Aliya Of Crestwood

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prepare food that was palatable, attractive and prepared in a manner that conserved nutritive value, flavor and appearance. This failure affected 139 residents that consume food from the kitchen. Findings include: Facility census (4/20/2026) documents that 147 residents reside in the facility. Document titled, NPO (Nothing By Mouth) Residents documents in part 8 residents do not consume oral intake, indicating that 139 residents consume food from the kitchen. R17's face sheet documents diagnoses that include but are not limited to type 2 diabetes, multiple sclerosis, depression, suicidal ideations, and spastic hemiplegia. R17's BIMS (brief interview for mental status) score, dated 2/24/26, is 14 which indicates R17 is cognitively intact. On 4/20/26 at 10:01am, R17 said, The nurses are really good here. My main concern here (facility) is the food. They (kitchen staff) can't even cook vegetables. They (kitchen staff) overcook vegetables.…

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

Based on observation, interview, and record review, the facility failed to follow their policy by 1. Failed to ensure male staff properly wear beard nets while in the kitchen. 2. Failed to ensure gloves were removed during food preparation after touching multiple nonfood surfaces and items in the kitchen, and 3. Failed to ensure food in the freezer was properly labeled and dated with a use by date. These failures have the potential to affect all 139 residents receiving food from the facility kitchen.Findings include,On 04/20/2026 at 10:48 AM, upon entrance to the kitchen, V7 Dietary Director is noted to have a beard. The beard guard he is wearing is under his chin. V7 was observed to pull the beard guard on when this surveyor entered the kitchen.On 04/20/2026 at 10:51 AM, upon entrance to the walk-in freezer there are two packages of frozen peppers and onions with no label/open date on the packages. V7 was inquired of them. V7 said, They should've been labeled and dated separately.On 04/21/2026 at 9:51 AM, upon entrance to the kitchen, V7 Dietary Director and V38 Dietary Aide are…

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 staff don appropriate personal protective equipment (PPE) when providing high contact care to a resident, failed to utilize personal protective equipment per facility policy when coming in contact with soiled linen, and failed to ensure soiled linen was bagged tightly before sending it to the laundry to be cleaned. These failures affected one (R154) resident reviewed for infection control and had the potential to affect all 147 residents at the facility. Findings include: On 04/20/2026 at 11:25am, there was an EBP sign posted close to R154's door frame. V22 (Physical Therapy Assistant) donned gloves, entered R154's room, assisted R154 in putting R154's knee brace. V22 placed a walker closer to her and R154 and hung R154's indwelling catheter bag on one of the supports of the walker, touched R154's hand and asked R154 if he was dizzy. R154 stated he was not dizzy. V22 then placed a gait belt around R154's waist, placed the walker in front of R154 and assisted R154 to stand and let R154 use the walker…

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

Based on observation, interview, and record review the facility failed to maintain a safe, functional, and sanitary environment by failing to ensure dryer lint traps were clean and without damage. This failure has the potential to cause a fire and has the potential to affect all 147 residents at the facility. Findings include: On 4/21/2026 at 11:20 AM V35 (Housekeeping/Laundry Aide) stated dryer lint traps were cleaned every two hours. V33 (Housekeeping/Laundry Director), V35 and surveyor observed dryer number two which had a damaged lint screen and large amount of lint. V35 stated V34 (Laundry Aide) told V8 (Maintenance Director) about the damaged lint trap at least a week ago.On 4/21/2026 at 11:25 AM V34 (Laundry Aide) stated the damaged lint trap was reported yesterday or the day beforeOn 4/21/2026 at 11:28 AM V8 (Maintenance Director) was asked about the damaged lint trap. V8 stated, V8 was just informed today. V33 (Housekeeping/Laundry Director) just told V8. No one reported it before today.On 4/22/2026 at 2:50 PM V8 (Maintenance Director) stated dryer number two was taken out…

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 staff ordered and administered medications to a newly admitted resident (R156); failed to document the administration of medications immediately following administration for 12 (R6, R25, R52, R61, R87, R106, R115, R120, R126, R131, R139, and R142) residents. These failures affected 13 residents reviewed in a sample of 76 residents. Findings include: 1) R6's Medication Admin Audit Report, dated 4/22/26, documents that on 4/08/26, R6's medications that were due for 9:00am: Docusate Sodium, Hydroxyzine HCl, Levetiracetam, Furosemide, Loratadine, Gabapentin, Aspirin, Calcium, Nabumetone, Polyethylene Glycol, Magnesium Oxide, and Vitamin C were administered at 11:33am (one hour and 33 minutes late). R25's Medication Admin Audit Report, dated 4/22/26, documents that on 4/08/26, R25's medication, Cetirizine, that was due for 8:00am was given at 2:15pm (5 hours and 15 minutes late) and R25's medication, Lexapro, that was due 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.

