Goldwater Care Princeton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform a PASARR (Pre-admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for two of two residents (R59 and R61) reviewed for PASARR screening, in the sample of 49. Findings include: The facility policy, Preadmission Screening and Annual Resident Review (PASARR), dated (reviewed) 11-13-18 documents, It is the policy to screen all potential admissions on a individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review screening process (Level 1) for all new and readmissions per requirement to determine if the individual meets the criteria for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Annually and with any significant change of status, the facility will complete the PASARR Level 1 screen for those individuals identified per the Level 11 screen requiring specialized services. 1. R59's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to perform physician ordered daily weights for one of one resident (R19) reviewed for daily weights in a sample of 49. Findings include: On 6/10/24 at 9:30am, R19 was sitting up in her chair with her feet resting on the floor. Edema was noted on R19's bilateral feet, ankles and to mid-calf. On 6/11/24 at 1:00pm, R19 sitting in her recliner with her feet resting on the floor. On 6/12/24 at 1:00pm, R19 remained up in the recliner with her feet resisting on the floor. Pitting edema noted on her bilateral feet and lower legs. R19 verified that she is not weighed every day as ordered. R19 verified that occasionally she goes to the facility scale to get weighed. R19's Physician Order Sheet, dated 12/19/23, documents to do daily weights (order on the MAR/Medication Administration Record) and notify the medical doctor or the nurse practitioner if resident has a weight gain of 3 pounds in a day or 5 pounds in a week, every day on day shift for Congestive Heart…

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 interventions to reduce a residents' risk of a fall and safety interventions for transfer for two of five residents (R3, R26) and failed to follow their elopement policy, failed to document the testing of the elopement device and doors and failed to ensure an elopement device was in place for one (R31) of one residents reviewed for elopement in a sample of 49. Findings include: The facility policy, Fall Prevention Program, dated (revised) 11-21-17 directs staff, To assure safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assuasive devices are utilized as necessary. Fall/safety interventions may include but are not limited to: Transfer conveyances shall be used to transfer residents in accordance with the plan of care. Nursing personnel will be informed of residents who are at risk of falling.…

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 ordered nutritional drink for a resident with weight loss was offered for one (R26) of one resident reviewed for nutrition in a sample of 49. Findings include: The facility's undated Nutrition Intervention Program (NIP) policy documents Policy: Residents identified as needing additional nutrition interventions will be started on the NIP Program. Identified Residents include, but not limited to 1. Significant weight loss at 1 month, 3 month, 6 months. This policy also states, The nutrition interventions can be initiated by the food service manager, dietician, or nursing staff. R26's current Physician Order Sheet/POS documents diagnoses including but not limited to Unspecified Dementia, Severe, with agitation and Conversion Disorder with Seizures or Convulsions. R26's Minimum Data Set/MDS assessment, dated 4/4/24, documents R26 is severely cognitively impaired, requires supervision or touching assistance for eating, and that R26 had a significant weight loss, not physician prescribed. R26's Registered…

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 perform an ongoing assessment of the resident's respiratory status for one resident of one resident (R44) reviewed for oxygen therapy, in a sample of 49. Findings include: The (undated) facility policy, Oxygen Therapy General Standard directs staff, Purpose: To provide adequate tissue oxygenation for problems associated with Reduced oxygen carrying capacity of blood. A licensed nurse will conduct ongoing resident assessments for oxygen administration. A pulse oximeter will be used to determine oxygen saturation levels. R44's current Physician Order Sheet dated June 2024 document R44's current diagnoses as: Chronic Obstructive Pulmonary Disease. This same form documents an order for R44's oxygen therapy, Oxygen 3L (Liters) via NC (Nasal Cannula) PRN (As Needed), to maintain SPO2 (Saturation of Peripheral Oxygen) above 88%. R44's Medical Record documents, 6/11/2024 90%, 6/10/2024 96%, 5/14/2024 95.0%, 5/7/2024 95.0%, 5/6/2024 96.0%, 5/4/2024 95.0%,…

