dated 5/16/2025, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions)…

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 implement its policy by not checking the food brought in by family members for one (1) of two (2) sampled residents (Resident 73). This deficient practice has the potential for Resident 73 to choke (severe difficulty in breathing because of a constricted or obstructed throat or a lack of air) and aspirate (when food, liquid, or other material enters a resident's airway and eventually the lungs by accident) on food which can lead to death. Findings: During a review of Resident 73's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses of dysphagia (difficulty swallowing), hyperlipidemia (abnormally high concentration of fats or lipids [fat particles] in the blood), and adult failure to thrive(a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and…

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 implement a toileting schedule (timed voiding) for three (3) of 3 sampled residents (Resident 40, 16, and 82), who were assessed as candidates on the bowel and bladder (B&B) program screener (an assessment of the bowel and bladder to see if residents are candidates to join a scheduled toileting) as indicated on the facility policy and procedure. This deficient practice has the potential for Residents 40, 16, and 82 to become incontinent (loss of bowel and bladder control). Findings: 1. A review of Resident 40's admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of muscle weakness and hypertension (high blood pressure). A review of Resident 40's History and Physical (H&P), dated 5/17/2024, indicated resident did not have the capacity to understand and make decisions. A review of Resident 40's Minimum Data Set (MDS, a standardized screening and assessment tool),…

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 the necessary respiratory care services for four (4) of 4 sampled residents (Resident 2, 49, 63, and 641) in accordance with the facility's policy and procedure. 1. For Resident 2, the facility failed to ensure the oxygen via nasal cannula (a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels) was administered according to physician's order. This deficient practice had the potential for Resident 2 not being able to receive the benefits of the supplemental oxygen ordered if the oxygen tubing is not in an optimal working condition. 2. For Resident 2 and 49, the facility failed to ensure the nasal cannula was placed in a clean plastic bag when not in use. This deficient practice had the potential for the residents to develop a respiratory infection. 3. Resident 641's oxygen nasal cannula (NC; a device that delivers extra oxygen through a tube and into your nose) and water container for…

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 follow proper food handling practices in accordance with its policy and procedure by failing to ensure: 1. A container of rice was sealed properly. 2. A container of brown sugar was sealed properly. 3. A can opener was clean and free of gunk (unpleasantly sticky or messy substance) and rust (a reddish-brown substance that forms on the surface of iron and steel as a result of reacting with air and water). These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, which can lead to other serious medical complications and hospitalization. Findings: During an observation in the facility's kitchen on 6/25/2024 at 7:49 PM, the following were observed: 1. A clear plastic container of rice storage was not sealed properly. 2. A clear plastic container of brown sugar was not sealed. 3. A can opener 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 follow infection control practices by failing to: 1. Change gloves while providing incontinence (inability to control bowel and bladder function) care for Resident 40. This deficient practice had the potential to spread infection to staff and residents. 2. Implement water sample (to collect and deliver for analysis a sample of water representative of the bulk of water being examined) testing to validate the facility's water water management program control measures (actions that can be taken to reduce the potential of exposure to a hazard) initially or on an ongoing basis to ensure the facility's water was free of waterborne (carried or transmitted by water and especially by drinking water) pathogens (any organism that can cause disease) such as legionella (a bacterium which cases legionnaires' disease [a severe form of pneumonia - lung inflammation usually caused by infection]). This failure had the potential to place the residents in…

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 have an appropriate call light (an alerting device for nurses or other nursing personnel to assist a resident in need) according to the resident's condition and to have the call light within reach for 1 of 20 sampled residents (Resident 5). This deficient practice had the potential to delay in the necessary care and services for Resident 5. Findings: A review of Resident 5's admission Record indicated resident was admitted on [DATE] with the following diagnoses of muscle weakness and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Resident 5's History and Physical (H&P), dated 12/11/2022, indicated Resident 40 does not have the capacity to understand and make decisions. A review of Resident 5's Care Plan with focus on potential for injury, revised 12/20/2022, indicated to keep call light within reach. A review of Resident 5's Care Plan with focus on risk for falls, revised…

