Gardena Convalescent Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 39) who has a Peripherally Inserted Central Catheter ([PICC] - a thin flexible tube that is inserted into a vein in the upper arm above the right side of the heart, used to give intravenous fluids, blood transfusions, and medications) was placed on Enhanced Barrier Precaution ([EBP] - an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). This failure had the potential to increase the risk of infection and cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) among residents and staff.Findings:During a review of Resident 39's admission Record, the admission Record indicated, Resident 39 was admitted to the facility on…

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 four residents (Resident 1), was provided with a safe and hazard-free environment while providing care. This deficient practice had the potential to cause severe injuries to Resident 1 including hospitalization and death.Findings: During a concurrent observation and interview on 7/9/2025 at 12:30 p.m. with Resident 1, in Resident 1's room, Resident 1's right upper cheek was observed slightly swollen and purple in color and the right elbow had a dime size abrasion (scratch). Resident 1 was unable to move right upper and lower extremity. Resident 1's speech was slurred but Resident was able to communicate with simple words. Resident 1 stated she fell in the facility while the nurse was in the room and was sent to the hospital. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses including hemiplegia…

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 Certified Nursing Assistant (CNA 1) had the specific competencies, and skill sets necessary to care for one of four residents (Resident 1), by failing to report Resident 1's alleged fall incident. This deficient practice resulted in a delay in Resident 1's treatment/evaluation. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses included nondisplaced fracture of the left tibial spine (a break that has not shifted or separated at the top of the tibia bone in the lower leg near the knee), traumatic subdural hemorrhage without loss of consciousness (a serious condition where blood pools between the brain and its outer protective layer (the dura) after a head injury, potentially causing pressure on the brain), and end stage renal disease ([ESRD], is the final, permanent stage of chronic kidney…

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: 1. Ensure one out of three sampled residents (Resident 1) glucose (the process of measuring the amount of sugar in a patient ' s blood) was checked after returning to the facility after being out on pass. This deficient practice of not checking the blood sugar after returning to the facility had the potential for Resident 1 exacerbate (a worsening of a medical condition that increases symptoms and may require hospitalization) his diabetes (a chronic condition characterized by high blood sugar levels). Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included fall (an unplanned descent to the floor with or without injury to the patient), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease ([COPD] -a chronic lung disease causing…

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 During an interview and record review the facility failed to: 1. Ensure one out of three sampled residents (Resident 1) had a care plan for non-compliance (when a patient don't follow the rules, regulations, or advice that ' s been set in place) when out on pass ([OOP] a patient is temporarily allowed to leave the facility for a specified period of time, with the expectation of returning). This deficient practice of not developing a care plan (a document that summarizes a person ' s health needs, current treatments, and desired outcomes) for Resident 1 ' s non-compliance had the potential to place the resident at risk for injury and not be continuously monitored for diabetes mellitus([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing). Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included fall (an unplanned descent to the floor with or without…

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: 1. Ensure one out of three sampled residents (Resident1) had a plan in place after being identified as a high risk for falls (a patient has a significantly increased likelihood of experiencing a fall due to various factors like poor balance, muscle weakness, which could potentially cause physical harm if they do fall) for continuous supervision and monitoring while out on pass ([OOP] a patient is temporarily allowed to leave the facility for a specified period of time, with the expectation of returning). This deficient practice of not having a plan in place for continuous supervision and monitoring had the potential risk for Resident 1 to fall while out on pass. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included fall (an unplanned descent to the floor with or without injury to the patient), diabetes mellitus ([DM]- a…

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: 1.Ensure four of six sampled residents' (Residents 15, 30, 37, and 38) Medication Regimen Review ([MRR]- a review of medications to identify problems/errors) was completed monthly. This deficient practice placed Residents 15, 30, 37, and 38 at risk of not having medication irregularities identified. Findings: A. During a review of Resident 15's admission Record, the admission Record indicated the facility admitted the resident on 12/20/2011 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and end stage renal disease (irreversible kidney failure). During a review of Resident 15's History and Physical (H&P), dated 12/19/2024, the H&P indicated Resident 15 had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set ([MDS] a resident assessment tool) dated 12/2/2024, the MDS indicated Resident 15's cognition…