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 assess a resident's dialysis fistula as ordered for one of one residents (R51) reviewed for dialysis, in a sample of 49. Findings include: The Assessment of Resident policy, revised 4/18/22, documents 9. Document resident comments, complaints as appropriate and assessment findings in the nursing progress notes. 10. Notify the physician of significant findings and request necessary change in orders. 12. Initiate Nursing Interventions. On 5/2/24, a Physician ordered Check Bruit and Thrill (a vibration that is palpated above or below the fistula (dialysis access site) to ensure blood flow) of dialysis fistula to left forearm every shift (Y=positive/N=negative) every day and night shift for fistula monitoring. On 6/12/24 at 9:00 AM, V18 (Registered Nurse) demonstrated in the Electronic Medical Record how the bruit and thrill assessments were documented. After the bruit and thrill assessment was entered as completed or not completed, another screen auto populated and asked the question Is behavior observed. V18…

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 residents on Psychotropic medications have supporting diagnoses and identified targeted behaviors with monitoring for three (R26, R33 and R44) of three residents reviewed for Psychotropic medications in a sample of 49. Findings include: The facility's Psychotropic Medication - Gradual Dosage Reduction, revised 2/1/18, documents Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions. Guidelines: The plan to alternatives to psychotropic medication and/or use of psychotropic shall be incorporated into the care plan with suitable goals and approaches. This will be initiated by the resident's needs/problems, goals and approaches as it relates to the use of psychotropic drug use. 1. R26's Physician Order Sheet/POS documents an order, dated 5/29/24, for Seroquel 50mg (Milligrams), give 75mg by mouth two times 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 record review and interview the facility failed to conduct a quarterly care plan meeting since admission for one of 6 (R1) residents reviewed for care plans in a sample of 6. Findings Include: The facility policy named, Comprehensive care plan, dated 11/17/2017, documents, The resident and/or resident representative shall be invited to review the plan of care with the interdisciplinary team either in person, via telephone, or video conference (if available) at least quarterly. R1's Nurses Notes, documents R1 was admitted on [DATE]. R1's Minimum Data Set progress note, dated 5/19/2023, documents, R1's invite to a care plan meeting. On 10/13/2023 at 2:20PM V6/Care Plan Coordinator stated, I have been in this role since March of this year. I did invite V9/R1's daughter to the care plan meeting for R1 on 5/19/2023 for the yearly review. I did not send out an invite for R1's quarterly review in August. I do not know why I did not send a care plan invite for August to have the quarterly care plan prior 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 administer medications safely for one of three residents reviewed (R3), in a sample of six. This failure resulted in R3 ingesting R2's medications. FINDINGS INCLUDE: The undated facility policy, Medication Administration General Guidelines, directs staff, medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Five Rights- Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. When medications are administered by mobile cart taken to the resident's location (room, dining area, etc ) medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med (medication) pass or for more than one resident. R2's current Physician Order Sheet, dated October 2023 includes the following medications: Aspirin (blood thinner) 81 MG (milligrams) one tablet in the morning; Clopidogrel (antiplatelet)75 MG one tablet in the morning;…

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 investigate an allegation of a potential misappropriation of resident property for one (R9) of three residents reviewed for criminal activity in a sample of three. Findings include: The facility's Abuse Prevention and Reporting - Illinois policy, revised 10/24/22, documents Internal Reporting Requirements and Identification of Allegations: Supervisors shall immediately inform the administrator of person designated to act as administrator in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. R9's current clinical record, documents R9 as moderately cognitively impaired with diagnoses including Unspecified Dementia, moderate, with Agitation. R9's Criminal History Record, dated 1/16/23, documents R9 is a Registered…