Based on observation, interview, and record review, the facility failed to implement individualized fall prevention intervention for a resident identified at risk for falls, failed to prevent falls during provision of ADL (activities of daily living) care, and failed to ensure oxygen tanks were secured in the storage room. These failures affected two (R4 and R8) residents and have the potential to affect all 17 residents in Unit C Wing. Findings include: 1) On 04/20/2026 at 1:33pm, R8 stated the CNA (who was later identified as V40 – CNA) was changing him and she put him on his side facing the window and she was pushing something on his side and the next thing he knew he was on the floor, naked. R8 stated (V40) left him for about 35minutes. She came back with other staff (who was later identified as V17 – CNA, V25 (Licensed Practical Nurse), and V41 CNA) and they picked him up on the floor. R8 stated he informed (V16 – Licensed Practical Nurse) the next day that he fell; and she told him he needed to go the hospital. On 04/22/2026 at 9:46am, V40 (Certified Nursing Assistant) stated…

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

Based on observation, interview and record review, the facility failed to remove expired medication from three of four carts reviewed for medication storage. This failure has the potential to affect 53 residents that receive medications from these carts.Findings include: On 04/20/2026 1:17 PM, checked the Hall A-1 cart with V25 (LPN) and observed the following: 1 bottle of Zinc Oxide 50 mg with an expiration date of 11/2025.1 bottle of Vitamin B tablets with an expiration date of 12 /12/20251 bottle of Famotidine 20 mg with expiration date of 2/20261 bottle of Loratadine 10 mg, expiration date 02/20251 bottle of Vitamin A 2400 mcg, expiration date 9/2025.V25 was presented with this observation, and she acknowledged that the medications are expired, V25 added that someone from pharmacy usually comes to check the carts, not sure how those medications are still in the cart04/20/2026 2:05 PM, checked the Hall D/B Cart with V26 (LPN) and noted the following: Locked Controlled Substances - No issues or concerns.1 bottle of Aspirin 81 mg, expiration date 3/20261 bottle of liquid…

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 interviews and record review, the facility failed to ensure that hospice staff received appropriate orientation and demonstrated competency regarding the facility's policies and procedures. These failures affect all 14 (R3, R4, R7, R12, R42, R54, R69, R81, R89, R102, R103, R107, R122, and R138) residents receiving hospice care on the sample list of 76. Findings include:Facility presented document titled, Current Hospice Care Resident-14, updated 3/28/26, which documents 14 (R3, R4, R7, R12, R42, R54, R69, R81, R89, R102, R103, R107, R122, and R138) residents receiving hospice care at the facility.R138's FRI (facility reported incident, date of incident 4/01/26, documents, in part, (R138) sustained a fall. 911 called. Transferred to hospital. Right forehead laceration with 6 sutures. Based on thorough investigation through medical record reviews, staff interviews. The resident (R138) was being transported to the shower room (per hospice CNA/Certified Nursing Assistant/V43) and became anxious and attempted to stand up and fell forward due to poor safety awareness, 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 observation, interviews, and record reviews, the facility failed to ensure that the call light in one shower room on B Wing Unit 2 was functioning properly. This deficiency affected 31 residents, including all 14 residents on B Wing Unit 2 and 17 residents on C Wing Unit 2 of the facility.Findings include:Facility census, dated 4/20/26, documents 14 residents on B Wing Unit 2 and all 17 residents on C Wing Unit 2 of the facility.On 4/20/26 at 10:06am, R104 said, And another thing is that I have to walk all the way to the other shower room (B Wing Unit 2) because the shower room in my hall doesn't work and hasn't worked since I've been here. The dang call light don't work in that shower room either. Yes staff and management said everyone in my area has to use the other shower room ( B Wing Unit 2).R104's face sheet documents an admission date of 2/13/26 and diagnoses that include but are not limited to chest pain, aortocoronary bypass, and hernia.R104's BIMS (brief interview for mental status) score, dated 2/24/26, is 15 which indicates R104 is cognitively intact.On 4/20/26…

