Temple City Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent unnecessary use of psychotropic medication (any medication that affects brain activities associated with mental processes and behavior) for two out of five sampled residents (Resident 8 and Resident 11) in accordance with the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 6/2021 by failing to: 1.Ensure Resident 8's physician order for Lorazepam (a medication used to manage anxiety (mental health condition that cause fear, dread and other symptoms) included the resident's symptom or behavior for the facility staff to monitor. 2. Ensure Resident 11's behavior that associated with the use of Quetiapine Fumarate (a medication used to manage schizophrenia [a mental health condition that affects how people think, feel and behave]) was monitored. As a result of the failure, the facility placed the residents at risk for experiencing side effects of the medication and prolonged use of the medication that…

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 complete a comprehensive Minimum Data Set ([MDS] a federally mandated resident assessment tool) for two of seven residents (Resident 3 and 10) reviewed for limited range of motion ([ROM] full movement potential of a joint) and mobility (ability to move). This failure also resulted in delayed transmission of Resident 3 and 10's MDS assessments to the Federal database. Cross reference F657 and F688. Findings: a. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 12/27/2025 with diagnoses including acute respiratory failure (sudden inability of the lunch to provide oxygen to the blood or remove [NAME] dioxide) with hypercapnia (abnormally high levels of carbon dioxide), attention to gastrostomy ([G-tube] surgical opening fitted with a device to allow feeding to be administered directly to the stomach for people with swallowing problems), dementia (progressive state of decline in mental…

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 assess two of seven sampled residents (Resident 33 and 6) with limited range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) on the ([MDS] a federally mandated resident assessment tool) by failing to: 1. Accurately assess Resident 33's MDS for entries related to related to Restorative Nursing Programs (nursing aide program in which Restorative Nursing Assistants [RNA] help residents to maintain their function and joint mobility) to reflect the current programs performed. 2. Accurately assess Resident 6's functional limitation in range of motion (limited ability to move a joint that interferes with daily functioning or places a resident at risk for injury). This failure had the potential to affect the provision of intervention to address Resident 33 and 6's mobility and ROM limitations and provided inaccurate information to the Federal database. Cross reference F688. Findings: 1.During 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, interview, and record review, the facility failed to follow the facility's policy and procedure (P&P) for the development of care plans for one out of three sampled residents (Resident 38) when: The facility did not develop a care plan to address the communication needs of Resident 38, a resident who did not speak English. This deficient practice placed the residents to not receive resident specific care and services according their individual needs. During a review of Resident 38's admission Record (AR), the AR indicated that the resident was admitted on [DATE] with diagnoses that included hypertension (elevated blood pressure), diabetes mellitus (elevated blood sugar levels), and repeated falls. The AR also indicated that the resident's primary language is not English. During a review of Resident 38's History and Physical (H&P), dated 3/30/2026, the H&P indicated that the resident does have the capacity to understand and make decisions. During a review of Resident 38'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 observation, interview, and record review, the facility failed to revise and update the care plan (CP) for two of seven residents (Resident 10 and 6) with limited range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) by failing to: 1. Revise and update Resident 10's CP for Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) services for ambulation (the act of walking). 2. Revise and update Resident 6's CP to specify the RNA program and discontinuation of PT services. These failures had the potential to result in inaccurate provision of services for ROM and mobility to Resident 6 and resulted in the absence of intervention for Resident 10's ability to walk. Cross reference F688. Findings: 1. During a review of Resident 10's admission Record, the admission Record indicated 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 that two of 53 nursing staff (Director of Nursing [DON] and Certified Nurse Assistant [CNA] 10) Basic Life Support (BLS, the level of care provided to victims of life-threatening illness or injuries until medical care is available, including recognition of cardiac arrest and activation of the emergency response system), that included cardiopulmonary resuscitation (CPR, an emergency procedure combing chest compressions and rescue breaths to circulate blood and oxygen when the heart stops or breathing ceases) licenses were not expired. This deficient practice had the potential to place the residents, who were identified as full code, at risk for not receiving adequate and proper life-saving measures during a code blue (a life-threatening medical emergency requiring an immediate trained response for CPR), potentially leading to greater harm and/or death to other residents residing in the facility.Findings: During a concurrent interview and record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pressure relieving devices to one of seven sampled residents (Resident 18) reviewed for limited range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) who was assessed as high risk for the developing pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). This failure had the potential for Resident 18 to develop pressure injuries, which could lead to pain and discomfort. Findings: During a review of Resident 18's admission Record, the admission Record indicated the facility initially admitted Resident 18 on 3/13/2025 and readmitted on [DATE] with diagnoses including Parkinson's disease, dementia, dysphagia (difficulty swallowing), and contractures (stiffening/shortening at any joint that reduces the joint's range of motion) of both knees and the right hand. During a review of Resident 18's Minimum Data Set ([MDS] a federally…

