Vista Pacifica Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to ensure the resident was treated with dignity and respect for one of three sampled residents (Resident 1), when Mental Health Worker (MHW 1) did not assist the resident after he fell from his wheelchair and failed to provide support when the resident dropped his cigarette. This failure resulted in Resident 1 becoming angry and agitated with staff member. Findings: A review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (mental health condition with symptoms of schizophrenia [thoughts or experiences that seem out of touch with reality, disorganized speech or behavior] and a mood disorder [intense and persistent changes in mood, energy, and behavior]) and osteoarthritis (tissues in the joint break down over time) of knee. A review of Resident 1's Progress Notes, dated February 15, 2025, indicated, .Incident Note .Approximately at 1950 (7:50 p.m.), res (Resident 1) 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 interview and record review, the facility failed to report the neglect for one of three sampled residents (Resident 1) to the California Department of Public Health (CDPH) within 2-hours. Resident 1 was denied a cigarette and left without assistance back into his wheelchair by Mental Health Worker (MHW) 1. This failure had the potential to result in Resident 1 to remain at risk of further harm and emotional distress. Findings: On February 27, 2025, at 10:50 a.m., an interview was conducted with the Administrator (Admin), who stated, he was the facility's abuse coordinator and that staff were expected to report all witnessed or suspected abuse or neglect within two hours to CDPH and other agencies. A review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (mental health condition with symptoms of schizophrenia [thoughts or experiences that seem out of touch with reality, disorganized speech or behavior] and a mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement ongoing infection surveillance monitoring for suspected scabies (a highly contagious skin condition caused by mites that burrow into the skin), for six of six residents (Resident 1, 2, 3, 4, 5, and 6). This deficient practice had the potential for a delay in the care and treatment and possible spread of infection throughout the facility. Findings: On September 4, 2024, at 10:50 a.m., an unannounced visit was conducted to investigate infection control issues. On September 4, 2024, at 11:14 a m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was observed to be sitting up in bed with legs exposed. Resident 1's lower extremities were observed to be red with rash alll over. In a concurrent interview, Resident 1 stated he had scabies for a month, and the facility was just treating him now. Resident 1 stated the physician saw him on September 1, 2024, and told him he had scabies. 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.

Based on interview and record review, the facility failed to ensure the designated Infection Preventionist (IP - professional who ensures healthcare workers and patients are doing all the things they should to prevent infections) completed the required specialized training for the IP certification program. This failure resulted in the Infection Control and Prevention Program of the facility not having the benefit of a fully qualified and competent IP having the potential to negatively affect the quality of care provided to all the residents. Findings: On September 4, 2024, at 10:50 a.m. an unannounced visit was made to the facility. On September 4, 2024, at 1:10 p.m., an interview with the designated Infection Preventionist (IP) was conducted. The designated IP stated she did not have IP certification at this time. On September 4, 2024, at 2:52 p.m., an interview with Director of Nursing (DON) was conducted. The DON stated the designated IP was not certified. The DON stated the designated IP did not have to be certified to be in the position if in the process of certification. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, for one of three residents sampled (Resident A) did not receive candy infused with cannabis (dried leaves and flowering tops of the Cannabis sativa or Cannabis indica plant which contains active chemicals that cause drug-like effects all through the body) while at facility. This failure had the potential to cause untoward effects of the cannabis to Resident A's overall health and mental condition. Findings: On August 13, 2024, at 11:00 a.m., an unannounced investigation was conducted at the facility for a complaint of resident abuse and quality of care. On August 13, 2024, at 1:30 p.m., an interview was conducted with Program Counselor (PC) 1. PC 1 stated staff donate candy to the facility on a regular basis, the counseling program would collect the candies, and would give out the candy as a reward to the residents. PC 1 stated some canabis infused candies which contained THC (the substance primarily responsible for the effects of marijuana 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.

