Smith Medical Nursing Care Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interviews, and a review of the facility policy titled Preventive Maintenance, the facility failed to ensure that it maintained a safe, clean, and comfortable home-like environment in 10 of 29 resident rooms related to dust and grime build-up and vegetation growth on resident room air conditioner/heater units, grime buildup on medical equipment in resident rooms, dusty ceiling vents in resident bathroom, rusty equipment and furniture in resident rooms, and missing paint in a resident room. These failures placed the residents at risk from the use of unsanitary equipment and the potential for a diminished quality of life. Findings include: A review of the undated facility policy titled Preventive Maintenance, revealed: It is the policy of (the facility) to check the premises, temperature of the facility, the grounds and equipment to ensure the premises, temperature, grounds and equipment remain in perfect working order and is clean, safe and sanitary. It is 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 record review, staff interviews, and review of the facility policies titled Completion of Minimum Data Set (MDS) and Comprehensive Care Plan, and Patient's Plan of Care, the facility failed to develop a care plan for one resident (R) (R28) with a diagnosis of Post Traumatic Stress Disorder (PTSD). This failure had the potential for R28 to not receive treatment and/or care according to their needs and place the resident at risk for adverse consequences. The sample size was 22. Findings include: A review of the facility policy titled Completion of MDS and Comprehensive Care Plan, last revised 3/15/2005 revealed: Procedural Guidelines: 7) Comprehensive Care Plans: The center should develop a comprehensive care plan for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. The care plan will describe the services that are to be furnished to attain or maintain the patient'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 observations, staff interviews, record review, and review of the policy titled Falls Management, the facility failed to complete neuro checks for one resident (R) (R22) after a fall and failed to complete fall risk assessments for two residents (R22 and R20) of 22 sampled residents. These failures had the potential for residents to not receive treatment and/or care according to their needs and placed R22 and R20 at risk for adverse consequences. Findings include: A review of the facility's undated Falls Management policy revealed the following sections: Assessment After a fall, a head-to-toe assessment should be comprehensive in order to note any injuries. If an injury is noted, documentation should describe the injury clearly. Any complaint of pain should be noted. If no injuries note. Immediate intervention Nurses may have to choose short term interventions such as alarms, 30 min checks, keeping residents in sight, etc. until review by the Care Plan team. Fall Follow Up Subsequent documentation 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 observations, resident interviews, and staff interviews, the facility failed to ensure one resident (R) (R26) of 22 sampled residents received a meal tray timely to prevent food from being cold. This deficient practice had the potential to cause R26 to have a decreased nutritional intake and the potential for weight loss. Findings include: A review of the admission Minimum Data Set (MDS) dated [DATE] revealed R26 had a Brief Interview for Mental Status (BIMS) score of 13 (indicating intact cognition) and was dependent on all aspects of Activities of Daily Living (ADL) care, including eating. During an interview on 3/22/2024 at 10:50 am with R26 it was reported that the food was sometimes cold at breakfast, so she would ask for cereal. She said all the meals were cold and that every now and again the food was warm enough to eat. R26 reported that she does not feel that meals are served timely because sometimes lunch is served at 12:30 pm and other times at 1:00 pm. During an interview with R26 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. A review of R26's admission MDS dated [DATE] revealed Section GG (Functional Abilities and Goals) documented that R26 was dependent on staff for all ADLs. Section H (Bowel and Bladder) documented that R26 had an indwelling urinary catheter. Section I (Active Diagnoses) documented diagnoses including, but not limited to, neurogenic bladder, and a urinary tract infection in the last 30 days. During an observation on 3/22/2024 at 12:52 pm R26 was observed sitting in her geriatric chair in her room with her catheter bag on the floor. During an observation on 3/23/2024 at 8:08 am R26's catheter bag was observed lying on the base of the overbed table. During an observation on 3/23/2024 at 4:15 pm R26's catheter bag was observed lying on the floor. In an interview on 3/24/2024 at 11:33 am, Certified Nursing Assistant (CNA) CC, reported that she cares for R26 when on her rotation, and the catheter bag should be kept off the floor. Based on observations, staff interviews, record review, and review of 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.