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 interview and record review, the facility failed to maintain a current copy of the resident's advanced directive (a legal document that provide instructions for medical care and only go into effect if the resident cannot communicate his/her wishes) in the resident's medical record for one (1) of 1 sampled resident (Resident 46). This deficient practice had the potential for Resident 46 to not have her wishes met regarding life-sustaining treatment (any treatment that serves to prolong life without reversing the underlying medical condition). Findings: A review of Resident 46's admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of malignant neoplasm (also known as cancer; a disease in which abnormal cells divide uncontrollably and destroy body tissue) of left lower limb and immunodeficiency (immune systems ability to fight infectious diseases and cancer is compromised or entirely absent). A review of Resident 46's…

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 (Cross reference F686) Based on interview and record review, the facility failed to ensure a comprehensive person-centered care plan was initiated for one (1) of 20 sampled residents (Resident 26). This deficient practice resulted in the delayed care and services for Resident 26's pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin). Findings: A review of Resident 26's admission Record indicated resident was a admitted to the facility on [DATE] with the diagnoses of muscle weakness and osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bones changes) A review of Resident 26's History and Physical (H&P), dated 6/13/2023, indicated resident had the capacity to understand and make decisions. A review of Resident 26's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 6/8/2024, indicated resident was severely impaired in cognitive (the functions your brain…

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 resident care plans were revised for one (1) of 20 sampled residents (Resident 5) This deficient practice had the potential to inadequately care for resident's needs, resulting in a decline in Resident 5's functionality. Findings: A review of Resident 5's admission Record indicated resident was admitted to the facility on [DATE] with the following diagnoses of muscle weakness and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Resident 5's History and Physical (H&P), dated 12/11/2022, indicated Resident 40 did not have the capacity to understand and make decisions. A review of Resident 5's Occupational Therapy (OT, a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life) titled Occupational Therapy - OT Evaluation & Plan of Treatment, dated 8/30/2023,…

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 two (2) of 20 sampled residents (Residents 643 and 10) were provided one to one (1:1, one staff to one resident) feeding assistance as ordered. This failure had the potential to put Residents 643 and 10 at risk for weight loss and aspiration (accidentally inhaling a foreign object, food or liquid through the vocal cords into the airway). Findings: 1. A review of Resident 643's admission Record, indicated the resident was initially admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric (between the trochanters [bony protrusions on the femur - thighbone]) fracture (as partial or complete break in the bone) of the left femur and dysphagia (swallowing difficulties) oropharyngeal phase (starting in the mouth and/or the throat). A review of Resident 643's History and Physical Examination (H&P), dated 4/4/2024, indicated the resident does not have the capacity to understand and make decisions. A review of Resident…

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 (Cross reference F656) Based on interview and record review the facility failed to ensure one (1) of two (2) sampled residents (Resident 26) was given appropriate treatment for a Stage 2 (the skin breaks open; it can look like an abrasion, blister, or a shallow crater of the skin) Pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin). This deficient practice resulted in Resident 26's pressure injury progressing from a Moisture-Associated Skin Damage (MASD, inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine stool, sweat, wound drainage, saliva, or mucus) wound, to a stage 2 pressure injury. Findings: A review of Resident 26's admission Record indicated the resident was a admitted to the facility on [DATE] with the diagnoses of muscle weakness and osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bones changes) A review of Resident 26's…

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 one (1) of 5 (five) sampled residents (Resident 54) had sufficient supply of gabapentin (nerve pain medication) to administer in accordance with the physician's order and facility's policy and procedure. These deficient practices resulted to a delay in the administration of the medication and had the potential to create medication - related adverse consequences such as unrelieved nerve pains to Resident 54. Findings: A review of Resident 54's admission Record indicated Resident 54 was admitted on [DATE] with type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar by either the body does not produce enough insulin, or it resists insulin) with diabetic neuropathy (nerve damage caused by diabetes which can affect nerves that supply feeling and movement in the arms and legs). A review of the Physician's Order, dated 11/14/2022, timed at 3:57 PM indicated to administer gabapentin capsule 100…

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 follow its Medication Storage policy by failing to: 1. Refrigerate Residents 48's unused Novolin R Flex Pen (form of insulin, a naturally occurring hormone, used to control blood sugar in patients with diabetes). 2. Refrigerate Residents 59's unused Basaglar Kwik Pen (is a long-acting insulin that helps lower high blood sugar levels). This deficient practice increased the risk for Residents 48 and 59 to receive insulin that had become ineffective or toxic due to improper storage possibly leading to health complications, which may result to harm and hospitalization. Findings: 1. During a concurrent observation of Medication Cart 3 in Station 2 and interview with Licensed Vocational Nurse (LVN 4) on 6/28/2024 at 2:35 PM, Residents 48's Novolin R Flex Pen was observed in Medication Cart 3. LVN 4 stated a green sticker on Residents 48's Novolin R Flex Pen indicated the medication needs to be refrigerated. LVN 4 also stated Residents 48's unused Novolin R Flex Pen was not and was supposed to be in the refrigerator.…