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 an individualized person-centered care plan (a document that summarizes a person's health condition, care needs, and current treatments) with measurable objectives, timeframe, and interventions to meet the residents needs for two of two sampled residents (Residents 58 and 167) by failing to: 1. Ensure a care plan for out on pass was develop for Resident 58. 2. Ensure a care plan with interventions for Peripherally Inserted Central Catheter ([PICC] - a thin flexible tube that is inserted into a vein in the upper arm above the right side of the heart, used to give intravenous fluids, blood transfusions, and medications) line was develop for Resident 167. These deficient practices had the potential to negatively affect the delivery of care and services for Residents 58 and 167. Findings: a. During a review of Resident 58's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission…

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: 1. Ensure resident was involved in decision making and notified in change of physician for one of one sampled resident (Resident 52). This failure had violated Resident 52's resident rights to choose her own physician. Findings: During a review of Resident 52's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated 52 was admitted to the facility on [DATE]. The admission Record indicated, Resident 52's diagnoses included left hip osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), hypertension ([HTN] - high blood pressure), and hyperlipidemia (a condition where there are high levels of fats, or lipids, in the blood). During a review of Resident 52's History and Physical (H&P), dated 12/21/2024, the H&P indicated, Resident 52 had the capacity to understand and make decisions. During a review of Resident 52's Minimum Data Set…

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: 1. Implement the facility's policy and procedures on reporting an unusual occurrence when Resident 58 left the facility and did not return. This deficient practice had the potential to result in serious harm, injuries and death. Findings: During a review of Resident 58's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 58 was admitted on [DATE] with diagnoses which included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dysphagia (difficulty swallowing), and acute kidney failure (a sudden loss of kidney function that prevents the kidneys from filtering waste and regulating electrolytes and fluids in the body). During a review of Resident 58's History and Physical (H&P), dated 11/4/2024, the H&P indicated Resident 58 had the capacity to understand…

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 staff failed to: 1. Report to California Department of Public Health (CDPH) of resident leaving and not returning to the facility on [DATE] for one of two sampled residents (Resident 58). This deficient practice resulted in the delay of investigation by the CDPH. Findings: During a review of Resident 58's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 58 was admitted on [DATE] with diagnoses which included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dysphagia (difficulty swallowing), and acute kidney failure (a sudden loss of kidney function that prevents the kidneys from filtering waste and regulating electrolytes and fluids in the body). During a review of Resident 58's History and Physical (H&P), dated 11/4/2024, the H&P indicated Resident 58 had…

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: 1. Ensure a smoking safety assessment was completed for one of 6 sampled residents (Resident 48). 2. Ensure an assessment was completed before going out on pass for one of 2 sampled residents (Resident 58). This deficient practice had the potential to result in a safety hazard for Resident 48 and serious harm for Resident 58. Findings: a. During a review of Resident 48's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 48 was admitted on [DATE] with diagnoses which included epilepsy (seizures), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (a chronic disease that causes people to compulsively use nicotine) and encephalopathy (a brain disorder that affects brain function or structure). During a review of Resident 48's Minimum Data Set (MDS- a federally mandated resident 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 interview and record review, the facility failed to: 1. Ensure the Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 17 sampled residents (Resident 36). This deficient practice had the potential to negatively affect the plan of care and delivery of care and services for Resident 36. Findings: During a review of Resident 36's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated 36 was admitted to the facility on [DATE]. The admission Record indicated, Resident 36's diagnoses included pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) of sacral region (large, triangle-shaped bone in the lower spine that forms part of the pelvis), sepsis (a life-threatening blood infection), and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing). During a review of Resident 36's History 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: 1. Submit a Preadmission Screening and Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) for one of three sampled residents (Resident 21) which included an existing psychiatric diagnosis. This deficient practice resulted in a delay of Resident 21 receiving a PASSR II evaluation for mental health needs. Findings: During a review of Resident 21's admission Record (Face sheet), the admission Record indicated Resident 21 was re-admitted to the facility on [DATE], with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows and manic highs) heart disease, hypertension (high blood pressure), and muscle weakness. During a 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 interview and record review, the facility failed to: 1. Ensure a Level 2 Preadmission Screening and Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) evaluation was obtained for one of six sampled residents (Resident 48). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 48. Findings: During a review of Resident 48's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 48 was admitted on [DATE] with diagnoses which included epilepsy (seizures), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (a chronic disease that causes people to compulsively use nicotine) and encephalopathy (a brain disorder that affects brain function or…