Based on observation and staff interviews, the facility failed to maintain a clean and sanitary kitchen and failed to ensure all opened items in the reach in cooler and reach in freezer was labeled with an open dated and labeled with a used by date. The deficient practice had the potential to affect 29 of 31 residents receiving an oral diet. Findings include: Initial kitchen observation on 1/27/2023 at 9:00 a.m. revealed upon entry to the kitchen new flooring was in the process of being installed. There were several areas with missing tiles, while other areas had new tiles installed. There was a straight back chair near the hot water heater that was located at entrance of the kitchen. There was a blue tray sitting on the chair with a coffee pot on it. The gas stove was observed with food on the top and inside the stove grates. Pipes between fryer were observed with particles. Reach in freezer observed to have several unlabeled undated food items. DM stated that she did not know what some of the items were and she stated that she could not read the dates on a plastic bag that she…

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 staff interviews and review of the facility policy titled, Infection Prevention and Control Program, the facility failed to have a qualified Infection Preventionist who had completed the required specialized training in infection prevention and control. This failure placed all residents at risk for the potential transmission of infections and communicable diseases. The facility census was 31 residents. Findings include: Review of the facility's undated policy, Infection Prevention and Control Program revealed the Infection Prevention and Control Program will include the following elements: A designated individual as the Infection Preventionist (IP) who is responsible for the center's Infection Prevention and Control Program. Designated Infection Preventionist will be a member of the center QAPI (Quality Assurance and Performance Improvement) committee and report on Infection Prevention and Control Program on a regular basis. During an interview on 1/29/2023 at 4:11 p.m. with the Director of Nursing (DON) revealed that the previous DON/IP for the facility quit in October…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and review of the facility policy, the facility failed to offer and/or administer the pneumonia and influenza vaccine to four residents (R) (R#133, R#28, R#132 and R#26) of five residents reviewed for the vaccines. Findings include: Review of facility's undated policy titled Immunization of Resident revealed it is the policy of this facility that all residents receive immunizations and vaccinations that aid in preventing infectious diseases unless medically contraindicated or otherwise ordered by the resident's attending physician or the facility's medical director. Upon admission to the facility, permission must be obtained from the resident (or representative) to administer pneumococcal vaccine if there is no documented history of vaccination and influenza vaccine annually (in the fall) unless contraindicated. PROCEDURE: 1. All new residents must be assessed for pneumococcal vaccine status upon admission. 3. Influenza immunization must be offered annually from October…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to offer and/or administer the COVID-19 vaccine to four residents (R) (R#133, R#28, R#132 and R#26) of five residents reviewed for the vaccines. Findings include: Review of the medical record for R#133 revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to major neurocognitive disorder. There was no indication that COVID vaccine was offered or administered to the resident. Verified by Director of Nursing (DON). Review of the medical record for R#28 revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to COVID pneumonia, toxic metabolic encephalopathy, and acute respiratory failure. There was no indication that the COVID vaccine was offered or administered to the resident. Verified by DON. Review of the medical record for R#132 revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to insomnia, vitamin D…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to ensure that the environment was safe, clean, and comfortable for residents, staff, and visitors related to disrepair of the main lobby, front and back halls, dining room, and shower rooms. The facility census was 31. Findings include: Upon entering the building on 1/27/2023 at 7:30 a.m., the following was observed: - The floors in the main lobby were partially tiled with exposed concrete. - The front hall had a hole in the floor all the way across the hall approximately 2 feet deep with two wooden pallets on top of the hole. There were four chairs blocking the area. This was directly outside of room [ROOM NUMBER], which was occupied by residents. In room [ROOM NUMBER], two armoires were observed in the middle of the room (not against the wall). - Four large doors, a stool, and a walker were observed stored in the hall leaning against the wall outside of room [ROOM NUMBER]. - At the end of the front hall, there was an unsecured door where additional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, policy review, and review of Centers for Medicare and Medicaid Services (CMS) Guidelines, the facility failed to ensure family members of non-hospice residents were allowed to visit at a time of the residents'/families' choosing without needing to schedule their visits with the facility in advance for one of 20 sampled residents (R) (R#21). Findings include: Review of CMS Center for Clinical Standards and Quality/Survey and Certification Group (QSO) Memorandum #QSO-20-39-NH, revised 3/10/2022, revealed, Facilities must allow indoor visitation at all times and for all residents as permitted under the regulations. While previously acceptable during the PHE [public health emergency], facilities can no longer limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits. Review of the undated visitation policy titled Visitor Regulation revealed visiting hours are 9 a.m. to 9 p.m. daily. Restrictions include limitations as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide one of one resident (R) (R#134) with the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (Form CMS-10055) who was discharged from Medicare Part A services in the last six months. Findings include: A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#134 was admitted to the facility on [DATE] with diagnosis of Anemia, Coronary Artery Disease, Heart Failure, Hypertension, Peripheral Vascular Disease, Depression, Malnutrition, Alzheimer's Disease, and Hyperlipidemia. On 1/28/2023 the facility provided the list of residents discharged within the last six months from Medicare covered Part A stay with benefit days remaining. There was only one resident on the list (R#134) with discharge date of 11/22/2022. The form noted that the resident stayed in the facility. A review of the SNF Beneficiary Protection Notification Review form noted that R#134 received services from 11/16/2022 until…

