Reo Vista Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services to meet professional standards for two of 32 sampled residents when: 1. Resident 123's midline catheter (tube inserted in the upper arm with the tip located just below the armpit to allow access to the bloodstream for medications, fluids, blood draws, and other treatments) dressing was not changed and monitored. 2. The facility failed to provide a nutritional supplement in accordance with the resident's physician's orders. (Resident 2) This failure had the potential for complications related to intravenous (IV - method of delivering fluids, medications, or nutrients directly into the bloodstream through a vein) therapy and the potential for not meeting Resident 2's nutritional needs. Findings: 1. Per the facility's admission record, Resident 123 was admitted on [DATE] with diagnoses that included pneumonia (lung infection). A review of Resident 123's physician's orders indicated, on 4/13/25 an order was made for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to monitor and reassess a change in condition (significant worsening of a resident's physical or mental health) for one sampled resident (303). This failure had the potential for complications related to Resident 303's health. Findings: Per the facility admission record, Resident 303 was admitted on [DATE] with diagnoses that included chronic kidney disease stage 3 (condition where the kidneys gradually lose their ability to filter waste products from the blood, leading to a buildup of toxins and other substances in the body). Per the facility progress notes, on 4/12/25 at 3:36 P.M., a potassium level of 5.6 (normal levels 3.5 and 5.5) was reported to the physician. The physician ordered to insert a peripheral intravenous (IV) catheter (a small, thin, flexible tube inserted into a vein to deliver fluids, medications, or blood products directly into the bloodstream). The IV was inserted into Resident 303's back of left hand. Per the facility…

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 prevent a stage four (bedsore extended to muscle, tendon or bone) pressure injury from developing after admission for one of three residents (Resident 15) reviewed for pressure injuries. This failure had the potential to affect Resident 15's quality of life. Findings: Resident 15 was admitted to the facility on [DATE] with diagnoses including fracture of shaft left femur (long, central part of thigh bone) according to the facility's admission Records. During an observation on 4/14/25 at 9:09 A.M. Resident 15 was in bed with an air mattress and overbed trapeze. Resident 15 stated he was on air mattress due to a bedsore on his buttock. Resident 15 was pointing towards his buttocks area. A review of admission records for Resident 15 titled, 01. NURSING-ADMISSION/readmission EVALUATION/ASSESSMENT, dated 11/20/24 was conducted. The admission record indicated no pressure injuries. During an interview on 4/15/25 at 7:45 A.M. with Resident 15, Resident 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status by not providing a nutritional supplement for one of four residents (Resident 2) reviewed for nutrition and with a significant weight loss. This failure had the potential to result in Resident 2's unplanned weight loss which could lead to further decline in weight and overall health condition. Findings: Resident 2 was re-admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty in swallowing) following cerebral infarction (disrupted blood flow to the brain) according to the facility's admission Record). On 4/14/25 9:52 A.M. Resident 2 was observed in her bed watching TV. During interview Resident 2 did not respond verbally but nodded that she was okay. Resident 2 did not respond to further questions. During a review of Resident 2's physician's orders in the electronic medical record (EMR), the physician's orders indicated, .RNA dining program daily at lunch .Boost…

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 a medication was given as ordered by a physician for one of three residents (Resident 107) observed for medication administration. This failure had the potential for Resident 107's medical needs to be unmet. Findings: Resident 107 was admitted to the facility on [DATE] with diagnoses including diabetes (high blood sugar), according to the admission Record. Licensed Nurse (LN) 31 was observed preparing and administering medications to Resident 107 on Wednesday, 4/16/25, at 7:55 A.M. Resident 107 was given the following medications: benazepril (a blood pressure medication), empagliflozin (a diabetes medication), apixaban (a blood thinner), gabapentin (a medication to treat nerve pain), arginine (a supplement), ascorbic acid (a vitamin), aspirin (a blood thinner), ferrous sulfate (an iron supplement), multivitamin, and insulin glargine (a diabetes medication). A review of Resident 107's medical record was conducted on 4/16/25. 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 one of 8 residents (41) reviewed for psychotropics (drugs that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) had the proper indication for the use of an anti-anxiety medication (a drug used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness and muscle tightness that may occur as a reaction to stress). This failure resulted in Resident 41's continued use of an antipsychotic medication without proper indication and possible exposure to the medication's side effects. Findings: A review of Resident 41's undated admission Record indicated that Resident 41 was admitted to the facility on [DATE] with diagnoses that included Anxiety Disorder (feelings of worry, nervousness and fear) and Major Depressive Disorder (persistent feelings of sadness and loss of interest in activities). An interview on 4/16/25 at 8:52 A.M., with Resident 41 was conducted. Resident 41 was seen lying in…