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

Based on observation, interview, and record review, the facility failed to implement the care plan for one resident (R91) and failed to ensure that the resident's urinary catheter drainage bag was properly covered. These failures affected one (R91) resident in a sample size of 76 residents reviewed for urinary catheters.Findings include:R91 unable to be interviewed due to altered mental status.R91's face sheet documents diagnoses that include but are not limited to neuromuscular dysfunction of the bladder, chronic kidney disease, and cognitive communication deficit.R91's BIMS (brief interview for mental status) score, dated 4/10/26, is 00 which indicates R91's cognition is severely impaired.R91's care plan, dated 4/03/26, documents, in part, Foley: (R91) requires use of an indwelling catheter r/t (Neurogenic Bladder) is at risk for of infection, with interventions that documents, in part, Keep draining bag covered to promote privacy.R91's physician order, ordered date 4/03/26, documents, in part, Provide Catheter (urinary catheter) care Q (every) shift and PRN (as needed).On 4/20/26…

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 honor the resident's right to have informed consent prior to initiation of antipsychotic medication, including the risks/benefits, goals of treatment, diagnosis, schedule of administration. This failure affected one resident (R10) in a sample of 72 residents reviewed for consent.R10's face sheet documents in part the following diagnoses: spinal stenosis, unspecified dementia with psychotic disturbance, protein calorie malnutrition, epilepsy, anxiety disorder, severe intellectual disabilities, major depressive disorder, contractures of right upper arm, dysphasia, tremors, dysphagia, and muscle weakness.R10's minimum data set (1/20/2026) documents in part that R10 is rarely/never understood and has severe cognitive impairment for daily decision making. Additionally, the MDS indicates there were no behaviors in the lookback period and does not have serious mental illness, schizophrenia, schizoaffective disorder. R10's physician orders document (8/17/2025) Olanzapine 20mg Give 20 mg via G-Tube in the evening for treat…

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 accurately complete assessments and minimum data set items. This failure affected two residents (R10, R138) reviewed for assessment accuracy in a sample of 76 residents. Findings include: 1) R138 unable to be interviewed due to altered mental status. R138's face sheet documents an admission date of 3/28/26, and diagnoses that include but are not limited to traumatic subdural hemorrhage, generalized anxiety disorder, cerebral ischemia, bilateral primary osteoarthritis, contusion of scalp, unspecified fall, and unspecified dementia. R138's BIMS (brief interview for mental status) score, dated 4/13/26, is 99 which indicates R138 was unable to complete in the interview. R138's MDS (minimum data set) section C, dated 4/13/26, documents, in part, that R138's cognitive skills for daily decision making is moderately impaired. Record review of R138's Restorative Comprehensive Assessment, dated 3/30/26, documents, in part, 5. Mentation: 0. Alert and Orientes x3;…

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 revise the resident's care plan to correctly reflect the resident's inability for splint use, and diagnosis related to antipsychotic medication use. This failure affected one resident (R10) reviewed for care plan in a sample of 76 residents.Findings include:R10's face sheet documents in part the following diagnoses: spinal stenosis, unspecified dementia with psychotic disturbance, protein calorie malnutrition, epilepsy, anxiety disorder, severe intellectual disabilities, major depressive disorder, contractures of right upper arm, dysphasia, tremors, dysphagia, and muscle weakness. There is no diagnosis of any schizophrenia, schizoaffective disorder, schizophreniform disorder. R10's minimum data set (1/20/2026) documents in part that R10 is rarely/never understood and has severe cognitive impairment for daily decision making. R10 is dependent on staff for ADL (activities of daily living) needs and has limited range of motion in all extremities. Additionally, the MDS indicates there were no behaviors 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 observation, interview and record review, the facility failed to ensure that staff ordered and administered medications to a newly admitted resident (R156) and failed to ensure that a witnessed fall was documented in the resident's electronic health record (R8). R156 was admitted to the facility on [DATE] between 1:30 and 2:00PM and did not receive any medications till the morning of 4/21/2026. These failures affected two (R8 and R156) of two residents reviewed for quality of care. Findings include: 1.R156 is [AGE] years old admitted to the facility on [DATE], face sheet listed the following past medical history, chronic obstructive pulmonary disease, hypokalemia, alcohol abuse with withdrawal, rheumatoid arthritis, tobacco abuse counseling, hypothyroidism, noninfective gastroenteritis, chest pain, etc. admission evaluation dated 4/20/2026 documented that R156 is alert and oriented x3, can make needs known and communicate with a clear speech. After visit summary dated 4/20/2026, scanned in 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.