Based on interview and record review, the facility failed to ensure appropriate infection control practices in preventing the transmission of the coronavirus infection (COVID-19 - illness caused by a virus that can be transmitted from person to person) were implemented in accordance with the facility's policy and procedure and Center for Disease Control (CDC) guideline, when the residents and Healthcare Personnels (HCP/staff) were not tested for COVID-19 timely. This failure resulted in a delay in the identification of residents and HCP who were COVID-19 positive, thereby delayed the implementation of infection control measures to prevent further transmission of COVID-19 in the facility. Findings: On January 2, 2024, at 9:18 a.m., an unannounced visit to the facility was conducted for a Focused Infection Control survey and investigation of a Facility Reported Incident. On January 2, 2024, a review of the facility's document titled, (name of facility) - Resident and Employee COVID-19 Tracking (Employees Tested Positive), indicated the HCP were positive for COVID-19 on the following…

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 an allegation of physical abuse by a resident (Resident A) towards another resident (Resident B) was reported to the California Department of Public Health (CDPH) immediately, or not later than two hours after the allegation was made. This failure had the potential to result in a delay of the implementation of appropriate actions, provisions, and protections to the residents and placed the residents at risk for further abuse. Findings: On July 27, 2023, at 9:30 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. On July 27, 2023, at 10:58 a.m., an interview was conducted with the Director of Nursing (DON). She stated she received report in the morning of July 14, 2023, that Resident A and Resident B were involved in an altercation that occurred on July 13, 2023, at around 5 p.m. She stated Resident B spit at Resident A's face and shoved him when Resident A told him to stop spitting on the floor. 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.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. 38 insulated plate covers, seven insulated plate bases, and three full sheet metal pans were stacked and stored wet found in the readily to use storage areas; 2. Two various size of cooking pans had dry and heavy black substance buildups on the cooking surfaces and readily available for use; 3. The ice machine was not clean and sanitized properly per the manufacturer's recommendations; 4. The sanitizer concentration was not at the correct range for the manual ware washing in the three-compartment sink; 5. The kitchen did not have the correct manufacturer's instruction to have correct concentration for the sanitizer solution in the red bucket (red buckets are used as a standard of practice to contain sanitizer solution); and 6. The interior of the microwave was found dirty with dry whitish liquid spill and food debris on the side panel. These failures had the potential to cause food-borne illness in 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 ensure: 1. The facility's policy and procedure on Advance Directive (AD - a written instruction such as a living will, relating to the provision of treatment and services when the individual is unable to make decisions) was followed, for 16 of 26 residents reviewed for AD (Residents 1, 23, 36, 42, 51, 53, 54, 57, 65, 67, 70, 75, 76, 83, 86, and 106) when there was no documentation whether the resident chose to complete or decline to formulate an AD when it was offered; and 2. Information regarding formulating an AD was provided to the resident representative (RR), for one of 26 residents reviewed for AD (Resident 16), who did not have the capacity to understand or make a decision for himself. These failures had the potential for the residents to not exercise their right to complete or not complete an AD. Findings: 1. On April 19, 2022, through April 22, 2022, Residents 1, 23, 36, 42, 51, 53, 54, 57, 65, 67, 70, 75, 76, 83, 86, and 106 records were…

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 the menu was being followed for the therapeutic diet (a diet that is usually a modification of a regular diet. It is modified or tailored to fit the nutrition needs of a particular person. It could be a part of the treatment of a medical condition and normally prescribed by a physician) for lunch on April 18, 2022, and lunch on April 19, 2022, when: 1. Eight residents (Residents 6, 31, 34, 54, 56, 61, and 66) who were on NAS (no added salt) diet received salt packets with their meals; and 2. Four residents (Residents 39, 69, 75, and 104) who were on fortified (enhanced food addition to increase calories and/or protein) diet received regular mashed potatoes with their meals. These failures had the potential to result in compromising the medical and nutrition status of those 11 residents. Findings: 1. During a dining observation of the lunch meal on April 18, 2022, at 12:05 p.m., Resident 6 was observed to have a diet card which indicated NAS, regular texture diet with large portion on his lunch meal…