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 out of three sampled residents (Resident 3) received oxygen (the most critical gas for human survival) therapy with the oxygen nasal cannula (NC, a thin and hollow plastic tube that is placed under an individual's nostril to deliver oxygen) placed in the nostril and not over the resident's left cheek. This deficient practice placed Resident 3, who had diagnoses that affect the respiratory system (the body's way of bringing in oxygen), at risk of experiencing complications associated with the lack of oxygen. During a review of Resident 3's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included respiratory failure (condition where the lungs cannot adequately supply oxygen to the blood), pneumonitis (inflammation of the lung tissue, causing breathing difficulties, dry cough, and fatigue), and asthma (a condition in which the airways narrow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for the administration of medications for two out of four sampled residents (Resident 38 and Resident 1) when: 1.Licensed Vocational Nurse (LVN) 3 did not verify the frequency of Resident 38's medication order for Tylenol (or Acetaminophen, a medication used to manage pain) prior to its administration. 2. LVN 3 did not follow Resident 1's physician order for Hydrocodone-Acetaminophen (a medication used to manage pain). These deficient practices had the potential for the facility's staffs to increase a risk for medication errors, including missed doses, delayed administration, or over-administration. These deficient practices had a potential to result in Resident 38 and Resident 1's experience of inadequate pain control or adverse medication effects. Findings: 1. During a review of Resident 38's admission Record (AR), the AR indicated that the resident was admitted on [DATE] with diagnoses that…

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 proper storage of the medications and biologicals when: 1.Two out of two sampled Medication Carts (MC) contained expired medications- Ibuprofen (a medication used to control pain) and Hyoscyamine Sulfate (or brand name Levsin, a medication used to treat symptoms of gastrointestinal diseases [sicknesses that affect the digestive system]). 2. One of ten sampled residents (Resident 65) who was admitted to the facility with two bags containing a total of 19 medications that was kept at bedside. This deficient practice placed the residents at risk for receiving expired medications, which placed the residents at risk for reduced therapeutic effect (meaning the medication may not work as intended to treat the resident's condition). This deficient practice increased the risk of inadequate symptom management, unwanted effects, and potential harm to the residents. This deficient practice resulted in a medication bottle left at the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs by failing to: 1.Provide a palatable (describes food that is pleasant to taste, or an idea that is acceptable, satisfactory, or agreeable to the mind) and appetizing therapeutic diet for Resident 58 in accordance with the facility Policy and Procedure (P&P) titled, Food: Quality and Palatability 2. Provide the correct pureed (foods blended to a smooth, pudding-like consistency, free of lumps, seeds, or skins to aid those with severe chewing or swallowing difficulties) texture for Resident 24 in accordance with the facility's P&P titled, Diet and Nutrition Care Manual These deficient practices had the potential to result in Resident 58 and Resident 24 not finding their foods palatable and placed Resident 58 and Resident 24 at risk for potential choking, aspiration (occurs when food, liquid, saliva, or vomit enters the airway and lungs instead of the esophagus, often causing coughing,…