Based on observation, interview, and record review the facility failed to follow facility guideline and standard of care in utilizing a pressure relieving mattress for one resident (R112) with a history of pressure injuries out of a sample of 76 residents reviewed for pressure injuryFindings:R112 is at risk of pressure injury as evidenced by Minimum Data Set (MDS) Section M dated 4/16/2026 which stated: Is this resident at risk of developing pressure ulcers/injuries? Facility response: Yes. Skin treatment included a pressure reducing device for the bed.On 4/21/2026 at 10:21 AM R112 stated R112 weighed about 203 pounds. V30 (Licensed Practical Nurse/LPN) and surveyor observed pressure relieving mattress setting. V30 stated the mattress was set at between 325 pounds and 350 pounds. On 4/22/2026 at 8:40 AM R112 stated R112's weight was about 203 pounds. Low air loss mattress was observed to be set at 325 pounds. V30 (LPN) and V31 (Wound Nurse) observed low air loss mattress setting. V31 stated, Oh, that is not right. R112 weighs 203.6 pounds This is set wrong. V31 reset R11's low air…

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 provide necessary respiratory care consistent with professional standards of practice. This failure affected one (R88) resident reviewed for respiratory care in the total sample of 76 residents. Findings include: On 04/20/2026 at 10:30am, there was a sign posted by R88's door frame Oxygen in Use. Inside the room, R88 was lying on bed, not using a nasal cannula. R88's nasal canula was hanging on the side of her bed, not contained. R88's oxygen concentrator was off. R88 stated she did not know who turned off her oxygen concentrator.On 04/20/2026 at 10:35am, requested V10 (Unit 2 Supervisor) to check R88's nasal canula and stated it is not contained; it should be contained when not in used for infection control. On 04/22/2026 at 12:25pm, V2 (Director of Nursing) stated the expectation is to ensure the nasal cannula is contained in a plastic bag when not in used to prevent cross contamination and to prevent growth of infectious organism. R88's admission Record documented that R88's diagnoses include but are 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.

Based on observation, interview, and record review, the facility failed to check and log the resident's personal refrigerator temperature daily. This failure affected 1 (R62) resident reviewed for personal refrigerator in the total sample of 76 residents. Findings include: On 04/20/2026 at 12:09pm, R62 personal refrigerator temperature log was not signed daily. This surveyor requested V14 (Licensed Practice Nurse) to check the temperature log and stated there are missing entries on the log. On 04/22/2026 at 12:07pm, V2 (Director of Nursing) stated the staff responsible for checking the temperature of the resident's personal refrigerator daily are housekeeping, Kitchen, and Angel Rounds, but mostly by the Angel Rounds. Purpose of checking the temperature daily is to ensure the refrigerated food items are maintained within the temperature range to ensure food items inside the refrigerator are safe to eat to prevent food borne illnesses. R62's admission Record documented that R62's diagnoses include but are not limited to adjustment disorder with depression, psychosis, 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 interviews and record reviews, the facility failed to follow their policy and procedures to ensure residents received showers in accordance with professional standards of practice. This failure applies to one (R4) of four residents reviewed for receiving showers in the facility. Findings include: R4 is [AGE] years old, female, admitted to the facility 08/14/2025, diagnoses including but not limited to: Dementia, metabolic encephalopathy, cerebral ischemia, and gait and mobility abnormality. R4's (MDS) Minimal Data Set assessment of 08/21/2025, section C, the BIMS (Brief Interviewed Mental status) score was 10/15, which means moderately impaired cognitively. R4's MDS of 8/21/2025, GG section for Shower/bathe self, R4 requires Substantial/maximal assistance - Helper does more than half the effort. The helper lifts or holds the trunk or limbs and provides more than half the effort.On 9/29/2025 at 1:00 PM, R4's family member said, I went on vacation in the middle of the month, and when I came back to visit…

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 follow their medication administration policy by not administering scheduled pain medication within the hour timeframe as ordered and failed to notify the physician of the missed dose for one (R1) out of three residents reviewed for medication administration in a total sample of four.R1 is a [AGE] year old with the following diagnosis: idiopathic neuropathy, chronic pain syndrome, and venous insufficiency.On 8/5/25 at 3:08PM, R1 said on 7/19/2025 she did not receive the scheduled morning medications at any time during the day shift (7:00 AM - 3:00 PM). R1 said the day shift nurse (V4) did not come into R1's room the whole shift. R1 stated that V4 did not check vitals and did not ask R1 for her pain level. R1 said the CNA (V10) had gotten R1 up from bed around 10:30 AM that morning. R1 said her family members came to visit her from 12PM to 3:00 PM. R1 said at approximately 3:00 PM she asked the evening nurse why she hadn't received her day time…