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, interviews and record review, the facility failed to ensure that one of 20 sampled residents (R) (R#12) comprehensive Minimum Data Set (MDS) assessment was accurate related to dental needs/concerns. Findings include: During an observation on 1/27/2023 at 9:08 a.m. R#12 was observed to be missing all teeth with only a couple broken and discolored front teeth. He stated he doesn't have pain and can chew a little bit. He stated that he would like to have the broken teeth pulled and get dentures so he could chew better. When asked when the last time was, he was seen by a dentist, he stated, It's been a while. A review of the Quarterly MDS assessment dated [DATE] revealed that R#12 is a [AGE] year-old male admitted to the facility on [DATE] and presented with a Brief Interview of Mental Status (BIMS) score of four, indicating severe cognitive impairment. No concerns were checked in the dental section of this assessment. A review of prior comprehensive MDS assessments revealed the following:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that a resident with a serious mental diagnosis was referred for a Level II PASARR (Pre-admission Screen and Resident Review) evaluation for one of 20 sampled residents (R) (R#7). Findings include: A review of the medical record revealed that R#7 was admitted to the facility on [DATE]. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed that R#7 presented with behaviors of delusions and was receiving antipsychotic medications and antidepressant medications. The assessment further noted that R#7 was not receiving any psychological therapy by a mental health provider and had no Level II PASARR evaluation. A review of the Physician Order Sheet dated for January 2023 revealed that R#7 had a diagnosis of schizophrenia. There was no diagnosis of dementia in the clinic record. During a review of the medical record with Licensed Practical Nurse (LPN) DD on 1/27/2023 at 11:07 a.m.,…

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, record review, staff interview, and review of facility's policy, the facility failed to develop a care plan related to bilateral hand contractures for one of 20 sampled residents (R#13). Finding include: Review of a facility undated policy titled, Patient's Plan of Care, specified: It is the intent of this center to develop and maintain an individualized plan of care for each patient. 7. Comprehensive Care Plans: The center should develop a comprehensive care plan for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. The care plan will describe the services that are to be furnished to attain or maintain the patient's highest practicable physical, mental, and psychosocial well-being or services that are not provided due to the patient's exercise of his/her rights to refuse treatment. Observations on 1/27/2023 at 8:40 a.m. and 2:37 p.m. and 1/28/2023 at…