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 therapeutic diet (physician order diet) was served as prescribed by the physician for one of four sample residents (Resident 58). This deficient practice had the potential to result in Resident 58 not wanting to eat their food and had the potential to result in their nutritional requirements not being met, which may lead to dehydration, weight loss, and decreased quality of life. Cross Reference F805Findings: During a review of Resident 58's admission Record (AR), the AR indicated the facility admitted Resident 58 on 9/3/2024 and readmitted Resident 58 on 6/9/2025 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following a cerebral infarction (stroke, blockage of blood flow to the brain) affecting the left non-dominant side, hyperlipidemia (high cholesterol), and unspecified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one of 16 sampled residents (Resident 6) with Speech Language and Pathology ([SLP] profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) Evaluation or Screening in accordance with the physician's orders, dated 12/30/2025 and 1/12/2026. These failures resulted in Resident 6 receiving a puree diet (food altered into a smooth and creamy texture for people with difficulty chewing or swallowing) and did not receive intervention to improve Resident 6's speech. Findings: During a review of Resident 6's admission Record, the admission Record indicated the facility initially admitted Resident 6 on 11/6/2025 and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the left non-dominant side. During 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, interview, and record review the facility failed to ensure (Resident 1) who received psychotropic (medications to manage mood, behavior, or perception) was free of unnecessary chemical restraints. This deficient practice had the potential to result in Resident 1 receiving unnecessary medication and can lead to adverse medication reactions. During a review of Resident 1's admission Record (AR) indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of unspecified dementia (a progressive state of decline in mental abilities), difficulty in walking, Non-Hodgkin lymphoma (NHL - is a type of blood cancer that develops in the lymphatic system). During a review of Resident 1's History and Physical (H&P), dated 8/8/2025, the H&P indicated Resident 1 was admitted from the General Acute Care Hospital (GAHC) with diagnosis of recurrent falls. During a review of Resident 1's History and Physical (H&P), dated 11/15/2025, the H&P indicated Resident 1 does not…

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 two sampled residents (Resident 1) reviewed for accidents and supervision, was free of accident hazards as possible by failing to identify the potential risk factors that led to resident falling on 12/28/2025, 1/7/2026, 1/12/2026, and 1/21/2026. Furthermore, the facility failed to ensure the Care Plan was revised after Resident 1 sustained a fall on 12/28/2025. As a result, Resident 1 fell again on 1/7/2026 and sustained an open cut to the bridge of the nose with bruising.These deficient practices resulted in Resident 1 sustaining a left hip fracture on 1/21/2026 [fourth fall] after falling from standing position and was transferred to General Acute Care Hospital (GACH) on 1/21/2026. On 1/23/2026, Resident 1 underwent surgery for a left hip hemi-arthroplasty (a surgical procedure that involves replacing half of the hip joint) and diminished in Activities of Daily Living (ADL) that included a decline from walking 10 feet…

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 an interview and record review, the facility failed to ensure that a resident was allowed to exercise the right to choose a physician for one of two sampled residents (Resident 1) reviewed for residents' rights. The facility did not work with Resident 1 to select another physician of the resident's preference when the current attending physician (Physician 1) was unable to provide the necessary care and services before transferring care to an alternate physician (Physician 2). This deficient practice had the potential to prevent Resident 1's preferences from being honored. During a record review of Resident 1's admission Record (AR), dated 12/20/2025, the AR indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), ESRD (End Stage Renal Disease-irreversible kidney failure) with hemodialysis (a treatment to cleanse the blood of wastes and extra fluids…

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 administered medication Lyrica (a medication that treats nerve pain) as ordered for neuropathy (disease or dysfunction of one or more nerves, typically causing numbness, tingling, burning pain in the hands and feet) for one of two sampled residents (Resident 1) as ordered by the attending physician. This deficient practice resulted in the resident missing the medication as scheduled and could result in increased discomfort. During a record review of Resident 1's admission Record (AR), dated 12/20/2025, the AR indicated Resident 1was admitted to the facility on [DATE] with medical diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), ESRD (End Stage Renal Disease-irreversible kidney failure) with hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to report an allegation of abuse for two of three sampled residents (Resident 1 and Resident 2) within 2 hours to the ombudsman, local police department, and to California Department of Public Health (CDPH) in accordance with the facility's Policy and Procedure titled, Abuse and Neglect Prohibition Policy. On 12/21/25 between 5 PM and 6 PM, a commotion was heard by certified nurse assistant (CNA) 1 and when CNA1 arrived at Resident 1 and Resident 2's room [room [ROOM NUMBER]], Resident 1 was observed with a slipper in her hand, and Resident 2, reported to CNA 1 that Resident 1 threatened to hit Resident 2 with the slipper. This deficient practice resulted in the facility underreporting allegations of abuse and had the potential for the facility not to follow abuse protocols. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/16/2025 with diagnoses that included paranoid schizophrenia…

