Carroll Lutheran Village

Based on observation, medical record review and interview, it was determined that the facility staff failed to maintain a medical record in the most accurate form. This was evident for 4 of 22 residents(Resident #13, #11, #120, #121) with care area investigations completed during the survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1. Observation was made of Resident #13, on 8/29/21 at 12:50 PM, in the dining area eating lunch. Resident #13 was wearing a short sleeved shirt. Resident #13's bare arms were exposed with nothing covering the arms. Review of Resident #13's medical record on 8/29/21 at 1:37 PM revealed a physician's order for geri-sleeves which stated, Geri-sleeves to bilateral upper extremities, check Q-shift for placement every shift with a start date of 6/18/21. Review of Resident #13's Treatment…

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, staff interview and record review, it was determined the facility failed to ensure an effective infection prevention and control program by failing to ensure that staff performed hand hygeine when indicated, failed to utilize personal protective equipment (PPE) in a manner that met minimum standards and minimize risk for infectious spread, and failed to ensure proper handling of a resident's Foley Catheter urine bag. This was found to be evident during observations of 9 residents (Resident #37, #54, #30, #53, #41, #20, #25, #60 and #61) but this noncompliant practice within the facility's infection prevention and control program left all residents, staff, and visitors at increased risk for infection during an active COVID-19 outbreak in the facility. The findings include: 1) Hand Hygiene The surveyor made multiple observations where facility staff members were not performing hand hygiene as necessary. On 5/8/2020, the Centers for Disease Control and Prevention (CDC) released updated guidance on Hand Hygiene noting that hand hygiene should be performed 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.

Based on observation and medical record review, it was determined facility staff that failed to treat a resident with dignity as evidence by standing to feed the resident while in a dining room with other residents. This was evident for 1 of 16 residents (Resident #13) observed for dining in the Good [NAME] Way Unit. The findings include: Observation was made, on 8/29/21 at 12:50 PM, of Geriatric Nursing Assistant (GNA) #13 feeding Resident #13. GNA #13 stood to feed Resident #13 from 12:50 PM to 12:54 PM. There were other staff in the dining room that sat while feeding other residents. Review of Resident #13's medical record on 8/29/21 at 1:37 PM revealed the resident required supervision and cues with meals and the resident also suffered from major depressive disorder with occasional tearfulness. The observation was discussed with the Assistant Director of Nursing on 9/1/21.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Psychotropic medications are used to treat mental health disorders. There are five main types of psychotropic medications, and each type has its own specific uses, benefits, and side effects. The five main types are anti-anxiety agents, antidepressants, antipsychotics, mood stabilizers, and stimulants. On 09/01/21 at 08:32 AM review of Resident #17's medical record revealed the resident was diagnosed with Major Depressive Disorder and Anxiety Disorder. On 09/01/21 at 08:40 AM, a record review of Resident #17's Medication Administration Record (MAR) revealed the resident had an order for Mirtazapine tablet 15 mg related to Major Depression Disorder and Duloextine HCL Capsule Delayed Release Sprinkle 30 mg related to Major Depression Disorder. Mirtazapine (Remeron) is an antidepressant medicine. It's used to treat depression and sometimes obsessive compulsive disorder and anxiety disorders. Duloxetine HCL is an Antidepressant and Nerve pain medication. It can treat depression, anxiety, diabetic peripheral…

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 medical record review and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for a Resident (#13) with a history of skin tears. This was evident for 1 of 2 residents (Resident #13) reviewed for skin conditions during the annual survey. The findings include: Review of Resident #13's medical record on 8/29/21 at 1:37 PM revealed a physician's order for geri-sleeves which stated, Geri-sleeves to bilateral upper extremities, check Q-shift for placement every shift with a start date of 6/18/21. Review of a 6/18/21 nursing note revealed documentation, sitting in new wheelchair hospice purchased in dining room when skin tear noted to right elbow with surround skin discolored. When observing resident after cleansing wound, noticed resident use arm to help position in chair. [physician name] updated and new orders to apply geri-sleeves. Review of Resident #13's June, July and August 2021 Treatment Administration Records (TAR) revealed the nurse's initialing every day that the resident…