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: 1. Ensure physician orders were carried out for one of 6 sampled residents (Resident 31). 2. Provide services which meet professional standards of quality regarding smoking safety for one of 6 sampled residents (Resident 48). This deficient practice had the potential to result in skin breakdown for Resident 31 and a smoking accident for Resident 48. Findings: a. During a review of Resident 31's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 31 was originally admitted on [DATE] and readmitted on [DATE], with diagnoses including spinal stenosis (a narrowing of the spinal column that occurs over time, putting pressure on the spinal cord and nerves), chronic kidney disease (a condition where the kidneys are damaged and can't filter blood properly), acute kidney failure (a sudden loss of kidney function that occurs when the kidneys are no longer able 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 interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to: 1. Assess and monitor one of 6 sampled residents smoking safety (Resident 48). This deficient practice had the potential to result in serious harm due to smoking without supervision. 2. Ensure one out of six sampled residents (Resident 49) had their pain management referral processed timely. This deficient practice resulted in a delay in assessing, monitoring (Resident 48) and care to manage the pain of Resident 49. Findings: a. During a review of Resident 48's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 48 was admitted on [DATE] with diagnoses which included epilepsy (seizures), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (a chronic disease that causes people to compulsively use…

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: 1. Ensure the low air loss mattress ([LALM] - a mattress designed to prevent and treat pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) was set and maintained at the correct setting for one of two sampled residents (Resident 36). This deficient practice placed Resident 36 at risk for worsening of pressure ulcer/injury and further skin breakdown. Findings: During a review of Resident 36's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated 36 was admitted to the facility on [DATE]. The admission Record indicated, Resident 36's diagnoses included pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) of sacral region (large, triangle-shaped bone in the lower spine that forms part of the pelvis), sepsis (a life-threatening blood infection),…

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: 1. Ensure one out of six sampled residents (Resident 37) received Restorative Nurse Assistant ([RNA]- a healthcare worker who helps residents improve and maintain function in physical abilities) services timely and five days a week as ordered. This deficient practice had the potential to result in Resident 37 having a decline in function or development of contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion). Findings: During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), malnutrition (an imbalance of essential nutrients in the body), and muscle weakness. During a review of Resident 37's History and Physical (H&P), dated 3/23/2024, the H&P indicated Resident 37 does not have the capacity to understand and make decisions. During 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 Based on observation, interview and record review, the facility failed to: 1. Ensure whether supervision was required during smoke breaks and ensure the environment was free from a fire hazard for one of 6 sampled residents (Resident 48). This deficient practice had the potential to result in an accidental fire in the facility and lead to residents' injuries. Findings: During a review of Resident 48's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 48 was admitted on [DATE] with diagnoses which included epilepsy (seizures), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (a chronic disease that causes people to compulsively use nicotine) and encephalopathy (a brain disorder that affects brain function or structure). During a review of Resident 48's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/10/2025, indicated Resident 48…

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: 1. Ensure dental services were provided for one of 6 sampled residents (Resident 110). This deficient practice had the potential to result in tooth decay, gum disease, bad breath and cavities. Findings: During a review of Resident 110's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 110 was admitted on [DATE] with diagnoses which included dependence on oxygen, thrombocytopenia, anemia and benign prostatic hyperplasia. During a review of Resident 110's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 110 cognitive skills were intact. The MDS indicated Resident 58 required substantial to maximal assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body…