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

Based on observation, interview, and record review, the facility failed to ensure current infection control practices were followed when a facility employee touched the spout of beverage cartons upon opening the cartons during mealtime. This failure had the potential for cross contamination (spread of germs and bacteria) and infection. Findings: A dining room observation was conducted on 4/14/25 at 11:34 A.M. at the facility's south dining room. The dining room was observed with four round tables with numbers 1, 2, 3 and 4. The Restorative Nursing Assistants (RNA-a Certified Nurse Assistant who worked alongside rehab staff to provide exercises for residents with limited mobility) were at tables 1, 2 and 3. Table 4 had two residents who were waiting for their trays to be served. On 4/14/25 at 12:05 P.M. meal trays for the residents in table 4 were served by Licensed Nurse (LN) 11. LN 11 opened three small cartons of beverages using her bare forefinger to open the spout on the cartons. LN 11 then proceeded to feed one of the residents in table 4. An observation and interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to notify the attending physician and resident representative on four of five residents (Resident 2, 3, 5 and 7) reviewed for changes in condition when: 1. Resident 2 ' s representative was not notified of a wound deterioration. 2. Resident 3 ' s attending physician was not notified of a significant weight loss. 3. Resident 5 ' s attending physician was not notified of a significant weight loss. 4. Resident 7 ' s representative was not notified of a wound deterioration. These failures had the potential for a delay in care in treatment. In addition, the residents ' representatives were not aware of the change in condition. 1. Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (an impairment of brain function, such as memory loss and judgment) and muscle weakness according to the facility ' s admission Record. During an interview on 9/9/24 at 8:48 A.M. with Resident 2 ' s granddaughter, the granddaughter stated…

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 did not ensure one of three residents (Resident 2) reviewed for pressure ulcers (bedsore) received the necessary care and services to prevent worsening of the resident ' s pressure ulcer. This failure had the potential for infection and affect the resident ' s overall well-being. Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (an impairment of brain function, such as memory loss and judgment) and muscle weakness according to the facility ' s admission Record. During a review of Resident 2 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/9/24, section GG0170 A through E indicated Resident 2 was dependent on staff with rolling in bed, sit to lying, lying to sitting on side of bed, sit to stand and transfers. A review of Resident 2 ' s care plans was conducted. Resident 2 ' s skin care plan initiated on 7/2/24 indicated, .at risk for skin breakdown related to activity intolerance,…

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 transmission-based infection control measures when personal protective equipment (PPE, protective garments worn to prevent exposure to infection hazards) was not readily available for staff when entering the room of a resident (2) on transmission-based precautions (TBP, control measures put in place to prevent the spread of disease). This failure increased the risk of MRSA transmission to all susceptible residents, staff, and visitors at the facility. Findings: Resident 2 was admitted to the facility on [DATE] with a diagnosis of a sacral pressure ulcer (injury to the skin and tissue at the base of the spine), per the facility's admission Record. A review of Client 2's physician orders, dated 4/18/24, indicated Resident 2 was on enhanced barrier precautions (EBP, intervention to decrease risk of disease transmission during resident contact that requires use of a gown and gloves) for a history of Methicillin-resistant…