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 develop interventions to address wandering on resident Care Plans for two (R1 and R2) of three reviewed for care plans. Findings include: 1. On 9/14/23, between 9:30am and 10:00am, R2 independently ambulated around the locked unit. R2's current Physician Order Sheet/POS documents R2 has diagnoses including Dementia. R2's Minimum Data Set/MDS assessment, dated 8/29/23, documents R2 is severely cognitively impaired. On 9/14/23, at 10:20am, V5 and V6 Certified Nursing Assistants/CNAs identified R2 as one of the wandering residents in the locked unit. R2's current Care Plan does not include any focus or interventions for wandering. On 9/14/23, at 3:37pm, V13 Social Service Director confirmed R1 and R2 are wandering residents who should have had wandering addressed on their care plans. 2) Current Physician order Summary Report indicates R1 has diagnoses that include Unspecified Dementia, Alzheimer's Dementia with Early Onset and Severe Dementia in other diseases with behavioral disturbance. Current Comprehensive…

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 complete Elopement Risk assessment, failed to include two residents identified as at risk for Elopement in the Elopement Risk Protocol and in the facility's Elopement risk binder for two residents (R1 and R2) Findings include: The facility's Identification of Elopement Risk policy, undated, documents Policy Statement: To identify residents that are at risk for elopement. Policy Interpretation and Implementation: 1. Residents will be evaluated for elopement risk on admission and quarterly. 2. The resident's service plan will be modified to indicate the resident is at risk for elopement episodes, if applicable. 3. Interventions to prevent elopement will be entered into the resident's service plan. 1. On 9/14/23, between 9:30am and 9:40am, R2 independently ambulated around the locked unit and then hovered around the exit door of the locked unit. R2's current Physician Order Sheet/POS documents R2 has diagnoses including Dementia. R2'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 ensure resident trust funds were accurate, monies due to residents were credited in a timely manner, and safeguards were in place for managing resident funds for two residents (R3 and R4) of six residents reviewed for resident trust funds in a sample of six. Findings include: The facility's Resident Funds policy, revised 4-29-19, documents Guidelines: This facility manages the personal funds of residents when such request is made by the resident. Resident funds may be managed by any of the following: d. The resident may choose to have the facility hold, safeguard, and manage his/her personal funds. This policy also states 4. Resident funds are deposited into an interest-bearing resident trust fund account which is different from the facility's banking account. And 6. Inquiries concerning the facilities management of resident funds should be referred to the administrator or the business office. 1. R3's Minimum Data Set/MDS assessment, dated 6-4-23, documents R3 is cognitively intact. On 8-23-23, at 11:15am R3…

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 all residents were informed regarding the facility Grievance process. This failure has the potential to affect all 66 residents who reside in the facility. Findings include: Facility Policy/Grievances dated/revised 9/25/17 documents: The resident has the right to voice grievances to this facility or other agency or entity that hears grievances. An Appointed Grievance Official is responsible for overseeing the grievance process. Resident Census and Conditions Report dated 6/27/23 indicates 66 residents in the facility on that date. On 6/28/23 at 10:00am meeting was held with six residents who reside in the facility (R10, R15, R38, R45, R56, R123). All but one resident (R123) stated they routinely attended the monthly resident group meetings. All six residents stated they were unaware of the facility grievance procedure. R10 and R15 stated that V10, Activity Director, is the staff member who arranges and attends the Resident Council monthly meetings. On 6/29/23 at 11:40am V5, SSD (Social Service Director)…

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 staff a Certified Dietary Manager. This failure has the potential to affect all 66 Residents residing in the Facility. Findings include: Facility Census and Condition Report, dated 6/27/23, documents 66 Residents residing in the Facility. Facility Position Title (Dietary Manager), created 3/23/17, documents: the Dietary Manager is responsible for partnering with the Dietician to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with current Federal, State and Local standards, guidelines and regulations governing our facility; review the departments procedure manuals and job descriptions, at least annually; and must possess a Food Service Sanitation Manager Certification. V12's (Dietary Manager) Certificate of Completion for Food Service Sanitation Manager Certification, dated 1/8/22, documents that V12 completed the online training. The Certificate of Completion also documents that This is not the Food Service Sanitation Manager Certificate. V12 stated your Food…