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: 1. Ensure a resident who received hemodialysis ([HD] - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with standards of practice for one of two sampled residents (Resident 166) by failing to: 2. Ensure Resident 166's dialysis emergency kit (E-KIT - supplies to help meet the needs of a dialysis resident in the event of an emergency) was readily available at the bedside, in case of excessive bleeding from the dialysis site. This deficient practice had the potential to result in staff inability to manage and control the bleeding from Resident 166's dialysis site in the event of an emergency. Findings: During a review of Resident 166's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated 166 was admitted to the facility on [DATE]. The admission…

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: 1. Ensure it was free of a medication error rate of five percent (5%) or greater, as evidenced by the identification of two out of 28 medication opportunities (observations during medication administration) for error, to yield a cumulative error rate of 7.14% for one of two sampled residents (Resident 167) observed during the medication administration facility task by failing to: 2. Administer Resident 167's Calcium Carbonate with Vitamin D (vitamin supplement, a mineral that builds and maintain strong bones and teeth, and for important physical functions such as muscle control and blood circulation) as prescribed by the physician and to monitor pulse rate (measurement of the heart rate, or the number of tines the heart beats per minute) prior to administration of Metoprolol Tartrate (medication used to treat high blood pressure) as ordered by the physician. These deficient practices had the potential to result in harm to Resident 167 by…

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: 1. Label with an opened date one vial (a small container, usually made of glass or plastic used to store liquids) 5 millimeter ([ml] - unit of measurement) of influenza vaccine (a vaccine that protects against the influenza virus) found from the facility's medication storage room [ROOM NUMBER] refrigerator. This deficient practice had the potential for harm to residents due to potential loss of strength of the influenza vaccine. 2. Remove two vials of unopened expired insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) from the facility's medication storage room [ROOM NUMBER] refrigerator for two of two sampled residents (Residents 14 and 15). This deficient practice had the potential to increase the risk of Resident 14 and 15 receiving expired insulin that could be ineffective in treating their blood sugar. Findings: 1. During a concurrent observation 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: 1. Ensure dental services were provided for one of 6 sampled residents (Resident 6). This deficient practice had the potential to result in tooth decay, gum disease, bad breath and cavities. Findings: During a review of Resident 6's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 6 was admitted on [DATE] with diagnoses which included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and insomnia (trouble falling asleep or staying asleep). During a review of Resident 6's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS…

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: 1. Provide one out of six sampled residents (Resident 37) with a therapeutic diet at lunch time as ordered. This deficient practice put Resident 37 at risk for further weight loss. Findings: During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), malnutrition (an imbalance of essential nutrients in the body), and muscle weakness. During a review of Resident 37's History and Physical (H&P), dated 3/23/2024, the H&P indicated Resident 37 does not have the capacity to understand and make decisions. During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool) dated 11/6/2024, the MDS indicated Resident 37 has moderate cognitive (ability to think and understand) impairment. Resident 37 was dependent on staff with dressing, bathing, and toileting. Resident 37…

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 assess, and managed pain in a timely manner, for one of three sampled residents (Resident 3). This deficient practice had the potential to affect the quality of life of the affected resident. Findings: A review of Resident 3's Face Sheet dated 4/4/2024, indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including cellulitis of left lower limb (wound infection), phantom limb syndrome with pain (sensation patients experience after removal of limb, and muscle weakness. A review of Resident 3's, History and Physical (H&P), dated 12/22/2023, indicated Resident 3 did not have the capacity to understand and make own decisions. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 was able to understand and be understood by others. The MDS indicated Resident 3 required set up for eating, oral hygiene, and substantial assistance for toileting. Resident 3 was dependent for shower/bath, lower body dressing, putting on/taking off…

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, activities of daily living, for three of four residents (Residents 1, 3 and 4), were attended to, promptly. This deficient practice had the potential to result in residents developing skin breakdown and other needs not met. Findings: During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included difficulty walking, muscle weakness, and hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys). During a review of Resident 1 ' s history and physical (H&P) dated 1/1/2024, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions. During a review of Resident 1 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 1/30/2024, the MDS indicated Resident 1 ' s cognitive skills (thought process) was moderately impaired and could understand and be…