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 develop a resident specific care plan that reflected Resident 1's change in condition of a skin tear to the left shin.This deficient practice had the potential for Resident 1 to not receive appropriate care, treatment, and/or services.During a review of Resident 1's admission Record (AR), the AR indicated an admission to the facility on 9/18/2024 with diagnoses that included cellulitis of right lower limb, chronic respiratory failure, and lack of coordination. During a review of Resident 1's History and Physical Assessment (H&P), dated 11/3/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's SBAR (Situation Background Assessment Recommendation) Communication Form and progress note dated 10/24/2025, timed at 10:11 AM, the SBAR indicated during resident care, Resident 1 was transferring from the shower chair to the wheelchair with assistance and hit her log on the foot pedal which caused a skin tear to the left shin. The note indicated pressure and steri strips…

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 comprehensive care plan was individualized for one of three sampled residents (Resident 1), who was diagnosed with cancer and prescribed belzutifan (medication to treat cancer) 120 milligrams twice a day, indicated specific side effects (an effect of a drug or other type of treatment that is in addition to or beyond its desired effect) and specific monitoring required when taking belzutifan. As a result of this deficient practice, Resident 1 was inadequately monitored and was at risk for potential adverse effects (unintended, undesirable, and potentially harmful reactions to a therapy, such as medication, that range from mild to severe and can sometimes be linked to the treatment's primary action or an individual's unique response) or toxicities associated with taking Belzutifan. During a review of Resident 1's admission Record (AR), the AR indicated the resident was originally admitted on [DATE], and readmitted on [DATE], 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 observations, interviews, and record review, the facility failed to provide necessary care and services for one (1) of three (3) sampled residents (Resident 1) who had a diagnosis of cancer (a disease characterized by the uncontrolled growth and division of abnormal cells). Specifically, the facility failed to coordinate services related to the care and medication management of Resident 1's cancer, including monitoring for adverse effects and toxicity associated with the administration of Belzutifan (a cancer treatment medication, known to carry risks of anemia [a condition in which the blood lacks sufficient healthy red blood cells to carry adequate oxygen to the body's organs and tissues, leading to symptoms such as fatigue, weakness, and shortness of breath]) and hypoxemia (an abnormal condition characterized by insufficient oxygen supply to the body's tissues). The facility failed to ensure that Resident 1's care was coordinated in accordance with the treatment plans established by Oncologist 1, 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.

Based on interview and record review, the facility failed to ensure one out of three sampled Licensed Vocational Nurses (LVN 2) and two out of three sampled Certified Nursing Assistants (CNA 3) had adequate competency and skill sets by ensuring the staffs completed the annual competency assessment and evaluation (a process that assess and evaluates an employees skills, knowledge and performance) for the appropriate job category when providing quality care. As a result of this deficient practice the residents had the potential not to receive quality of care under the standard of practice which could lead to a decline in the resident's wellbeing. Findings: During a review of LVN ' s 2 employee file records indicated the facility hired LVN 2 on 6/1/2012. LVN 2 ' s employee records included a Licensed Nurse Master competency Evaluation Worksheet undated. The section titled validators assessment was left blank indicating LVN 2 was not evaluated for skills and competency. During a review of CNA ' s 2 employee file records indicated the facility hired CNA 2/2/2021. CNA ' s 3 employee…