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

Based on observation, medical record review, and interviews, it was determined that the facility staff failed to meet professional standards by 1) documenting that a treatment of an application of geri-sleeves was applied to a resident's arms every day when the geri-sleeves were observed not on the resident and 2) documenting that a treatment of TED stockings were worn by a resident when they were observed not on the resident. This was evident for 1 of 2 residents (Resident #13) reviewed for skin conditions and 1of 5 residents (Resident #11) reviewed for unnecessary medications during the annual survey. The findings include: 1) Observation was made of Resident #13 on 8/29/21 at 12:50 PM in the dining area eating lunch. Resident #13 was wearing a short sleeved shirt. Resident #13's arms were exposed with nothing covering the arms. Review of Resident #13's medical record on 8/29/21 at 1:37 PM revealed a physician's order for geri-sleeves which stated, Geri-sleeves to bilateral upper extremities, check Q-shift for placement every shift with a start date of 6/18/21. Review of Resident…

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

Based on observation, record review and staff interview, it was determined facility staff failed to provide care and treatment in accordance with the resident's physician's orders as evidenced by the facility staff documentation that a treatment was performed when it was observed not performed, and failed to ensure physical and occupational therapy screening was completed as ordered by the physician. This was found to be evident for 3 out of 22 residents (Resident #13, #11 and #64) with care area investigations completed during the survey. The findings include: 1) Observation was made of Resident #13 on 8/29/21 at 12:50 PM in the dining area eating lunch. Resident #13 was wearing a short sleeved shirt. Resident #13's bare arms were exposed with nothing covering the arms. Review of Resident #13's medical record on 8/29/21 at 1:37 PM revealed a physician's order for geri-sleeves which stated, Geri-sleeves to bilateral upper extremities, check Q-shift for placement every shift with a start date of 6/18/21. Review of Resident #13's Treatment Administration Record (TAR) on 8/29/21 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.

Based on medical record review and interview, it was determined that the facility failed to prevent a resident from falling out of bed while receiving care. This was found to be evident for one out of eight residents reviewed for accidents (Resident #66) during the survey. The findings include: On 8/30/21, review of Resident #66's medical record revealed the resident resided at the facility for several years and whose diagnoses included but were not limited to end stage dementia, high blood pressure, osteoporosis and anxiety. Review of the Minimum Data Set assessment, with an assessment reference date of 5/12/21, revealed that the resident required extensive assistance of one person physical assist for bed mobility, toilet use and personal hygiene, the resident was totally dependent on two person physical assist for transfers from bed to chair, and totally dependent on one person support for bathing. Further review of the medical record revealed the following nursing note, dated 5/19/21: Resident was in bed and receiving personal care by GNA [geriatric nursing assistant] orientee.…

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 medical record review and staff interview, it was determined that the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to monitor the blood pressure and heart rate prior to administering a blood pressure medication per physician's orders. This was evident for 1 of 5 residents (Resident #53) reviewed for unnecessary medications during the annual survey. The findings include: Review of Resident #53's medical record on 8/30/21 at 2:57 PM revealed the resident was admitted to the facility in January 2021 with diagnoses that included acute/chronic systolic and diastolic congestive heart failure, chronic atrial fibrillation, presence of cardiac pacemaker, essential hypertension and Chronic Obstructive Pulmonary Disease (COPD). Further review of Resident #53's medical record revealed a physician's order for Metoprolol 25 mg. ER (extended release), one tablet daily, hold for sbp (systolic blood pressure (which is the top number of a blood pressure reading) less than 90, Pulse HR (heart rate) less than 60 (beats per minute). Review of Resident…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to ensure a resident receiving antipsychotic medication had an attempted gradual dose reduction (GDR). This was evident for 1 out 5 residents (Resident #11) reviewed for unnecessary medications during the annual survey. The findings include: Seroquel is an antipsychotic medication that can treat schizophrenia, bipolar disorder, and depression. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to anti-psychotic, anti-depressant, anti-anxiety, and hypnotic medications. Review of Resident #11's medical record, on 8/30/21 at 1:03 PM, revealed that Resident #11 was admitted from the assisted living unit in March 2021 due to advanced dementia per the physician's history and physical note, dated 3/9/21. The note documented, Resident is suffering from dementia of advanced degree (Alzheimer type) without associated behavioral disturbance. The note documented, on Seroquel 25 mg daily - 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 and staff interview, it was determined that facility staff failed to keep medication carts locked when unattended. This was evident on 1 of 2 nursing units observed during the annual survey. The findings include: Observation was made, on 9/1/21 at 9:17 AM, of the Way of Love Medication Cart 1 sitting in the hallway unlocked and unattended. The surveyor was able to open the drawers to the medication cart and observe scissors, insulin and resident medications. At 9:18 AM, the nurse (Staff #20) walked up to the surveyor and said, I am so sorry. The surveyor asked Staff #20 if she was pulled to do medications and she confirmed that she had, due to a staff member calling out. The Director of Nursing was made aware of the observation on 9/2/21 at 3:00 PM.