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 Infection policy and procedure (P&P) by failing to report a Coronavirus disease ([Covid-19] a highly contagious illness caused by a virus that could easily spread from person to person) outbreak to the California Department of Public Health District Office (CDPH DO). This failure had the potential to result in the spread of Covid-19 cases in the facility and placed residents, staff and the community at risk for contracting the Covid 19 virus. Findings During a review of Resident 3's admission Record (Face Sheet), the admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness, and diabetes mellitus (high blood sugar). During a review of Resident 3's History and Physical (H&P) dated 8/24/2023, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set ([MDS], a…

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 ensure a dignity bag (a bag used for privacy to cover and hold the urine collection bag so that it is not visible) was used to cover the urine collection bag for one of two residents (Resident 9). This deficient practice had the potential to cause embarrassment and affect Resident 9's self-worth and dignity. Findings: During a review of Resident 9's admission Record, dated 7/18/2023, the admission record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included quadriplegia (paralysis from the neck down, affecting all four limbs), anxiety disorder (a group of mental disorders characterized by significant feelings of fear), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and hypertension (high blood pressure). During a review of Resident 9's Minimum Data Set (MDS…

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 observation, the facility failed to ensure residents' call lighs devices were placed within the resident's reach for three out of four sampled residents (Residents 13, 51, 122). This deficient practice had the potential to result in a delay or an inability for the residents to obtain necessary care and services as needed. Findings: a. During a review of Resident 13's admission Record, dated 7/18/2023, the admission record indicated Resident 13 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included failure to thrive (a state of decline and may be caused by chronic diseases and functional impairments; manifestations include weight loss, decreased appetite, poor nutrition, and inactivity), hepatic encephalopathy (loss of brain function occurs when the liver is unable to remove toxins from the blood), end stage renal disease (ESRD - a stage where the kidneys can no longer support the body's needs for waste removal and 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: 1. Follow menu as written for nine residents on renal and regular diets. 2. Follow menu one of nine residents (Resident 54) by putting crunchy fish instead of baked fish plate. This deficiency had the potential for resident to receive the wrong carb and caloric intake when not following the menu, resulting meal dissatisfaction, decreased nutritional intake and weight loss and potentially alter the nutritional value of meals for residents. Findings: A. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was initially admitted to the facility on [DATE]. Resident 54's diagnoses included acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), gout (a type of inflammatory arthritis that causes pain and swelling in your joints). During a review of Resident 54's History and Physical (H&P), dated 9/7/2023, the H&P indicated Resident 1 had 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 observations, interviews, and facility policy review the facility failed to ensure food preparation operations were conducted under sanitary conditions in the facility's kitchen for 54 of 62 residents by. 1. Failing to ensure proper hand hygiene was performed during the preparation of meals. 2. Failing to ensure hairnets, gloves, and masks were worn while in the kitchen and during the preparation of meals. 3. Failing to ensure the kitchen was free of standing water on the kitchen equipment and the floor. 4. Failing to ensure there were no unopened foods or foods stored on the floor in the dry storage area. 5. Failing to ensure clean utensils were used to serve and prepare food. These deficient practices had the potential to put residents at risk by spreading illness, contaminating food, and causing the growth of microorganisms that could lead to food-borne illnesses (food poisoning). Findings: During the initial kitchen tour observation on 1/9/2024 at 8:56 a.m., observed the following: 1. Standing water on top of the juice machine and on the floor next to the juice machine.…

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 observe infection control measures for two of two sampled residents (Resident 41, Resident 51) by failing to: 1. Ensure Resident 51's indwelling catheter (a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag was not touching the floor. 2. Ensure hand hygiene was performed after touching soiled items while performing wound care on Resident 41. These deficient practices resulted in contamination of the resident's care equipment and placed the residents at risk for infection and had the potential to spread infection that could delay the healing process and cause further complications for Resident 41. Findings: a. During a review of Resident 51's admission Record, the admission record indicated Resident 51 was admitted to the facility on [DATE], with diagnoses including but not limited to, acute chronic systolic heart failure (the heart does not pump efficiently or contract the way…