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 prevent fall () for one (1) of three (3) sampled residents (Resident 1), assessed as high risk for falls when Resident 1 was not provided assistance when getting up from the bed to go to the bathroom and failing to initiate a fall care plan (a document created for a resident receiving healthcare, personal care, or other forms of support) , as indicated on the facility policy and procedure. This deficient practice resulted to Resident 1 ' s fall on 5/19/2024 and transfer to General Acute Care Hospital (GACH 1). Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 5/9/2024 with diagnoses which included muscle weakness, history of falling, and abnormality of gait and stability. A review of Resident 1 ' s Fall Risk Evaluation, dated 5/9/2024 indicated Resident 1 ' s score was 11 which indicated high risk of fall. Resident 1 ' s risk factors included were history of falls in the past 3 months, change of condition in the last 14 days, and balance problem while walking.…

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 interview and record review, the facility failed to notify the doctor for one of one sampled resident (Resident 1), of Resident 1's change in condition of a decreased oxygen saturation (the amount of oxygen carried by red blood cells) of 78% (a normal level is between 95% and 100%) once identified as indicated in facility's policy and procedure. This failure had the potential to result in delayed treatment and provision of services for Resident 1, negatively affecting the resident's health and well-being. Findings: A review of Resident 1's admission Record, indicated Resident 1 was initially admitted at the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that include pneumonia (PNA- inflammation of the lungs due to a bacterial or viral infection, acute respiratory failure(a sudden condition in which not enough oxygen passes from the lungs into the blood), moderate persistent asthma (a respiratory disorder characterized by inflamed airways and difficulty breathing), and…

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 interview and record review, the facility failed to ensure one of one sampled resident (Resident 1), had an active doctor's order for oxygen (O2) therapy (helps people with lung diseases or breathing problems get the oxygen their bodies need to function) administration and an indication (the condition that leads to the requirement of a treatment) for oxygen use, before and during oxygen administration. This failure placed resident at risk for inadequate oxygen with the potential to negatively impact Resident 1's health and well-being. Findings: A review of Resident 1's admission Record, indicated Resident 1 was initially admitted at the facility on 1/14/2024 and readmitted to the facility on [DATE] with diagnoses that include pneumonia (PNA- inflammation of the lungs due to a bacterial or viral infection, acute respiratory failure(a sudden condition in which not enough oxygen passes from the lungs into the blood), moderate persistent asthma (a respiratory disorder characterized by inflamed airways and…

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 interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of two sampled residents (Resident 1), who was assessed at risk for falls as indicated in the resident's Fall Risk Evaluation. This deficient practice had the potential for Resident 1 to incur avoidable falls while in the facility and sustain injury from falls. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses of dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities) and depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment of daily life). A review of Resident 1's History and Physical, dated 11/29/23, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS; a standardized assessment and care screening tool), dated…

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 interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had a diagnosis of dementia and severely impaired with cognition (thought process) was provided with adequate supervision, in accordance with the facility's policy and procedure on Resident Safety. This deficient practice resulted in Resident 1 eloping from the facility on 12/9/2023 from 12:50 PM to 1:21 PM (approximately 30 minutes), when the resident was left unsupervised while sitting on the wheelchair and was allowed to get out of the facility's backdoor. Resident 1 was found on the same day, 12/9/2023 after a police officer notified the facility to report that Resident 1 was brought by the Fire Department to the acute hospital. Resident 1 was readmitted back to the facility on [DATE] at 5:10 PM. Resident 1 sustained an abrasion to the forehead. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses of dementia (impaired ability 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services for one of 19 sampled residents (Residents 9) as ordered by the physician. Resident 9, who was at risk for falls, had an order for floor mats at the bedside and to wear a soft helmet at all times, which were not implemented as ordered. This failure had the potential for the resident to not receive treatment/services as ordered. Findings: A review of Resident 9's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE], with diagnoses that included abnormality of gait and mobility (difficulty walking, an abnormal pattern of walking). A review of Resident 9's a Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/15/21, indicated the resident usually made self-understood and usually understood others, and had severe cognitive impairment (having trouble remembering, learning new things, concentrating, or making decisions that affect their everyday…