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 implement infection control precautions to prevent cross-contamination (transfer of bacteria or other contaminants from one surface to another), when one facility staff was observed wearing long artificial fingernails while preparing medications for the residents. This failure increased the risk of cross-contamination which could result in the development and transmission of infections to a vulnerable population of 106 residents in the facility. Findings: On April 21, 2022, at 8:36 a.m., medication administration observation was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 was observed wearing long artificial fingernails (approximately one inch) while preparing the residents' medications. LVN 1 was observed separating a stack of multiple plastic medication cups. LVN 1's long artificial fingernails were observed to touch the inner part of the plastic medication cups. LVN 1 was observed to hand the medication cup to the resident and the resident drank the medication from the medication cup. On April…

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 care plan to address the use of anticoagulant (medication to prevent blood clots) medication, for one of five residents reviewed for unnecessary medications (Resident 58). This failure had the potential for Resident 58 to be at risk of bleeding or adverse reactions from the medication and to not be managed and provide immediate appropriate treatment and interventions. Findings: On April 18, 2022, at 9:39 a.m., during the initial tour of the facility, Resident 58 was interviewed. Resident 58 stated he was on a blood thinner medication. On April 18, 2022, Resident 58's record was reviewed. Resident 58 was admitted to the facility on [DATE], with diagnoses which included hypertension (elevated blood pressure). The Order Summary Report, dated April 21, 2022, included a physician's order, dated February 16, 2022, which indicated, .Xarelto (medication to prevent blood clots) Tablet Give 20 mg (milligram - a unit of measurement) 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 ensure the correct amount of eye drop medication was administered according to the physician's order, for one of six residents (Resident 103) observed during medication administration observation. This failure resulted in Resident 103 to not receive the prescribed amount of the eye drop medication and had the potential for complications such as loss of vision and blindness. Findings: On April 21, 2022, at 8:36 a.m., medication administration observation was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 was observed to prepare Resident 103's Brimonidine eye drop medication (medication to treat eye disorder) and handed the bottle of eye drop medication to Resident 103. Resident 103 was observed to administer and instill one drop of the eye medication into each eye. The medication solution was observed to drop on Resident 103's eye lashes, instead of into the inner lower eyelid. There was no instructions or teaching given 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 ensure appropriate foot care and treatment was provided, for one of two residents reviewed (Resident 65), when the facility did not provide diabetic shoes with plastic inserts as ordered by the physician. This failure had the potential for Resident 65 to develop complications on the feet related to diabetes mellitus (DM - abnormal blood sugar). Findings: On April 19, 2022, at 10:54 a.m., during the initial tour of the facility, Resident 65 was observed wearing slippers. Resident 65 declined to be interviewed. On April 19, 2022, Resident 65's record was reviewed. Resident 65 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus. The Order Summary Report, included a physician's order, dated December 14, 2021, which indicated, .Provide Diabetic shoes with plastic Inserts r/t (related to) Type 2 DM . There was no documented evidence Resident 65 received the diabetic shoes the physician ordered. On April 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.