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 food were stored prepared and distributed of food under sanitary conditions and served food in accordance with professional standards for food service safety and the facility's policy and procedure for 47 of 47 residents in the facility by failing to: 1. Document in the Sanitization Bucket Log the concentration of Quaternary Ammonia solution( a solution used to kill germs and bacteria) parts per million (PPM) that indicates the solution concentration effectively eliminate disease causing organisms. 2. Document in the Dish Machine Cleaning Log the temperature of the water during dish washing, during rinse and sanitation concentration. 3. Ensure the kitchen trashcan remained closed as required to prevent contamination and maintained sanitary food preparation environment. These deficient practices placed the residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages) and increased the risk of pest infestation and cross-contamination affecting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of her individuality for one out of the 13 sampled residents (Resident 27) who was observed being assisted by a facility staff who standing over and not at the eye level of the resident while assisting her during a meal. This deficient practice had the potential to affect Resident 27's self-esteem, self-worth, and the resident's sense of independence Findings: During a review of Resident 27's admission Record (Face Sheet), the facility admitted Resident 27 on 10/5/2018, and readmitted on [DATE] with diagnoses including diabetes mellitus (DM: long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated). During a review of Resident 27's History and Physical…

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 accommodate the needs two of three sampled residents (Resident 1 and Resident 12) by ensuring the resident's call lights (a device used to alert staff to the resident ' s room) were placed within the resident reach in accordance with the facility's policy and procedure [P&P] titled Answering Call lights. This deficient practice had the potential for the residents not to receive care and services that could result in accidents and falls. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses that included Parkinson ' s Disease without Dyskinesia (a disorder of the central nervous system that affects movement, often including tremors), Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). During a review of Resident 1'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 inform and provide written information for one (1) of 1 sampled resident (Resident 4) regarding their right to be informed and signed a written consent about the medication's use and side effects (undesired effect) before receiving Invega Sustenna (medication to treat schizophrenia [disorder that affects a person ' s ability to think, feel, and behave clearly]) that was not dispensed from facility ' s pharmacy. This deficient practice resulted in Resident 4's violation of residents right and received Invega Sustenna and experience side effects that could lead to a decline in the resident ' s well being. Findings: During a review of Resident 4's admission Record indicated an admission on [DATE] with diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often tremors), encephalopathy (a change in how your brain functions), and muscle weakness. During a review of Resident 4's History and Physical assessment…

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 complete the Notification of bed-hold and Return form (a form that indicates the resident's rights to return to the facility after hospitalization) for one of two sampled residents (Resident 29) who was transferred to the General Acute Care Hospital (GACH) in accordance with the facility's policy and procedures. This deficient practice resulted in the violation of the resident's rights to be informed about the Notification of bed-hold and Return policy and to be aware that the resident can return to the facility after hospitalization as ordered by the physician. Findings: 1. During a review of Resident 29 ' s admission Record (Face Sheet), the facility admitted Resident 29 on 1/9/2025, and readmitted on [DATE] with diagnoses diabetes mellitus (DM: long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and hypertension (a long-term medical condition in which the blood pressure in 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 develop a resident specific care plan that included interventions to monitor for the side effects such as bruising and bleeding for the use of Apixaban ( a medication that thins blood or an anticoagulant medication) used to treat and prevent blood clots) for DVT (deep vein thrombosis - a blood clot that blocks the flow of blood in the veins) for one of one sampled residents (Resident 35) prophylaxis (prevention). This deficient practice had the potential for the staff not to be able to provide care needed by the resident who was at risk for bleeding to develop bleeding in the body that could lead to excessive bleeding and blood loss resulting to death. Findings: During a review of Resident 35's admission Record indicated a readmission to the facility on 2/9/2025 with diagnoses that included encounter for palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), peripheral vascular…

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 unnecessary use of medication by ensuring one of one sampled resident (Resident 25) was monitored for bruising and bleeding while receiving Apixaban (a medication used to thin the blood and to treat or prevent deep venous thrombosis [DVT, a condition in which harmful blood clots form in the blood vessels of the legs]). This deficient practice increased the risk of Resident 35 to experience adverse effects (unwanted and dangerous side effects of medication) that could lead to health complications, such as excessive bleeding in the intestines and stomach or other parts of the body, bruising that could lead to death. Findings: During a review of Resident 35 ' s admission Record indicated a readmission to the facility on 2/9/2025 with diagnoses that included encounter for palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), peripheral vascular disease (a circulatory condition…