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 upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that 8 of 25 residents (R8, R10, R11, R13, R14, R16, R17, R18) remained free from significant medication errors. Findings include:1. R10’s POS (Physician Order Sheets) include Escitalopram (Antidepressant) 20mg (milligrams) give 1 tablet one time a day. Special instruction: take with 10mg tablet for total dose of 30mg daily (start date: 11/21/24). On 7/15/25 at 8:30am, V11 (LPN/Licensed Practical Nurse) dispensed (1) 20mg (milligrams) Escitalopram tablet in R10’s medication cup (with scheduled 8am medications) and affirmed she was prepared to administer them however the prescribed dose is 30mg. Surveyor inquired what R10’s Escitalopram order states V11 accessed R10’s EMAR (Electronic Medication Administration Record) and stated, “Escitalopram 20 milligrams give 1 tablet 1 time a day and take with a 10-milligram tablet.” Surveyor inquired about R10’s Escitalopram prescribed dose V11 responded “30 milligrams.” R10’s Escitalopram 20 milligram tablet (not 30…

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 upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that medication orders received include a prescribed dose, and failed to maintain a medication error rate below 5%. There were 4 medication errors out of 37 opportunities, resulting in a 10.81% medication error rate. Three of three residents (R7, R10, R12) in the medication administration sample were affected. Findings include:1.R10's POS (Physician Order Sheets) include Escitalopram 20mg (milligrams) give 1 tablet one time a day. Special instruction: take with 10mg tablet for total dose of 30mg daily (start date: 11/21/24).On 7/15/25 at 8:30am, V11 (LPN/Licensed Practical Nurse) dispensed (1) 20mg Escitalopram tablet in R10's medication cup (with scheduled 8am medications) and affirmed she was prepared to administer them however R10's prescribed Escitalopram dose is 30mg. Surveyor inquired how much Escitalopram was dispensed in R10's medication cup V11 checked the single dose package and affirmed it was 20mg. Surveyor inquired what R10's Escitalopram order states…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide incontinence care timely for a resident who was identified as dependent on staff. This affected one of three residents (R2) reviewed for incontinence care. Findings Include: R2's minimal dated set (MDS) section C brief interview for mental status dated 6/27/25 documents: a score of fifteen which indicates cognitively intact. Section H (bowel/bladder) dated 6/30/25 documents: frequently incontinence. Section GG (functional ability) documents: toileting- dependent. R2's Minimum Data Set, dated [DATE] documents: roll left and right. The ability to roll from lying on back to left and right side and return to lying on back ln the bed documents substantial/maximal assistance. On 7/1/25 at 10:48pm, R2 who was assessed to be alert and oriented to person, place and time said, she was left soiled and saturated with urine for 3.5 hours on one occasion and over two hours on another. R2 said, being left in saturated urine made her feel stressed, frustrated…

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 follow their policy and provide a written notice of room change with and explanation of the room change for one of one resident (R2) reviewed for written room change notice. Findings include: On 2/27/25 at 10:39am V1 (R2's sister/ POA-Power of Attorney) said the facility did not discuss R2's room change with her. V1 said she did not get a copy of the room change notice. On 2/27/25 at 4:40pm request was made to V4 (Director of Nursing) V5 (Administrator) and V7 (Social Service) to review the written notice of room change for R2. On 2/28/25 upon exit of this survey V5 (Administrator), V4 (Director of Nursing), and V7 (Social Worker) did not present a copy of the written notice of room change and explanation of room change for R2, the facility did not present documentation denoting a written notice was given to R2's family/poa/ resident representative Facility policy dated 11/1/2023 denotes in-part room change/transfer within facility. To assure residents and/ or their representatives are appropriately notified of room…

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 follow their abuse prevention policy and report an allegation of abuse to the abuse coordinator and or Director of Nursing on 2/21/25 for one of one resident (R1) reviewed for abuse reporting. Findings include: R1 face sheet denotes R1 has diagnosis of dementia. On 2/27/25 at 4:19 pm V3 (Registered Nurse) said V1 (visitor) approached him on 2/21/25 and said that V2 (Certified Nursing aide/CNA) slapped R1 on the knee. V3 said he did not report the allegation to V4 (DON) or V5 (Administrator). On 2/27/25 at 4:25 pm (Director of Nursing) said he was not aware of the allegation of abuse for R1. Facility policy titled abuse prevention dated 3/2022 denotes in-part, internal reporting requirements and identification of allegations. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator…