Based on observation, it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of insects. This was evident for the ground floor and the kitchen. The findings include: On 8/31/2021 at 9:19 AM, a black bug was observed crawling across the hallway outside the facility's laundry room. At 9:24 AM, during a tour of the kitchen, the janitor's closet at the entrance of the kitchen was observed with multiple fruit flies in the air and on the walls above the floor sink. Review of the facility's Pest Control Log with Ecolab did not identify any issues with pests on the last inspection completed 8/31/21. The Administrator and Director of Nursing were made aware of these findings on 9/1/2021 at 12:45 PM.

Based on observations of the facility's food service operations and staff interviews, it was determined that the facility failed to assure proper sanitation of dish and cookware and failed to utilize appropriate hair restraints to keep hair from contacting food and food contact surfaces. Concerns were identified in main kitchen and the auxiliary kitchen in the health care center. The findings include. Initial tour of the facility's main kitchen, beginning at 6:50 PM on 9/19/18, revealed two male dietary employees (staff #14 and #15) with beard growth working in the kitchen without any type of hair restraint covering facial hair growth. Initial tour of the health care center's kitchen service on 9/19/18 revealed that the dietary staff were preparing to close the kitchen for the day. The dish-washer was off for closing prep. Review of the dishwashing temperature logs revealed no water temperature recordings for the three meals of 9/18 and the three meals of 9/19/18. The logs failed to show the wash and rinse water temperatures for 6 meals. Observation of the lunch time meal 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 and interviews with staff and residents, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment for residents as evidenced by 1. unclean resident wheelchairs, 2. damaged or missing resident overbed tables, and 3. other damage noted in resident rooms. This was true for 2 (Residents #6 and #27) of 7 Residents and 2 (Rooms #415-2 and #413) of 24 resident rooms observed. The evidence includes: 1. During an observation of resident wheelchairs that took place on 9/24/2018 at 10:05 AM, it was noted that Resident #6's wheelchair had a layer of dust and sticky dirt on the crossbars and lower parts of the chair. The resident stated dirty when the surveyor pointed to these parts. It was also noted that Resident #27's wheelchair had dirt on the lower chassis. The resident was briefly interviewed and stated that the chair had not been cleaned since the resident arrived in July. The Facility Administrator and Administrator-in-Training were shown these…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of Resident #88's medical record on 9/25/18 revealed that the resident was discharged to a hospital on 6/22/2018. A late entry note was written on 6/23/18 indicating that resident #88 was experiencing chest pain and was sent to the hospital emergency room for evaluation. The note contained documentation that a doctor was notified and the resident's wife. The note did not contain any information that resident #88 was informed of the transfer to hospital, and the resident's response to the transfer. An interview was conducted with a staff educator (staff #17) at 1:33 PM on 9/25/18. The requirement of this regulation was reviewed with staff #17. The nursing progress note that resident #88 was sent to the hospital emergency room was reviewed with staff #17 who acknowledged that there was no indication in the documentation as to the resident's orientation and preparation for transfer. Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare 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 observation, staff interview and facility documentation review, it was determined the facility staff failed to 1) keep medication storage areas clean, 2) failed to label a medication when opened and 3) failed to lock a medication cart when unattended. This was evident for 3 of 5 medication carts observed. The findings include: 1) Observation was made on [DATE] at 7:27 PM of the medication cart on Way of [NAME] #4. The inside of the fourth drawer that contained Breakfast Carnation Essentials, liquid medications, gloves and Kleenex was covered in caked on spills and multiple debris. The debris was also caked on the inner slats of the front of the drawer. Staff #5 was present at the time of the observation and immediately emptied the drawer and washed the inside of the drawer. The Way of [NAME] medication cart #1 was observed. The inside of the second drawer from the top was dirty. Medication cart #3B was observed and the fourth inside drawer was dirty. In the bottom right hand side drawer, there was 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 observations, medical record review and interviews with facility staff, it was determined the facility failed to ensure that a resident's call bell was within reach at all times. This was evident for 2 (#65, #72) of 30 residents observed in the 200 hall. The findings include: 1) Observation was made on 9/20/18 at 10:55 AM of Resident #65 sitting in wheel chair in the resident's room. The wheel chair was positioned near the foot of the resident's bed and the resident's call bell was observed hanging over the head board of the bed which was not within reach of the resident. When asked if he/she could self-propel the wheel chair to reach the call bell, the resident indicated he/she could not. Staff #10 was advised of this finding at that time and placed the resident's call bell within his/her reach. Review of Resident #65's medical record revealed that the resident was dependent on staff for activities of daily living and had diagnoses that included dementia. 2) Observation was made, on 9/2018 at 12:02 PM, of Resident #72 sitting in a wheel chair in the resident's room. 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 medical record review and staff interview, it was determined that the facility failed to notify the physician of a significant weight gain. This was evident for 1 (#28) of 5 residents reviewed for nutrition. The findings include: Review of the medical record for Resident #28 on 9/24/18 revealed a weight taken on 7/27/18 of 144.2 lbs. (pounds). The next weight taken on 8/1/18 was 157.9 lbs. which was a 13.7 lb. weight gain in 5 days. A second weight was taken on 8/2/18 which was 156.9 lbs., a 12.7 lb. weight gain in 6 days. There was no documentation found in the medical record that the physician was notified on 8/1/18 or 8/2/18 of the significant weight gain. The unit manager stated on 9/24/18 at 12:50 PM a change in condition and physician notification for that weight gain should have been done. The Nursing Home Administrator was advised on 9/25/18 at 2:05 PM.