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 notify the responsible party (RP) before changing a resident's room for one of two sampled residents (1). This failure created the risk of Resident 1's RP being unaware of Resident 1's location while attempting to visit. Findings: Per the facility's admission Record, Resident 1 was admitted to the agency on 7/13/19 with diagnoses to include Hemiplegia (inability to move one side of the body). On 4/24/24 at 12:15 P.M., an interview was conducted with Resident 1's RP (RP 1). RP 1 stated, the facility had changed Resident 1's room multiple times and they did not always notify RP 1 that the room change had occurred. RP 1 further stated, that the facility did not notify her of Resident 1's latest room change on 4/23/24 until 4/24/24 at 10:23 A.M. On 4/24/24 at 12:35 P.M., an interview was conducted with Social Services (SS). SS stated, the facility notified RP 1 on the morning of 4/24/24 that Resident 1 had a room change the previous day. On 4/30/24 at 1:30 P.M., a telephone interview was conducted with the Director of Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately code activities of daily living (ADL-basic daily tasks such as bathing, dressing, getting in and out of bed, walking, eating and toileting) in the MDS assessment (a clinical assessment tool) for one of one resident reviewed for MDS. (Resident 3) This deficient practice had the potential to not meet resident ' s needs for safety and well-being, as well as miscommunication among caregivers regarding Resident 3 ' s ADL plan of care. Findings: Resident 3 was admitted to the facility on [DATE] with diagnoses including paraplegia (inability to voluntarily move the lower parts of the body) and cervical spinal stenosis (narrowing of space inside the backbone putting pressure on the spinal cord and nerves) according to the facility ' s admission Record. Resident 3 was observed lying in bed on 2/20/24, at 10 A.M. with a blanket up to his chest and a call pad (used to call for staff assistance) was on top of the blanket. Resident 3 stated…

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 comprehensive resident-centered care plans were developed and revised for two residents with stage four pressure ulcers (bedsores extended to muscle, tendon or bone). (Resident 1 and 4) These failures had the potential for these residents ' pressure ulcers to worsen and become infected. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including stage four pressure ulcer of sacral region (the triangular shaped bone at the base of the back) according to the facility ' s admission Record. During an observation on 1/11/24, at 9:46 A.M., Resident 1 was in bed with eyes open but with no verbal response upon greeting. Resident 1 was observed on an air mattress with a wound vac (a device that helps heal the wound from the inside using a small pump which removed fluid and germs from the wound) hanging on the right side of the bed. At 11:05 A.M., Resident 1 was observed in a gurney with two Emergency Medical…

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 update their care plan for 1 of 1 resident (Resident 1) with history of falls. This failure had the potential for Resident 1 ' s current fall prevention interventions to not be communicated to all health care providers. Findings. Resident 1 was admitted from the acute hospital on [DATE] with diagnoses that included unspecified dementia (A group of thinking and social symptoms that interferes with daily functioning) and history of falls. During an interview on 10/25/23 at 10:20 A.M., with restorative nursing aide (RNA) 1, RNA 1 stated she saw Resident 1 on the floor in the dining room. RNA 1 stated Resident 1 tends to stand up and down in his wheelchair. An observation was conducted in the dining room on 10/25/23 at 10:30 A.M. Twelve residents were attending activities with two activity staff present. During an interview on 10/25/23 at 10:30 A.M., with Activity assistant (AA) 1, AA 1 stated she was in the dining room when Resident 1 fell.…

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 a room change was documented in the medical record for 1 of 1 resident (Resident 1) reviewed for complete and accurate medical record. This failure had the potential to cause confusion amongst the healthcare team. Findings. Resident 1 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (a general term for loss of memory, language , problem solving and other thinking abilities that interfere with daily life) and history of falls , according to the Resident ' s 1 face sheet. During an interview on 10/25/23 at 10: 36 A.M., with licensed nurse (LN ) LN1, LN 1 stated the nurses had been placing Resident 1 in front of the nurse ' s station for close supervision due to Resident 1 ' s episode of trying to get out of the wheelchair unassisted. During an interview and joint record review of Resident 1's care plan on 10/25/23 at 5:00 P.M., with the Quality Assurance nurse (QA) QA nurse 1, QA nurse 1 stated…