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, interviews and record review, the facility failed to provide Activities of Daily Living (ADL) care related to showers and shaving for three of 20 sampled residents (R#132, R#12, and R#6). Findings include: 1. Review of the medical record for R#132 revealed that he is a [AGE] year-old male admitted to the facility on [DATE]. Review of the admission assessment dated [DATE] noted that R#132 is dependent on staff for grooming. Review of the Baseline Care Plan dated 1/13/2023 noted that R#132 is dependent on staff for shaving. On 1/27/2023 at 9:36 a.m. R#132 was observed in his room unshaved, hair was long afro type and appeared unwashed, oily, and matting. During an interview with the resident at this time, he stated that he would like a shave, but no one has offered. On 1/28/2023 at 8:59 a.m. R#132 was observed to still be unshaven. His hair was still oily, matted, and unwashed. During an interview with Certified Nursing Assistant (CNA) EE on 1/28/2023 at 12:57 p.m., she stated that she worked…

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, record review, staff interview and facility policy review, the facility failed to provide care and services related to contracture management and range of motion (ROM) for one of two residents (R) (R#13) reviewed for mobility. Findings include: Review of the undated facility policy titled Rehabilitation Nursing Care revealed nursing personnel are trained in rehabilitative nursing through on-going educational programs and orientation, and the Center encourages an active program of rehabilitative nursing care which is an integral part of nursing care and is directed toward assisting each guest to achieve and maintain an optimal level of self-care and independence. Rehabilitative nursing care services are performed daily for guests who require such services and are recorded on the guest's chart. Record review revealed that R#13 was admitted on [DATE] with diagnoses of schizophrenia, dementia, history of Parkinson's disease and flexure contractures. Review of the quarterly 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, interviews and record review, the facility failed to ensure that one of 20 sampled residents (R) (R#12) was provided with routine dental services. Findings include: A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R#12 is a [AGE] year-old male admitted to the facility on [DATE] and presented with a Brief Interview of Mental Status (BIMS) score of four, indicating severe cognitive impairment. A review of the Face Sheet in the clinical record for R#12 revealed that the resident is currently receiving Medicaid funding. During an observation on 1/27/2023 at 9:08 a.m. R#12 was observed to be missing all teeth with only a couple broken and discolored front teeth. He stated he doesn't have pain and can chew a little bit. He stated that he would like to have the broken teeth pulled and get dentures so he could chew better. When asked when the last time was that he seen by a dentist, he stated, It's been a while. A review of the clinical record revealed no…

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

Based on observations, interviews, and record review, the facility failed to develop a water management policy and implement a procedure to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water system; and failed to maintain an effective Infection Control Program to prevent the spread of infections by not ensuring staff practiced appropriate techniques related to cleaning lint trap of dryer resulting with large accumulation of lint buildup. This had had the potential to affect 31 residents who resided in the facility. Findings include: 1. The Center for Disease Control (CDC) website (https://www.cdc.gov/legionella/wmp/overview.html) indicated: Water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Such programs are now an industry standard for many buildings in the United States. A review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide a working system that allows residents to call for staff assistance through a communication system that relays the call directly to a staff member for one resident room (158A). The facility census was 31 residents. Findings include: Observation and test of the call light system on 1/27/2023 at 9:39 a.m. revealed the call light in room [ROOM NUMBER]A for resident (R) (#22) did not work. During an interview on 1/27/2023 at 9:39 a.m., R#22 stated that his call light has not worked for five to six months. He stated he told them, but they won't fix it. R#22 stated he guess they don't have enough time. Surveyor pressed call bell and looked outside room door. Call light outside room door did not come on. Bathroom call light and roommate call light functioning properly. Resident #22 stated that if he needed assistance, he pulls the call light in the bathroom. During another observation and test of the call light system on 1/30/2023 at 8:37 a.m. 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.