Based on observation, interview, and record review, the facility failed to ensure residents who required supervision during smoke break were monitored closely, for one of 97 residents (Resident 16) observed for smoking. This failure had the potential to place Resident 16 at risk for injuries and accidents related to smoking. Findings: On April 18, 2022, at 11:45 a.m., Resident 16 was observed at the patio during smoke break. Resident 16 was observed sitting in his wheelchair smoking a cigarette without wearing a smoking apron. Resident 16 was blind and had left upper limb and left lower limb amputations (surgical removal of the limb). In a concurrent interview with Resident 16, resident responded with incoherent speech. While Resident 16 was smoking his cigarette with his right hand, the cigarette ashes fell on his right side and onto the floor, nearly missing his body and clothing. In addition, Resident 16 was not aware the cigarette ashes had fallen. On April 18, 2022, beginning at 4:19 p.m. to 4:25 p.m., Resident 16 was observed at the patio during smoke break. Resident 16 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 interview and record review, the facility failed to ensure the depakene level (laboratory test done to check the depakene [medication to treat impulse disorder] level in the blood) were completed as ordered by the physician, for one of 26 residents reviewed (Resident 46). This failure had the potential for Resident 46 to not be monitored for the therapeutic level of the depakene medication needed to effectively address his impulse disorder. Findings: On April 20, 2022, Resident 46's record was reviewed. Resident 46 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a mental disorder). The document titled, Order Summary Report, included the following physician orders: - .Depakene Solution (Valproate Sodium) Give 500 mg (milligrams - unit of measurement) by mouth three times a day for mood swings related to Schizophrenia ., dated September 26, 2021; and - .Fasting Free Valproic Acid .one time a day every 1 (one) month(s) starting on the 2nd .for depakote use ., 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 observation, interview, and record review, the facility failed to ensure the resident's food preference was honored, for one of residents observed during meal observation (Resident 6). This failure had the potential for Resident 6's food intake be affected and could result in weight loss. Findings: On April 18, 2022, at 11:57 a.m., during lunch observation in the dining room, Resident 6 was observed being served with the following food items: - Shredded beef with rice; - Mixed vegetables; - Four oz. (ounce - unit of measurement) of milk; - Four oz. of juice; and - One slice of cake. Resident 6's diet card indicated, No: Milk to drink. In a concurrent interview with Resident 6, he stated he did not drink milk and he did not like it. Resident 6 was observed to not drink the milk. On April 19, 2022, at 12:09 p.m., during lunch observation in the dining room, Resident 6 was observed being served with the following food items: - Breaded chicken cutlet; - Mashed potatoes with gravy; - Mixed vegetables; -…

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 medications were administered in accordance with professional standards of practice when medications were not administered immediately after they were prepared and were not documented as given immediately after they were administered, for nine of nine residents observed during medication pass (Residents 26, 64, 48, 61, 72, 42, 60, 27, and 32). These failures had the potential to result in medication errors. Findings: On January 23, 2020, at 8:35 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated she was done with medication administration scheduled for 9 a.m. LVN 1 stated for medication administration scheduled at 9 a.m., she would start pre-pouring the medications (process of preparing medications in advance and storing them until they were administered to the resident/s) by 7:20 a.m. for all the residents who were scheduled to receive medications at 9 a.m. LVN 1 stated she would start pre-pouring 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. On January 24, 2020, the record for Resident 32 was reviewed. Resident 32 was admitted to the facility on [DATE], with diagnoses including hypertension and hypothyroidism (low level of thyroid hormone in the blood). The document titled, Order Review Report, for January 2020, included a physician's order, dated July 31, 2018, which indicated, Lopressor (a medication to lower blood pressure) Tablet Give 25 mg by mouth two times a day .Hold if SBP < 100 HR < 60 . The MAR, for December 2019, indicated lopressor was administered to Resident 32 on December 8, 9, and 28, 2019 (three times), when Resident 32 had SBP readings below 100. The MAR, for January 2020, indicated lopressor was administered to Resident 32 on January 1, 3, 4, 15, and 17, 2020 (five times), when Resident 32 had SBP readings below 100. On January 24, 2020, at 1:31 p.m., LVN 2 was interviewed. LVN 2 stated Resident 32's BP should be taken before administering the BP medication to make sure the BP medication parameters on the physician's order 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.

Based on observation, interview, and record review, the facility failed to ensure the menu for low fat low cholesterol diet was followed, for 12 of 12 residents who were on low fat low cholesterol diet. This failure had the potential for the residents to not receive the appropriate diet which could compromise their nutritional status and may lead to medical complications. Findings: On January 23, 2020, the facility document titled, DAILY MENU GUIDE, was reviewed. The menu indicated, .Low Chol (cholesterol) Low Fat .jelly . On January 23, 2020, between 11:40 a.m. to 12:25 p.m., and between 12:40 p.m. and 1:15 p.m., a tray line observation was conducted with the Dietary Staff (DS). The residents who were on low fat low cholesterol diet were observed to receive margarine instead of jelly. Jelly was observed to not be available during the tray line service. On January 23, 2020, at 1:15 p.m., the Director of Dietary Services (DDS) and the DS were interviewed. The DDS and the DS confirmed there was no jelly available for the residents who were on low fat low cholesterol diet during 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.