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's Quality Assurance and Performance Improvement (QAPI- a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes)/ Quality Assurance (QA) Committee failed to identify areas of improvement related to resident falls. This failure put residents' safety at risk and increased the potential more falls would occur. Cross reference F689. Findings: On 9/26/23, a facility-provided list of residents who had falls from July 1, 2023 through September 26, 2023 was reviewed. The fall list indicated: July: thirty-two resident falls, two had injuries requiring hospital evaluation and/or treatment. August: twenty resident falls, two had injuries requiring hospital evaluation and/or treatment. September: thirty resident falls. On 10/4/23 at 3:10 P.M., an interview was conducted with the quality assurance nurse (QAN). The QAN stated the facility's QA committee met monthly and the QAPI met quarterly to discuss facility trends as identified through review of resident medical…

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 medical record review, the facility failed to accurately code the Minimum Data Set (MDS is a nursing assessment tool) for one of three sampled residents (Resident 4) reviewed for MDS coding. This deficient practice will result in providing inaccurate information to the Federal database. Findings: Resident 4 was admitted on [DATE] with diagnosis which included Parkinson's disease (a brain disorder that causes uncontrollable movements) per the facility's Face Sheet. Resident 4 was discharged on 7/27/23 per nursing progress note. A review of Resident 4's Progress notes dated, 6/29/23 was conducted. This progress note indicated, .Resident reported fall incident with husband in the bathroom. Per resident report, she attempted to transfer for w/c (wheelchair) to toilet then lost her balance due to her inability to control muscle movement . A review of Resident 4's interdisciplinary team (IDT) progress notes dated, 6/30/23 was conducted. This progress note indicated, On 06/29/2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement care plans for one of three sampled residents (Resident 1) when: 1. Resident 1 did not have a written care plan developed for their indwelling urinary catheter (tube inserted into the body to drain urine). 2. Resident 1's written care plan for activities of daily living (ADL, self-care activities like locomotion and getting dressed) was not implemented. This failure had the potential to result in Resident 1's urinary catheter care to not be provided by staff which could lead to urinary tract infection. In addition, not providing the required level of assistance to Resident 1 during ADL had the potential for accidents to occur. Findings: 1. A review of Resident 1's facesheet and admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included sepsis (severe complication related to a current infection) and dementia (impaired ability to remember, think, or make decisions that interferes 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 interview and record review, the facility failed to revise one of three residents' (Resident 1) written care plan with clear, resident-specific interventions after the resident sustained a fall with injury on 8/17/23. In addition, a post fall rehab screening that had been recommended by the interdisciplinary team (IDT, a multi-disciplinary group) was not followed after Resident 1 fell. As a result, there was a potential for Resident 1 to experience more falls. Findings: A review Resident 1's facility admission Record indicated the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses to include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment) dated 6/3/23, indicated the resident scored 02 on the brief interview of mental status (a score of 02 meant the resident had severe cognitive impairment). The same MDS assessment indicated the 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 interview and record review, the facility failed to provide care and services necessary to ensure that one of three sampled residents (Resident 1) with an indwelling urinary catheter (tube inserted into the body to drain urine) had a clinical condition that demonstrated the need for the catheter. These failures had the potential to result in the unnecessary use of an indwelling urinary catheter or urinary tract infection(s). Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included sepsis (severe complication related to a current infection During a review of Resident 1's Admission/readmission Evaluation/Assessment dated 5/3/23, the assessment indicated Resident 1 was admitted to the facility with a urinary indwelling catheter. There was no documentation found in Resident 1's medical record that showed the clinical indication or reason for the use of an indwelling urinary catheter. Review of Resident 1's Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure safe transport for one of 3 sampled residents (1). As a result, Resident 1 was dropped during transport and had to be evaluated at a hospital for injuries. Findings: During an unannounced visit on 10/11/23, at 9:10 A.M., the Quality Assurance Nurse (QAN) was interviewed. The QAN stated, on 10/4/23 it was reported to the facility that Resident 1 had been dropped during transport to dialysis (a treatment to clean the blood when the kidneys cannot). The QAN stated Resident 1 was evaluated for injury at the hospital after the incident. On 10/22/23, at 10:15 A.M., Resident 1 was interviewed. Resident 1 stated on 10/4 when he went to dialysis, he was dropped while being transferred off the gurney. Resident 1 stated it was because they only had one person transferring him, and it was supposed to be two people. Resident 1 stated he had to go to the hospital afterwards to be checked for injury. On 10/22/23, at 10:30 A.M., the Director of Nursing (DON)…