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 serve meals at the scheduled mealtime. This failure has the potential to affect all 66 Residents residing in the facility. The facility also failed to provide bedtime snacks for five residents (R10, R15, R38, R45, R56) of six residents reviewed for bedtime snacks in the sample of 33. Findings include: Facility Census and Condition Report, dated 6/27/23, documents 66 Residents residing in the Facility. Facility Mealtimes, undated, documents Facility meal times of 7:00 am, 11:00 am and 5:00 pm. Facility Resident Council Minutes, dated 12/29/22, documents Dietary Concerns of food sometimes not hot. Facility Resident Council Minutes, dated 4/27/23, documents Dietary Concerns of food is not very hot. Facility Resident Council Minutes, dated 5/25/23, documents Dietary Concerns of meals served late. On 6/28/23, at 11:00am through 11:29am, all residents in the [NAME] Side dining room did not have a meal tray. The Facility meal cart was delivered on 6/28/23 at 11:29am and passing of the meal trays began at 11:30am. On…

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

Based on observation, interview, and record review the facility failed to maintain required safe serving/holding food temperatures for Resident meals. This failure has the potential to affect all 66 Residents residing in the facility. Findings include: Facility Census and Condition Report, dated 6/27/23, documents 66 Residents residing in the Facility. Facility Serving Temperatures for Hot and Cold Foods Policy, dated 2020, documents: food will be served at the following temperatures to ensure a safe and appetizing dining experience; and required meat and vegetable temperatures of 135 degrees Fahrenheit to 170 degrees Fahrenheit. Facility Mealtimes, undated, documents Facility mealtimes of 7:00am, 11:00am and 5:00pm. Facility Resident Council Minutes, dated 12/29/22, documents Dietary Concerns of food sometimes not hot. Facility Resident Council Minutes, dated 4/27/23, documents Dietary Concerns of food is not very hot. Facility Resident Council Minutes, dated 5/25/23, documents Dietary Concerns of meals served late. On 6/27/23, at 11:40am, the meatloaf temperature was 102 degrees…

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 promptly act upon recommendations of the resident council group residents and failed to demonstrate the facility response to group recommendations for six residents (R10, R15, R38, R45, R56, R123) in the sample of 33. Findings include: Facility Dietary Manager Essential duties and Responsibilities dated 3/23/17 documents: Review departmental complaints and grievances from personnel and make written reports to the Dietician and/or Administrator of action(s) taken. On 6/28/23 at 10:00am meeting was held with six residents who reside in the facility (R10, R15, R38, R45, R56, R123). All but one resident (R123) stated they routinely attended the monthly resident group meetings. All six residents stated food served at mealtimes is not hot when served, meals were not served on time - frequently served 30 minutes to 1 hour late (from the posted mealtimes), they were unaware of the facility grievance procedure and had requested short activity trips outside of the facility. R10 and R15 stated that V10, Activity Director, is the staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise resident care plans for two of 20 residents (R19 and R59) reviewed for care plans in the sample of 33. Findings include: The facility's Comprehensive Care Plan Policy, revised 11/17/17, states, Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Guidelines: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. This same policy documents that comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment. The facility's Fall/Incident…

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 perform hand hygiene and follow a Physician order during skin care for one (R26) of three Residents reviewed for skin care in a sample of 33. Findings include: Facility Dressing Change/Clean/Non-Sterile Policy, revised 1/9/18, documents: 10. remove soiled dressing and place in plastic trash bag; 11. remove soiled gloves and place in plastic trash bag; 12. wash hands, or if hand are not visibly soiled, alcohol based hand gel may be used to decontaminate the hands; 13. apply clean gloves; 16. apply prescribed ointment and/or dressing per doctor order; and secure dressing in place if needed. R26's Wound Physician's Evaluation & Management Summary, dated 6/28/23, documents a Venous Wound on R26's Right Shin (lower leg). The wound size is 5.5 centimeter/cm by 5.0 cm by 0.1 cm, with a surface area of 27.5 cm, with moderate serous exudate/drainage. R26's treatment order documents on order for medicated ointments (Leptospermum Honey and Alginate Calcium) and a Dry Dressing (Gauze Island with border) to be applied once…

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.