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 ensure drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles, and include the appropriate dosage and length of therapy by failing to ensure: 1. Resident 4's medications were labeled correctly. Resident 4 was ordered by the physician o receive Depakote (also known as Divalproex Sodium medication to treat seizures and bipolar disorder [mental health condition that causes extreme mood swings]) ER (Extended Release, medications designed to make them last longer in the body). The bubble pack (a card that packages doses of medication within small, clear, or light-resistant amber-colored plastic) was labeled Divalproex Sodium DR (delayed release-a type of medication designed to release active ingredients slower rate in the gastrointestinal tract). 2. The Curad triple antibiotic ointment (ointment used to treat infection) and antibiotic Stomahesive protective powder (powder…

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 the facility's policy and procedure on infection control for three of 3 residents (Residents 13, 27 and 36) by failing to ensure: 1. Activity Assistant 1 (AS) and Certified Nursing Assistant (CNA) 4, performed hand hygiene while distributing resident meal trays to Resdent 13 and Resident 27. 2. Resident 36's nebulizer mask (mask used to deliver the liquid medication) was properly store when not in use to prevent contamination. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for the residents. Findings: 1.During a review of Resident 13's admission Record (Face Sheet), the facility admitted Resident 13 on 10/8/2017 and readmitted on [DATE] with diagnoses including diabetes mellitus (DM: long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and hypertension (a long-term medical condition in which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure seven (7) of 7 sampled residents (Residents 7, 19, 21, 34, 37, 49, and 16) had a completed Advanced Directive (AD, a written instruction, such as a living will or durable power of attorney for health care relating to the provision of health care when the individual is incapacitated)acknowledgment form. This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident's wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions. Findings: 1. During a review of Resident 16's admission Record, indicated the facility admitted Resident 16 on 1/30/2024 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - type of obstructive lung disease characterized by long-term poor airflow). During a review of Resident 16's History and Physical (H&P), dated 12/18/2023, indicated, Resident 16 did not have has the capacity 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 complete the Bed Hold (holding the resident ' s bed while in the hospital or out for therapeutic leave) Notification form and inform the residents and/or their responsible party/ representative for three of three sampled residents (Resident 7, Resident 34 and Resident 16) regarding the Bed Hold in accordance with the facility ' s policy and procedures and federal and state regulations guidelines. This deficient practice had the potential for the resident not to be informed of their rights that they are able to return to the facility after hospitalization or therapeutic leave at a specified duration of time. Findings: 1. During a review of Resident 16 ' s admission Record, indicated the facility admitted Resident 16 on 1/30/2024 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - type of obstructive lung disease characterized by long-term poor airflow). During a review of Resident 16's History and Physical (H&P), dated 12/18/2023,…

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 3. A review of Resident 42 ' s Face Sheet indicated the resident was readmitted to the facility on [DATE] with diagnoses that included malignant neoplasm (cancerous tumor) of unspecified part of bronchus (a large airway) or lung, malignant neoplasm (cancerous tumor-an abnormal cell growth) of the brain. A review of Resident 42 ' s History and Physical dated 1/26/2024 indicated Resident 42 does not have to the capacity to understand and make decisions. A review of Resident 42 ' s Order summary report with active orders, dated 2/29/2024, indicated an order for enteral (into the stomach or intestine) feed order every shift check G-tube (gastrointestinal tube-surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) patency with an order start date 1/26/2026. A review of Resident 42's care plan developed on 1/26/2024, indicated no interventions related to the management and monitoring of Resident 42 with GT. A review of the care plan revised on 3/16/2024…