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 results of an abuse investigation were sent to the California Department of Public Health (CDPH, department that licenses and regulates nursing homes) within five business days. This failure resulted in the CDPH not knowing the outcome of the facility's investigation regarding the alleged abuse. Findings: On 8/7/23, CDPH received the facility's faxed Report of Suspected Dependent Adult/Elder Abuse form, dated 8/7/23, which indicated the facility was reporting an allegation of physical abuse that occurred during Resident 1's care. On 8/18/23, an onsite visit was conducted to investigate the facility's report of alleged physical abuse of Resident 1. On 8/18/23 at 9:10 A.M., an interview was conducted with the facility's quality assurance nurse (QAN). The QAN stated the facility had reported an allegation of abuse related to Resident 1 on 8/7/23. The QAN stated the facility investigated the allegation and determined it was unsubstantiated. The QAN stated the facility did not report the results of their…

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 consistently offer evening snacks to seven of 13 residents (Residents 34, 44, 61, 69, 79, 97, and 111), reviewed for Between Meal Snacks. This failure had the potential for residents to go to bed hungry. Findings: 1. Resident 79 was re-admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), per the facility's Resident Face Sheet. Resident 79's BIMS (a cognitive assessment) score, dated 7/10/21, was 11 (score 8-11 indicates moderate impaired cognition). On 7/21/21 at 9:23 A.M., an interview was conducted with Resident 79 in his room. Resident 79 stated he was not offered any snacks in the evening, but he thought that was a good idea, because he would like to have something before he went to bed. 2. Resident 34 was re-admitted to the facility on [DATE], with diagnoses which included hemiplegia affecting right dominate side (paralysis on one side of the body), per the facility's Resident Face Sheet. Resident 34's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consent prior to administering psychotropic medications (a medication which affects the mind) for two of three sampled residents reviewed for informed consents (54, 72). As a result, the residents may not have been fully informed of the risks and benefits of the psychotropic medications. Findings: 1. Resident 54 was admitted to the facility on [DATE] with diagnoses which included anxiety (a mental disorder characterized by excessive worrisome), per the facility's Resident Face Sheet. Per facility's Physician Order, on 6/8/21 the physician wrote an order for Resident 54 for lorazepam (medication for anxiety) twice a day and every six hours as needed for anxiety and agitation (state of nervous excitement). 2. Resident 72 was re-admitted to the facility on [DATE] with diagnoses which included anxiety (a mental disorder characterized by excessive worrisome), per the facility's Resident Face Sheet. Per facility's Physician Order, on 6/30/21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a quarterly (every 92 days) MDS, assessment for one of two (26), reviewed for Resident Assessment, as required by Federal regulation 42 CFR 483.20 (d). This failure had the potential for Resident 26's ongoing clinical status to go unrecognized and unmonitored. Findings: Resident 26 was admitted to the facility on [DATE], with diagnoses which included wedge compression fracture of the lumbar vertebra (fracture in the lower back), per the facility's annual MDS, dated [DATE]. On 7/21/21 at 3:31 P.M., an interview was conducted with the MDSN, regarding Resident 26's MDS data completion. The MDSN stated she would investigate the missing quarterly assessment and get back to me. On 7/22/21 at 8:35 A.M., the MDSN stated Resident 26's quarterly MDS was supposed to be completed in May 2021, and it was overlooked. The MDSN stated she normally printed out a list of all resident's monthly MDS required assessments and then complete the reports. The MDSN…