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 two of two sampled residents (Residents 17 and 45) with an indwelling catheter (an indwelling catheter collects urine by attaching to a drainage bag) received the appropriate care and services to prevent infection. Residents 17 and 45 had cloudy color urine with sediments (solid matter left after the urine has been allowed to stand for some time). The nursing staff failed to monitor the resident's urine and report the abnormal findings immediately to the residents' physicians. This deficient practiced placed the residents at risk for developing a urinary tract infection (UTI, a very common type of infection in your urine/bladder) and potential for a delay in receiving care and treatment. Findings: 1. A review of Resident 17's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE], with diagnoses that included neuromuscular dysfunction of bladder (loss of control to urinate caused by a problem…

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 proper respiratory care for three of seven sampled residents (Residents 366, 64, and 34). 1. Resident 366 was observed receiving oxygen at a rate of 3 to 3.5 liters per minute (LPM) on separate occasions. The physician's order was 2 LPM. The tube of the oxygen was not labeled with the date of replacement. 2. Resident 34's oxygen tubing did not have a label. 3. Resident 64's oxygen tubing did not have a label. These deficient practices had the potential to harm by receiving too much oxygen and expose the residents to infection by not having the tubing labeled when it was chnaged last. Findings: 1. During an observation on 6/8/21 at 10:30 a.m., Resident 366 was observed receiving oxygen at 3.5 LPM via nasal cannula (NC, a tubing used to deliver oxygen via the nose) while she was lying in bed. The NC tubing did not have a label to indicate when it was last changed. During an observation and interview with a Licensed Vocational 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to document the administration of controlled medications (medications that could cause physical and mental dependence, and had restrictions on how they could be filled and refilled) for two of eight sampled residents (Residents 50 and 61) on the residents' Medication Administration Record (MAR). During an inspection of the controlled substance in the medication carts for Stations 1 and 2, the following were identified: 1. Resident 50, who was ordered Acetaminophen-hydrocodone (a controlled substance used to treat moderate to severe pain) 5-325 milligrams (mg) one tablet by mouth (PO) every 6 hours (hrs.) as needed (PRN) for severe pain (7 to 9, pain scale out of 10, 10 being the highest level of pain), received Acetaminophen-hydrocodone on 6/2/21 and 6/3/21 and was not documented on the resident's MAR. 2. Resident 61, who was ordered Tramadol HCL (controlled substance used to treat moderate to severe pain) 50 mg one tablet PO every 6 hrs.…

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 had 25 opportunities of medication administration observed and three of the 25 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 12 percent (%). The errors consisted of the following during a medication pass observation on 6/9/21 with Resident 39: 1. Vitamin B6 (a nutritional supplement to help the immune system) was not given. 2. Pepcid (a medicine used to treat increased acid in the stomach) was not given. 3. The gastrostomy tube (G-tube, a tube surgically inserted into the stomach to deliver fluids and medications) was not flushed with 30 milliliters (mL) of water after all medications were administered. This deficient practice had the potential for the resident to have a lower immune system and stomach irritation from missed doses of medication and had the potential for the resident's G-tube to get clogged and have complications from failing to flush the G-tube as ordered after…

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 label and store drugs according to accepted professional standards, which included the removal of expired medications and separation of oral from external medications in the storage areas. The following were observed: 1. Expired medications/nutritional supplements and expired needles observed on the shelves of the medication storage room and multi-dose medications did not have a label with an open date. 2. The medication cart in nursing station 2 had six medications with no open date and one suppository (medication administered through the buttocks) medication stored with oral medications. These deficient practices had the potential to compromise the safety and well-being of the residents. Findings: 1. During an observation of the facility's medication storage room on 6/10/21 at 8:30 a.m., the following were observed: a. Two (2) bottles of Total B with C vitamin (a nutritional supplement) expired on 4/2021, b. A bottle of saline nasal spray (a simple saltwater solution used to prevent dryness and help 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.