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 safe and sanitary food storage and preparation practices in the kitchen and label food in the kitchen, in accordance with the facility's policy and procedures on Food Storage: Dry Goods and Food Storage: Cold Foods. 1. A can of unopened Bread Crumbs with no label of date received was found in the Dry Storage Pantry. 2. Twenty one (21) packages of frozen hashbrowns with no label of date received was found in Freezer 4. These deficient practices had the potential to put residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: During the initial observation of the kitchen on 3/15/2024 at 10:41 AM, a can of breadcrumbs was observed with no label date of when received in dry storage are. The Dietary Supervisor (DS) stated it was important to label with date received, use by and open date. The DS stated this was, so the kitchen staff knows first in first out, and to know when the food expires. During the initial observation 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 check prior employers for three of five randomly selected employees Certified Nurse Assistant (CNA) 1, CNA 2, and Registered Nurse 1 (RN1) in accordance with the facility's policy and procedure, titled Abuse and Neglect Prohibition to prevent and protect residents from abuse. This deficient practice had the potential for the facility to hire employees with history of abuse, neglect or mistreatment of residents which put residents at risk for abuse and lead to possible physical and emotional harm residents. Findings: During a concurrent interview and record review with the Director of Staff Development (DSD) and review of the employee file of CNA 1 on 3/16/2024 at 11:32 am, the DSD stated CNA 1 was hired on 2/10/2024. The DSD stated there was no documented evidence that CNA 1 ' s previous employment was checked prior to hiring CNA 1. The DSD stated the previous employer of the employee must be verified prior to hiring to know if employee have abuse records in their previous employment. During a concurrent interview 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.

Based on interview and record review, the facility failed to ensure the Notice of Transfer and Discharge was provided to the resident's responsible party in accordance with the facility's policy titled Transfer and Discharge. for one of one resident (Resident 16) who was transferred to General Acute Care Hospital (GACH). This deficient practice had the potential for Resident 16's rights ensure for an appropriate discharge/transfer from the facility. Findings: A review of Resident 16 ' s admission Record, indicated the facility admitted Resident 16 on 1/30/2024 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - type of obstructive lung disease characterized by long-term poor airflow to the lungs). A review of Resident 16's History and Physical (H&P), dated 12/18/2023, indicated, Resident 16 did not have the capacity to understand and make decisions. A review of Resident 16's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/13/2024, the MDS indicated Resident 16 required moderate assistance with eating, oral hygiene, shower,…

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 Minimum Data Set (MDS- a resident assessment and care planning tool) dated 2/16/2024 assessment reflected an accurate assessment of the discharge destination for one of three sampled resident (Resident 55). Resident 55, who was discharged home was coded in the MDS assessment as being discharged to a General Acute Care Hospital (GACH). This deficient practice resulted in an inaccurate reporting to the Centers of Medicare and Medicaid (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential to result in Resident 55 not to receive interventions to address specific care concerns upon discharged to home. Findings: A review of Resident 55 ' s admission Record indicated Resident 55 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty in swallowing) and hyperlipidemia (high…

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 Resident 16's nasal cannula tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient ' s ears) was labeled with date as indicated in the facility ' s Policy and Procedure titled Oxygen Humidifiers. This deficient practice placed the Resident 16 at risk for infection. Findings: A review of Resident 16 ' s admission Record, indicated the facility admitted Resident 16 on 1/30/2024 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - type of obstructive lung disease characterized by long-term poor airflow) A review of Resident 16 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/13/2024, the MDS indicated Resident 16 required moderate assistance with eating, oral hygiene, shower, body dressing, and personal hygiene. A review of Resident 16's Order Summary Report, dated 3/15/2024, indicated to administer oxygen at two (2) liters per minute (L/min) via nasal cannula as needed for shortness of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 33 and 42) were appropriately assessed and completed the facility's Surveillance Data Collection Form to screen the residents for the adequate use of antibiotics (medications to treat infection). This deficient practice had the potential to result in the development of antibiotic-resistant organisms (organisms resistant [or not effectively treated] with antibiotics) and lead to unnecessary or inappropriate antibiotic use. Findings: 1.A review of Resident 33 ' s Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar), cellulitis (a bacterial skin infection) of left toe. A review of Resident 33 ' s History and Physical dated 2/23/2024 indicated Resident 33 has fluctuating capacity to understand and make decisions. A review of Resident 33's order summary report,…

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.