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 (69), reviewed for shower ADL care. As a result, there a was potential for Resident 69 to feel unclean and to have unidentified skin issues. Findings: Resident 69 was re-admitted to the facility on [DATE] with diagnoses which included idiopathic peripheral autonomic neuropathy (occurs when the nerves that control involuntary bodily functions are damaged), per the facility's Resident Face Sheet. A review of Resident 69's MDS, dated [DATE], had a BIMS (a cognitive assessment) score of 15 (13-15 indicated cognitively intact). The ADL assessment indicated, Resident 69 needed one person assist with bathing. An interview was conducted on 7/20/21 at 10 A.M., Resident 69 stated she did not get her scheduled shower on 7/19/21. Resident 69 stated had scheduled shower with CNA 6. Resident 69 was informed by CNA 6 that she was the only CNA on the floor working and was unable to provide the scheduled shower. Resident 69…

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 one of one sampled resident (211), received quality of care when the surgical sutures were not removed. This failure had the potential for Resident 211 to develop an infection post operatively due to not receiving continuity of care. Findings: Resident 211 was admitted to the facility on [DATE] with diagnoses that include surgical amputation of the right AKA and diabetes (abnormal blood sugar), per the facility's Resident's Face Sheet. On 7/20/21, a review of Resident 211's MDS, dated [DATE], indicated Resident 211's BIMS Score (test for cognitive function) was 14 out of 15, which indicated cognitively intact. On 7/21/21 at 11:03 A.M., a joint observation and interview with Resident 211 was conducted. Resident 211 was observed to have had a right AKA with seventeen (17) black sutures to the skin surface that were clean and dry without signs of infection. Resident 211 stated he had surgery in the middle of June 2021 and 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.

Based on observation, interview, and record review, the facility failed to ensure a pressure relieving mattress (LAL-low air loss) was programmed based on the resident's weight for one of six residents reviewed for pressure ulcer (18). This failure had the potential for Resident 18's Stage 3 pressure ulcer (Full thickness tissue loss) on the sacral (in the lower back) region to worsen and develop complications. Findings: Resident 18 was admitted in the facility on 9/16/21, which included Stage 3 pressure ulcer of the sacral region, unspecified severe protein-calorie malnutrition, per the facility's Resident Face Sheet. A review of Resident 18's MDS (an assessment tool), dated 4/27/21, indicated, Resident 18 had a BIMS (cognitive assessment) score of 00 which indicated severe cognitive impairment. Section G (functional status), indicated, Resident 18 was totally dependent on staff for activities of daily living. On 7/19/21 at 9:12 A.M., Resident 18 was observed laying on an LAL mattress. The LAL relieving mattress was set for the body weight of 180 lbs. (pounds). On 7/21/21 at 9:36…

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 act upon the pharmacist's recommendation for the use of as needed psychotropic medication (a medication which affects the mind) for two of four sampled residents (44, 81) for unnecessary medication. This failure had the potential for missed opportunities to identify the use of unnecessary psychotropic medication for Resident 44 and 81. Findings: 1. Resident 81 was admitted to the facility on [DATE] with diagnoses which included Anxiety, per the facility's Resident Face Sheet. A review of Resident 81's medical record was conducted. Per the Physician Order Report, dated 6/26/20, Resident 81 may receive Alprazolam (a psychotropic medication used to relieve symptoms of anxiety) 0.5 mg one tablet three times a day PRN. There was no end date per the Federal regulation. Per the Medication Regimen Review Binder, dated 6/20 through 6/21, there was no documented evidence Resident 81's psychotropic medication was reviewed by the CP. On 7/22/21 at 1:16 P.M., 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 the use of PRN psychotropic medication (a medication which affects the mind) was limited to 14 days for one of four sampled residents (44) reviewed for unnecessary medications. As a result, there was a potential risk for Resident 44 to have received an unnecessary medication. Findings: Resident 44 was re-admitted to the facility on [DATE] with diagnoses which included anxiety, per the facility's Resident Face Sheet, Per the facility's Physician Order, on 12/11/20 the physician wrote an order for Resident 44 for a PRN psychotropic medication to treat anxiety (a mental disorder characterized by excessive worrisome). The end date read, Open Ended. On 7/22/21 at 1:16 P.M., a joint interview and record review of the CP's Recommendation Note was conducted with the CP. The CP stated psychotropic medications should not be ordered beyond 14 days. The CP stated the review of PRN psychotropic medication was important to ensure the medication use was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medications were secured in a shared bathroom when a medications were found in the a bag labeled for Resident's 69. This failure had a potential for other residents, visitors and unauthorized staff to have access to Resident 69's medications. Findings: Resident 69 was readmitted to the facility on [DATE], per the facility's Resident Face Sheet. A review of Resident 69's MDS, dated [DATE], had a BIMS (a cognitive assessment) score of 15 (13-15 indicated cognitively intact). On 7/19/21 at 8:56 A.M., an observation of Resident 69's shared bathroom was conducted. Inside the bathroom there was a blue plastic bag with several medication container labeled with Resident 69's name that were filled with pills. On 7/19/21 at 8:58 A.M., a concurrent observation and interview was conducted with the CM. The CM confirmed the medications found in the shared bathroom belonged to Resident 69. On 7/19/21 at 8:59 A.M., an interview with Resident 69…