Based on observation, interview, and record review, the facility failed to ensure proper food storage and preparation by failing to ensure the following: 1. Dietary staff did not perform handwashing after touching dirty utensils and picking up a clean pan. 2. Food products were not labeled. 3. Staff did not perform handwashing or change gloves after touching face mask while preparing residents' food. 4. The refrigerator temperature was not kept at 41 degrees Fahrenheit (F) or below. 5. Dietary staff did not know how to calibrate the food thermometer. 6. Food in the walk-in refrigerator was not kept at or below 41 degrees F. 7. Dietary staff did not wear gloves while preparing foods. These deficient practices had the potential to decrease food quality, cause food contamination, and foodborne illnesses due to unsafe food handling practices. Findings: An initial tour of the kitchen with [NAME] 1 was conducted, on 6/8/21 at 8:20 a.m., the following were observed: 1. On 6/8/21 at 8:20 a.m., during an observation and interview, a Dishwasher 1 was observed handling dirty utensils.…

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 ensure medical records were kept safe and secured from unauthorized use. During an observation, the facility stored their residents' medical records in the basement and it did not have a lock to keep it secured. This deficient practice had the potential for violating residents' rights to confidentiality of personal records. Findings: During an initial tour of the facility with the Maintenance Director (MD), on 6/11/21 at 10:15 a.m., residents' medical records (dated from 2018 to 2020) were stored inside the facility's gated basement storage room. The gate was not locked. There were residents' medical records stored inside white cardboard boxes (60 boxes) with lids placed on shelves located by the wall and 40 boxes on pallets by the gate. Each box had a label on the outside with the resident's name and dates (ranging from July 2018 to February 10, 2020). During an interview, on 6/11/21 at 10:20 a.m., the MD stated he had a key to open the basement door. The MD stated he broke the lock that was on the gated…

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 maintain and implement its Infection Control Program to prevent the transmission of disease and infection as followed: 1. Residents 13 and 45 had hand held nebulizers (HHN, an inhalation machine connected to a plastic tubing attached to a mouthpiece or face mask used to administer treatment for breathing illnesses) with the mouthpiece and mask exposed and were not stored in a sealed or closed container. This deficient practice had the potential to result in oral and respiratory infections from the use of a soiled mouthpiece or face mask. 2. Resident 9 had a the nasal cannula (NC, a device made of plastic inserted into the nostril used to deliver supplemental oxygen or airflow to a patient or person in need of respiratory help) that was observed on the floor. This deficient practice put the resident at risk of acquiring potentially hazardous bacteria from the oxygen tubing. 3. Resident 17, who had an indwelling catheter (a tubing inserted…

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 and interview, the facility failed to have a functioning call light system for two out of 47 resident bedrooms (rooms [ROOM NUMBERS]). This deficient practice had the potential to prevent the residents from receiving assistance for all needs in a prompt and timely manner. Findings: During an observation on 6/8/21 at 11:55 a.m., the call light in room [ROOM NUMBER] was pressed and the call light indicator inside the room lit up. No staff entered the room to answer the call light for seven minutes. During an observation on 6/8/21 at 12:02 p.m., the Director of Nurses (DON) observed that the call light indicator inside room [ROOM NUMBER] was on. The DON stated that the call light indicator above the door outside of room [ROOM NUMBER] was not lit and the call light indicator at the nursing station for room [ROOM NUMBER] was also not lit. The DON stated the call light system in room [ROOM NUMBER] was not working because the facility staff were not aware the resident inside room [ROOM NUMBER]…

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 interview and record review, the facility failed to ensure one of five residents (Resident 64) had an informed consent for Trazodone (psychotropic drug, antidepressant medicine that works to balance chemicals in the brain). This deficient practice violated the resident's right to make an informed decision to take the medication. Findings: A review of Resident 64's Face Sheet (admission record) indicated Resident 64 admitted to the facility on [DATE] with diagnoses that included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and atrophy (wasting away). A review of Resident 64's physician's order, dated 5/20/21, indicated an order for Trazodone 300 milligram (mg) one tablet by mouth (PO) every bedtime (QHS) for depression manifested by (m/b) inability to sleep. On 6/10/21 at 9:23 a.m., during an observation and concurrent interview, Resident 64 was sitting on his wheelchair watching…

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 printed activities material for one of 28 sampled residents (Resident 43) in the resident's primary language (Chinese). The in-room monthly activities calendar and the large hallway monthly activities calendar were only offered in the English language. The failure had the potential to minimize Resident 43's participation in facility activities because the resident did not understand and was not aware of activities provided each day. Findings: A review of Resident 43's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE] with a diagnosis that included hemiplegia (weakness to one side of the body) affecting left non dominant side. A review of Resident 43's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 5/15/21, indicated the resident had no impairment in cognition (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing,…