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 ensure proper integrity of the facility roof that resulted in ceiling cracks in two residents' rooms and ensure dust free ventilatory outlets in all residents' rooms throughout the facility. This failure has a potential to affect all 131 residents residing in the facility. Findings include: On 02/18/2025 at 09:45 AM Surveyor was provided with facility census listing 131 residents residing in the facility. On 02/18/25 between 11:00 AM and 2:00 PM Surveyor completed initial observations that revealed: - abundant collection of black/dark grey, powder like particles on the ceiling, around and in the ventilatory outlet and smoke detector in room [ROOM NUMBER] - cracked plaster on the ceiling with rusty discoloration in room [ROOM NUMBER], water collection bucket underneath the crack in the ceiling - cracked plaster on the ceiling with rusty discoloration in the bathroom room [ROOM NUMBER] - abundant collection of dark grey/white, powder like…

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

Based on observation, interview, and record review the facility failed to follow their policy and procedures for dietary food storage, cleaning, and hand hygiene practices by not ensuring stored foods were free of contaminated substances, not ensuring stored foods were properly labeled, not ensuring coolers and freezers were clean and free of contaminated items, not ensuring food items not intended for resident use were discarded, and not performing hand hygiene after handling contaminated items. This failure applies to all 123 residents receiving food from the facility. Findings include: On 02/18/2025 at 10:18 AM In the facility's main kitchen observed a strong foul odor in the cooler along with two large boxes of meat with a red substance spilled on them. V26 (Dietary Aide) stated she observed the strong odor, and it could be spoiled food or something spilled and the cooler needs to be cleaned. Observed a container with a burger patty labeled black bean burger partially covered with plastic wrap with no labeled dates. Observed a large box of tomatoes, a large box of lettuce, and 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 observation, interview, and record review, the facility failed to follow the pharmacy policy by not storing unopened Insulin in the medication refrigerator and documenting open date labels for three of three (R439, R127, R82) residents reviewed during medication storage and labeling in the sample of 32. Findings include: On 02/19/2025 at 12:15PM Surveyor conducted an inspection of the 1st floor (Unit 2-C) medication cart. Surveyor observed undated insulin pen medications not labeled opened, and unopened insulin not properly stored in facility/medication refrigerator for two residents: R439 Novolin R Flex Pen 100unit/ML - No open date written on label. Not stored in appropriate facility/medication refrigerator per pharmacy policy for all unopened insulin should be refrigerated. R127 Lispro Kwik Pen 100unit/ML - No open date written on label. Not stored in appropriate facility/medication refrigerator per pharmacy policy for all unopened insulin should be refrigerated. On 02/19/2025 at 12:50PM Surveyor conducted an inspection of the 1st floor (Unit 1-C) medication cart.…

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 interviews and record reviews, the facility failed to follow its skin prevention policy and notify one resident's (R1) family regarding a new facility acquired wound timely. This affects one of three (R1) resident reviewed for change in condition notification. Findings include: On 1/23/25, V3 (wound care nurse) stated that R1 was at high risk for skin breakdown. V3 stated that R1 developed a facility acquired MASD (moisture associated skin damage) sacral wound due to loose stools, moisture in brief due to sweating, and loose skin (on 12/23/24). V3 stated that the was an overall decline in R1's medical condition. V3 stated that while R1 was in the hospital, R1 was started on dialysis treatments three times a week. V3 stated that since R1 was re-admitted from the hospital, R1's overall condition has declined. V3 stated that on 12/17 she discussed with R1's family that R1's multiple comorbidities and risk factors could cause skin impairments. V3 stated at that time, R1 did not have any skin alterations. V3 stated that on 12/30 V3 did R1's wound care treatment in the presence…

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 interviews and record reviews, the facility failed to follow its skin care prevention policy and develop a person-centered care plan with interventions to prevent or reduce the risk of developing skin breakdown. This affects one of three residents (R1) reviewed for care plan development. Findings include: On 1/23/25 at 10:00AM, V3 (wound care nurse) stated that R1 was at risk for skin breakdown. V3 stated that R1 developed a facility acquired MASD (moisture associated skin damage) sacral wound due to fragile skin, loose stools, moisture in brief due to sweating, and loose skin. V3 stated that there was an overall decline in R1's medical condition since R1 was re-admitted from hospital stay in November. On 1/23/25 at 12:00PM, V4 CNA (certified nurse aide) stated that R1 is dependent for all ADLs (activities of daily living). On 1/23/25 at 12:35PM, V7 LPN (licensed practical nurse) stated that stated that R1 was able to make slight movements, but not able to reposition self. R1's comprehensive care plan does not note a risk for an alteration in skin integrity or actual skin…