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 maintain one of two freezers (stand alone) reviewed for kitchen sanitation. This failure had the potential for cross-contamination which could result in food-borne illness. Findings: On 7/19/21 at 8:14 A. M., during initial entrance of the kitchen, an observation was conducted with the RD, the RDC, and the DSSA, of the stand-alone freezer. Ice build-up was observed around the interior circumference of the freezer, from the top to the bottom. The freezer contained individual packaged servings of flavored ice cream. The freezer opened from the top with two doors. Multiple small brown and black particles were observed on top of the freezer door gaskets. Inside the freeze, on the base of the top left rack were dark debris items, estimated to be 1/2 inch in size, along with ice cream containers. The left, rear rack had an orange, gelatin like substance smeared on the back-side of the shelf. On 7/19/21 at 8:15 A.M., the RDC stated the freezer looked dirty and ice was built-up. The RDC used a knife to hit the ice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately document a shower provided for one of 24 sampled residents (69), reviewed for documentation. As a result, Resident 69's medical record contained inaccurate documentation. Findings: Resident 69 was re-admitted to the facility on [DATE] with diagnoses which included idiopathic peripheral autonomic neuropathy (occurs when the nerves that control involuntary bodily functions are damaged), per the facility's Resident Face Sheet. A review of Resident 69's MDS, dated [DATE], had a BIMS (a cognitive assessment) score of 15 (13-15 indicated cognitively intact). The ADL assessment indicated, Resident 69 needed one person assist with bathing. An interview was conducted on 7/20/21 at 10 A.M., Resident 69 stated she did not get her scheduled shower on 7/19/21. Resident 69 stated she had a scheduled shower with CNA 6. Resident 69 was informed by CNA 6 that she was the only CNA on the floor working and was unable to provide the scheduled…

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 one sampled resident (68) was treated with respect and dignity during meals, when a staff member stood above them while the resident was fed. This failure violated the resident's rights to be treated with respect and dignity. Findings: Resident 68 was re-admitted to the facility on [DATE] with diagnoses, which included gastro-espohageal reflux disease (heartburn) per the facility's Resident Face Sheet. According to Resident 68's Brief Interview for Mental Status (BIMS) the resident's score was 0 (on a scale of 0 to 15, with 15 the most cognitively intact). On 3/6/19 at 8:33 A.M., LN 31 was observed assisting Resident 68 with her meal tray. Resident 68 was seated on her wheelchair and a folded chair was positioned against the wall. LN 31 was standing up and began giving Resident 68 a bite of food and stated, Come on Mama. LN 31 continued to give Resident 68 a bite of food in a standing position. On 3/6/19 at 8:40 A.M., LN 31…