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 accurately code the functional limitations (Section G) in the joint range of motion (ROM, full movement potential of a joint) on the Minimum Data Set (MDS, a standardized assessment and care-screening tool) for one of 11 sampled residents (Resident 43). This deficient practice had the potential to cause inaccurate care planning and inadequate provision of rehabilitation and restorative nursing aide (RNA) program (nursing aide program that help residents to maintain their function and joint mobility) services for Resident 43. Findings: A review of Resident 43's face sheet indicated the resident was admitted to the facility 9/1/18 with diagnoses that included hemiplegia (weakness to one side of the body) affecting left non dominant side and stiffness of left hand. A review of Resident 43's (MDS) dated [DATE] indicated the resident's cognition (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing,…

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 one of 19 sampled residents (Resident 27) was assisted with activities of daily living (ADLs, such as transferring, dressing, toileting, personal hygiene, and bathing). This deficient practice had the potential for the resident to decline in ADLs and develop contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: A review of Resident 27's Face Sheet (admission record) indicated the resident admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included abnormality of gait (walking), type 2 diabetes mellitus (uncontrolled blood sugar levels), anxiety disorder, and hypertension (high blood pressure). Resident 27 was admitted for orthopedic aftercare (care to bones after an injury or a healing fracture). A review Resident 27's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 1/12/21,…

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 appropriate treatments and services to prevent development of a joint contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in the right knee for one of 11 sampled residents (Resident 49). Physical Therapy (PT) staff identified Resident 49 as high risk for developing contractures. Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment was ordered for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises three times a week instead of five or seven times a week. This failure resulted in development of Resident 49's right knee contracture, requiring further skilled physical therapy services and the resident's need of a right knee splint (rigid material or apparatus used to support and immobilize a broken bone or impaired…

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 post a No Smoking sign for one of seven sampled residents (Resident 366) who was using oxygen. This deficient practice had the potential to compromise the safety of the residents. Findings: During an observation on 6/8/21 at 10:30 a.m., Resident 366 was receiving oxygen at 3.5 liters per minute (LPM) via nasal cannula (NC, a tubing used to deliver oxygen via the nose) while she was lying in bed. Resident 366 did not have a No Smoking sign posted inside or outside the room. During a subsequent interview with Licensed Vocational Nurse 5 (LVN 5), she stated that the No Smoking sign should be posted whenever oxygen was in use. She immediately posted the sign after the interview. A review of Resident 366's Face Sheet (admission record) indicated that the facility admitted the resident on 06/05/21 with diagnoses that included pleural effusion (water in the lungs), pneumonia (an infection that inflames the air sacs in one or both lungs), and acute respiratory failure (occurs when fluid builds up in the air sacs 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 observation, interview, and record review, the facility failed to develop a dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that could interfere with daily life) plan of care that included non-pharmacological interventions prior to administering medications to control behaviors for one resident (Resident 13). This deficient practice had the potential for the resident to be over medicated/sedated and affect activities of daily living (ADLs, such as transferring, dressing, eating, toileting, and personal hygiene). Findings: During an observation on 6/8/21 at 8:30 a.m., Resident 13 was observed lying in bed awake with confusion. The resident was quiet and calm. During an interview on 6/8/21 at 10 a.m., Resident 13 stated she did not have any behaviors of striking out or throwing items at staff or thinking that her roommate wanted to hurt her. During an interview on 6/8/21 at 11:45 a.m., a Certified Nurse Assistant 1 (CNA 1) stated that he never saw…

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 one resident (Resident 8), who was receiving psychotropic (any drug that affects behavior, mood, thoughts, or perception) medications, was free from unnecessary drugs. Resident 8 was administered Seroquel (an antipsychotic medication used to treat mood disorders) 25 milligrams (mg) without an attempt for a gradual dose reduction (GDR). This deficient practice had the potential to result in significant adverse consequences from possible excessive doses, unnecessary medications, and prolonged use of a psychoactive medication. Findings: A review of Resident 8's Face Sheet (a record of admission) initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included a stroke (when the blood supply to part of your brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) with right sided weakness, dysphagia (difficulty in swallowing), and schizophrenia (a serious mental disorder in which…

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.