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 reviews, the facility failed to follow its tube feeding policy and check the resident's gastrostomy tube for residual prior to administering medications and bolus feeding. This failure affected one resident (R1) out of three residents reviewed for gastrostomy tubes in a sample of 5. Findings include: On 1/22/25 at 4:30PM, this surveyor observed V10 RN (registered nurse) administer medications and bolus feeding for R2. V10 was not observed checking R2's G-tube (gastrostomy tube) for any residual or checking placement prior to administering R2's scheduled medications. V10 was observed administering 150ml (milliliters) of water prior to initiating R2's bolus G-tube feeding. On 1/23/25 at 12:20PM, V6 LPN (licensed practical nurse) stated that the resident's G-tube should be checked for residual before administering medications and bolus feedings via G-tube. On 1/23/25 at 12:35PM, V7 LPN stated that the resident's G-tube should be checked for residual before administering medications and bolus feedings via G-tube. V6 stated that if the…

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

Based on observations, interviews, and record reviews, the facility failed to follow its enteral tube medication administration policy and administer water in between each medication administered and administer scheduled medications per physician orders for one resident (R1) out of three reviewed for medication administration in a sample of 5. Findings include: On 1/22/25 at 4:30PM, this surveyor observed V10 RN (registered nurse) prepare R2's medications for administration. V10 crushed R2's medications and placed each medication in a separate medication cup. V10 was observed dissolving each medication in water. V10 administered R2's medications via gastrostomy tube. V10 was not observed flushing the gastrostomy tube with 5-10ml of water in between each medication administered. On 1/22/25 at 4:30PM, V10 stated that R2's omeprazole was not present in the medication cart. V10 did not inform R2 that R2 was not receiving this medication. On 1/23/25 at 9:45AM, R2 complained of his stomach bothering him to V3 LPN (licensed practical nurse). R2 denied nausea or vomiting, but unable to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor its call light system and answer call lights within a timely manner for four residents (R2, R3, R4, R6) out of six residents reviewed for call light response times. Findings include: On 09/07/2024 at 9:58AM, V13 (R2's Family Member) states he lives in another state but came to visit R2 once V13 was informed that R2's health was declining and R2 was in the process of expiring. V13 states he was located inside of R2's room approximately two weeks ago and R2 appeared to be in pain. V13 states he located R2's call light and pressed it because he is not sure if R2 could use the call light on her own. V13 states he waited 45 minutes for someone to come to R2's room to answer R2's call light. V13 states he waited for so long that he went to the nurses' station to go and find a staff member to help assist R2 with her needs. V13 states he also made V1 (Administrator) aware that he waited a long time for someone to answer R2's call light.…

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 treatment as ordered by physician for resident who has swollen bilateral feet. The facility also failed to ensure ongoing assessment, identify, document, and obtain physician order for rashes on entire upper back, lateral, medial upper arm, and open wound on upper back This failure affects two (R34 and R90) of three residents in the sample of 22 reviewed for Quality of care. Findings include: 1. On 4/2/24 at 10:20AM, Observed R34 lying on bed wearing socks with noticeable tightness due to bilateral edema. She is alert and responsive with periods of forgetfulness and confusion. She said that her both feet/able has been swollen and it hurts at times. On 4/2/24 at 10:38AM, V2 DON (Director of Nursing) and V5 (Unit 2 Manager) said that R34 is alert but confused. Both said that she has Dementia. V2 DON provided copies of R34's active medical records including face sheet, physician order sheet and care plan. R34 is re-admitted on [DATE]…

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

Based on observation, interview and record review, the facility failed to implement an effective pest management program by not maintaining a clean kitchen dry storage area which resulted in live ants and mice droppings being observed which has the potential to affect all 104 residents that participate in dining services. Findings include: On 11/2/23 at 12:17PM, Kitchen dry storage area was observed with fifteen cylindrical dried small dark brown pieces on top of a flying insect light trap adhered to the middle of the wall. V34 (kitchen manager) confirmed that it was mice droppings and unsure how long it had been there. On 11/3/23 at 2:55PM, V34 (kitchen manager) tour of dry storage room observed multiple large open shelving units, with more than ten small ants crawling along the shelves edge with boxes of powdered sugar and brown sugar bags. In addition, one large clear storage bin with multiple small containers of syrup with more than 10 small ants crawling around the sides and inside of the container. On another shelve there was a large binder of recipes that had ants crawling…