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 2 of 2 sampled residents (34, 27), were care planned for comfort and proper body alignment in bed. This had the potential to result in discomfort and a decline in range of motion. Findings: 1) Resident 34 was admitted to the facility on [DATE] with diagnoses, which included pressure ulcer (injury to the skin) and diabetes mellitus (abnormal blood sugar in the body), per the facility's Resident Face Sheet. A review of the Minimum Data Set Assessment (standardized assessment of resident function) dated,12/10/2018, related to the resident Ability to Understand Others, was conducted. Resident 34 scored 1, on a 0 to 4 scale. (A score of 1, described a person who understood and comprehended most conversations). On 3/5/18 at 8:10 A.M., a concurrent observation and interview was conducted with Resident 34. Resident 34 was observed in bed resting under a cover, and on top of a specialty low air-loss mattress (air mattress designed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure interventions were implemented to prevent the development of a pressure ulcer (injury to skin from prolonged pressure) for one of eight (284) sampled residents. This had the potential to contribute to Resident 284's development of pressure ulcers. Findings: Resident 284 was admitted to the facility on [DATE] with diagnoses which included amputation (surgical removal) of right toes, diabetes (blood sugar imbalance that may require medicine to correct) with foot ulcer, and peripheral vascular disease (blood circulation disorder) per the facility's Face Sheet. On 3/5/19 at 10:07 A.M., during an interview Resident 284's family member stated the resident had no skin issues when they left the hospital and arrived at facility, but now had pressure ulcers. The resident's family member stated Resident 284 would be moved to a wheelchair for lunch, stay in the dining room for activities and be left sitting up in the wheelchair for most of the…

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

Based on interview and record review the facility failed to ensure resident needs were addressed promptly when their call lights were answered for two residents interviewed on initial tour of the facility, and five of 12 residents from the confidential group interview. This failure had the potential to affect the physical and psychosocial well-being of these residents. Findings: Resident A had a Brief Interview for Mental Status (BIMS) score of 14 (on a scale of 0 to 15, with 15 the most cognitively intact), according to the resident's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 2/14/19. This MDS assessment also indicated Resident A was always continent of bowel and bladder, and required extensive assistance with toilet use and personal hygiene. During an interview with Resident A on 3/5/19 at 9:20 A.M., the resident stated it took an hour at times to have her needs met when she used the call light. Resident A stated she drank a lot of water and needed to urinate about three times during an eight-hour shift. Resident A stated, I have been drinking less water…

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

Based on observation, interview and record review, the facility failed to follow manufacturer's guidelines for keeping soup bowls hot when serving. As a result of this deficient practice, there was a potential for the soup bowls to not maintain there insulation properities which could affect the temperature of food placed inside the bowls. Findings: During a confidential group interview on 3/6/19 at 10 A.M., three of 12 residents stated the food was cold. Resident D stated, The food is good if it's not cold. Resident C stated, We get cold food. Especially soups are frequently cold. On 3/7/19 at 11:30 A.M., an observation was made in the facility's kitchen. DA 14 was pouring soup into soup bowls, covering with plastic lids, then placing the covered bowls on a tray. When the tray was full, DA 14 stacked a second layer of covered soup bowls on top. He repeated the procedure until there were 4 layers of soup bowls. DA 14 then took the tray of soup bowls and placed it in oven 1. DA 14 created another tray of soup bowls, this time with only 2 layers of soup bowls and placed them in oven…

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 correctly label the resident's medical progress records for four of four sampled residents of Physician 1 (43, 68, 22, 24). This failure had the potential for the resident's medical information to be misplaced and not accessible to the healthcare providers when needed. Findings: Resident 43 was admitted to the facility on [DATE] with diagnoses that included liver cancer, kidney failure, and dysphagia (difficulty swallowing) per the facility's Resident Face Sheet. On 3/7/19 at 3:17 P.M., Resident 43's medical record was reviewed. The Doctor's Progress Notes dated 12/27/18 had no resident identifier written on the sheet of paper. On 3/7/19 at 3:21 PM, a joint interview and record review was conducted of Resident 43's medical record with the MRD. The MRD stated there should have been a resident identifier on all of the resident's documents in the medical record. The MRD acknowledged there was no resident name on the medical record and 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.