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 honor resident's right to visit family members outside of the facility for one of one sampled resident (Resident 6). This deficient practice caused Resident 6 to miss time with his family during the Christmas holiday and had the potential to negatively impact his psychosocial well-being. Findings: During a review of Resident 6's admission Record, dated 11/22/2023, the admission record indicated Resident 6 was admitted to the facility on [DATE] with the following diagnoses which included fracture (a break in the bone) of the occiput (back of the head), atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow, leading to blood clots, heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs) or stroke), benign prostatic hyperplasia (BPH - age-associated prostate gland enlargement that can cause urination difficulty), epilepsy (a disorder in which nerve cell activity…

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 proper care and treatment services for oxygen (O2) were provided for two of two sampled residents (Resident 122 & 222). This deficient practice had the potential to cause inadequate oxygen therapy and respiratory distress for all residents. Findings: During a review of Resident 222's admission Record (Face Sheet), dated 1/2/2024, the Face Sheet indicated Resident 222 was admitted to the facility on [DATE] with a diagnoses including Heart failure (the heart does not pump efficiently or contract the way it should between heartbeats), Hypertensive emergency (when the pressure in your blood vessels is too high), Type 2 Diabetes Mellitus (high levels of sugar in the blood), Acute Kidney Failure (when your kidneys suddenly become unable to filter waste products from your blood), Arteriosclerosis of Aorta (when fat and calcium has built up in the inside wall of a large blood vessel called the aorta), Acute Respiratory Failure 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 observation, interview and record review, the facility failed to ensure food served was palatable and attractive as voiced by one out of one sampled resident (Resident 46). This deficient practice had the potential to impact the residents' nutritional status and not meet the residents' desires to be served food they felt was palatable and attractive. Findings: During a review of Resident 46's admission records indicated Resident 46's was originally admitted to the facility 4/27/2023 and re-admitted on [DATE] with a diagnosis of Transient ischemic attack [TIA] (a temporary blockage of blood flow to the brain), Vertebral Artery (arteries in the neck supply blood to the brain and spine), Hemiplegia and Hemiparesis ([Hemiplegia- refers to paralysis on one side of the body after a stroke] Hemiparesis [ weakness on one side of the body]), Hypertension ( when the pressure in your blood vessels is too high), Benign Prostatic Hyperplasia (a noncancerous enlargement of the Prostate gland), Hyperlipidemia (too…

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 document the resident's approved out on pass (OOP) order to visit family for the Christmas holiday for one of one sampled resident (Resident 6). This deficient practice caused Resident 6 to miss spending time with his family during the Christmas holiday and had the potential to negatively impact Resident 6's psychosocial well-being. Findings: During a review of Resident 6's admission Record, dated 11/22/2023, the admission record indicated Resident 6 was admitted to the facility on [DATE] with the following diagnoses which included fracture (a break in the bone) of the occiput (back of the head), atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow, leading to blood clots, heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs) or stroke), benign prostatic hyperplasia (BPH - age-associated prostate gland enlargement that can cause urination difficulty),…

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 implement abuse prohibition and prevention program policy and procedure by not reporting an allegation of physical abuse for one of three sampled resident (Resident 1) to the California Department of Public Health (CDPH), after Resident 2 slapped Resident 1 on the face on 12/10/2023. This deficient practice had the potential for the underreporting of abuse incidents, and delay in investigation a physical abuse allegation, placing Resident 1 at risk for further abuse. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), cardiomyopathy (enlargement of heart), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). During a review of Resident 1's Minimum Data Set (MDS), a…

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 implement its abuse prohibition and prevention program policy by failing to submit the results of the investigation of an allegation of physical abuse to the state agency (California Department of Public Health [CDPH]) within 5 working days of the incident for one of three sampled residents (Resident 1). This deficient practice delayed the CDPH investigation of the allegation of physical abuse, potentially placing Resident 1 at risk for further abuse and violation of resident rights. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), cardiomyopathy (enlargement of heart), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). During a review of Resident 1's Minimum…

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.