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 inform the primary care physician of the change of condition for one of one resident (R21) reviewed for change of condition in a sample of 10. Findings include: On 01/11/2024 at 10:30AM during record review, R21's Progress Notes by V21 (nurse practitioner/NP) dated 12/19/2023 indicated R21 was seen and examined with pain of 7/10 on both lower extremities (BLE) especially to the ankle and knee and R21 said that she slipped off her commode and fell with complaint of (c/o) tenderness to touch on the outer lateral ankle which was also swollen. The same progress note indicated that V21 notified the nurse, recommended to administer any needed medication (prn) as soon as possible (ASAP) and to also inform the primary physician about the fall. Review of R21's Progress Notes dated 12/19/2023 to 12/20/2023 did not indicate any communication or notification to primary physician related to swollen and tender ankle. R21's Progress Notes by V21 dated 12/21/2023 indicated R21 complained of pain at 6/10 (pain scale) on BLE (bilateral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident who was identified as a maximum assist with activities of daily living prior to discharge and recommended 24-hour care was safely discharged back to his home. This affected one of three residents (R6) reviewed for sufficient preparation for transfer on the sample list of 21. This failure resulted in R6 being discharged home alone without 24 hour care to assist with incontinence care and lead to R6 being sent back to local emergency room with stage 1 pressure sore to buttocks six days after discharge. Findings include: R6 was admitted to the facility on [DATE] with a diagnosis of unspecified fracture of left wrist and hand, parainfluenza virus pneumonia, chronic obstructive pulmonary disease, congestive heart failure, difficulty walking, major depressive disorder, morbid obesity, seizures, diarrhea, anxiety, peripheral vascular disease, hypertension, and urinary tract infection. On 10/20/23 at 3:45Pm, R6 who was alert and oriented 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.

Based on interview and record review, the facility failed to revise the care plan after a change of condition for one of one resident (R21) reviewed for care plan in a sample of 10. Findings include: Review of R21's Progress Notes dated 12/22/2023 at 6:30PM indicated R21 returned from hospital with diagnosis (Dx) of fracture of left ankle and on non-weight bearing status. R21's care plan indicated last reviewed/revised on 12/21/2023 did not address the fracture and non-weight bearing status. On 01/11/2024 at 10:30AM during record review, R21's comprehensive care plan dated 12/21/2023 indicated no new problem, goal or approach after R21 came back from the hospital. At 3:00PM, R21's care plan was reviewed with V2 (Director of Nursing) and confirmed that no additional problem, goal or approach were noted on the comprehensive care plan. On 01/11/2024 at 3:00PM during interview with V2, V2 stated that the care plan should have been revised and updated after R21 came back from the hospital. On 01/11/2024 at 12:48PM during interview with V14 (Restorative Nurse), V14 said that R21's care…

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 provide incontinence care at least every two hours, and failed to ensure a shower or bath was provided at least two times a week. This affected two of three residents (R7, R10) reviewed activities of daily living care on the sample list of 21. This failure resulted in R7 being left and saturated in urine, and R10 receiving 1 staff provided bath in approximately 15 days. Findings Include: 1) R7 has the diagnosis of Cerebral Infarction. Minimal data set section C (cognitive patterns) dated 9/21/23 documents a score of eight which indicates moderate impairment. Section G (functional status) documents: R7 requires extensive assistance with one person physical assist with toilet use. Section H (bladder and bowel) documents: R7 is frequently incontinent (seven or more episodes of urinary incontinence.) On 11/16/23 at 2:42pm, R7 who was assessed to be alert to person and situation, was observed sitting in her wheelchair with wet areas in between her inner thighs. R7 was asked, why her pants were wet, R7 replied, I…

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 assess and monitor the resident after a fall for one of one resident (R21) reviewed for accidents in a sample of 10. Findings include: Review of R21's Progress Notes by V15 (Licensed Practical Nurse) dated 12/18/2023 indicated R21 had a fall, with no visible injury, and an NP (nurse practitioner) was informed with no new orders and to monitor R21. On 01/11/2024 at 3:00PM during record review with V2 (Director of Nursing), R21's progress notes and observations did not indicate any follow up monitoring and assessment of R21 after the fall on 12/18/2023 at 12:40PM until 12/21/2023 at 9:00AM. R21's Progress Notes by V21 (nurse practitioner/NP) dated 12/19/2023 indicated R21 was seen and examined with pain of 7/10(pain scale) on both lower extremities (BLE) especially to the ankle and knee and R21 said that she slipped off her commode and fell with complaint of (c/o) tenderness to touch on the outer lateral ankle which was also swollen. R21's Progress Notes by V21 dated 12/21/2023 indicated R21 informed V21 that no diagnostics…

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.