Based on a random sample of Medicare beneficiaries who were discharged from skilled therapy and nursing services within the past six months, it was determined that 1 (#43) of 3 Medicare beneficiaries reviewed did not receive written notice of Medicare Provider Non-Coverage. The findings include. If a skilled nursing facility provider believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and that an otherwise covered item or service may be denied as not reasonable and necessary, the facility must notify the resident or his/her legal representative in writing. The SNFABN (Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage) provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. The NOMNC (Notice of Medicare Non-coverage) informs the beneficiary of his or her right to an expedited review of a services termination. During the survey a random…

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 medical record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan with measurable goals. This was evident for 1 (#87) of 1 resident reviewed for hydration and 1 (#72) of 2 residents reviewed for accommodation of needs. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The findings include: 1. Review of Resident #87's medical record on 9/24/18 revealed documentation that the resident had recurrent urinary tract infections (UTI). The resident was treated for UTIs from 9/2/17 to 9/11/17, 10/26/17 to 10/29/17, 11/26/17 to 12/5/17, 2/7/18 to 2/14/18, 3/17/18 to 3/22/18, 4/28/18 to 5/6/18 and 6/29/18 to 7/5/18. On 9/25/18 at 12:10 PM, the Unit Manager (UM) was asked if there was a care plan for potential for urinary tract infections. The UM stated, I only create a care plan for UTI when the resident has an active UTI. The surveyor reviewed the number of UTIs the resident had and how it…

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 review of resident records and interview with facility staff, it was determined that the facility failed to include parameters for two as-needed pain medication orders. This was true for 1 of 5 residents (Resident #16) reviewed for unnecessary medications. The evidence includes: During a review of Resident #16's medical record that took place on 9/24/2018 at 9:45 AM, the following orders were found: Acetaminophen caplet 500mg: administer 2 caplets (1gram) by mouth every eight hours as needed for pain, and Tramadol tablet 50mg: Take 3 half tabs (75mg) by mouth every eight hours as needed for pain. Acetaminophen and tramadol are both pain relievers. Acetaminophen is available over-the-counter and is used more often as a first line pain medication than tramadol, which is stronger and requires a prescription. Tramadol also carries more significant side effects such as constipation, nausea, lethargy, and respiratory depression. When multiple pain medications are ordered with the as-needed modifier, the orders must also have parameters that clarify under what circumstances…

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 medical record review and interview with staff, it was determined that the facility failed to ensure that each resident's drug regimen was free from psychotropic drugs. This was evident for 1 (#11) of 5 residents reviewed for unnecessary medications. The findings include: On 9/24/18, a review of Resident #11's medical record was conducted. Review of Resident #11's physician orders revealed a 1/27/18 order for Quetiapine (Seroquel) 37.5 mg (milligrams) by mouth every day at bedtime for anxiety. Review of Resident #11's August 2018 and September 2018 MAR (Medication Administration Record) revealed that the resident received Quetiapine 37.5mg by mouth every day at bedtime for anxiety. Quetiapine is an antipsychotic medication and has an associated warning of increased mortality in elderly patients with Dementia. Continued review of the medical record failed to reveal that the physician documented an evaluation that included a clear rationale for the continued use of the antipsychotic medication Quetiapine, and a risk benefit assessment, non-pharmacological interventions 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.