Green Meadows Skilled Nursing And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the closed medical record, review of facility investigation, interview and review of the facility policy the facility failed to ensure Resident #82 was free from physical restraints. This affected one resident ( Resident #82) of three reviewed for accidents. Findings included: Review of the closed medical record revealed Resident #82 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, respiratory failure, iron deficiency anemia, kidney disease, non-ST elevation myocardial infarction, diabetes, pulmonary edema, diabetic neuropathy, hypertension, glaucoma, hyperlipidemia, insomnia, and anxiety disorder. Review of the plan of care dated 11/21/24 with a revision dated of 02/06/25 revealed Resident #82 was at risk for falls related to incontinence, decreased strength and endurance, history of falls, need for activity of daily living assistance, poor balance, and unsteady gait. Interventions included bed alarm, bariatric bed, clear pathways, educate resident 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 review of a Self Reported Incident (SRI) with the facility's investigation, policy review, medical record review, and interview, the facility failed to ensure protection of a resident during an investigation of emotional/verbal abuse and the facility failed to ensure a thorough investigation was completed into allegations of verbal/emotional abuse. This affected one (Resident #188) of two residents reviewed for abuse. Findings include: Review of Resident #188's closed medical record revealed diagnoses including systemic lupus erythematosus (lupus that affects multiple organs and systems), osteomyelitis (infection of the bone) of the left ankle and foot, right sided weakness following a stroke, stage four kidney disease and heart disease. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #188 was able to make himself understood, was able to understand others, was cognitively intact, and exhibited no behavioral symptoms. A nursing note dated 09/25/24 at 4:50 A.M. indicated a phlebotomist…

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 review of the medical record and interview with the staff the facility failed to ensure a Significant Change assessment was completed for Resident #2 after initiating hospice services. This affected one resident (Resident #2) of 26 residents reviewed for comprehensive assessments. Findings included: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, protein-calorie malnutrition, history of falling, kidney disease, vitamin D deficiency, hypothyroidism, hypertension, atherosclerotic heart disease, hyperlipidemia, osteoarthritis, hypotension, depression, anxiety disorder, heart failure, anemia, and edema. Review of the February 2025 physician's orders revealed Resident #2 had an order for hospice dated 01/12/25. Further review of the medical record revealed there was no evidence of a Significant Change Minimum Data Set assessment completed within 14-days of receiving hospice services for Resident #2. On 02/10/25 at 10:08 A.M. an…

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 review of the medical record and interview with the staff the facility failed to ensure the comprehensive assessment accurately reflected a pressure ulcer for Resident #82 and correct hearing status and anti-anxiety medication use for Resident #44. This affected two residents ( Resident #44 and #82) of 26 residents reviewed for comprehensive assessments. Findings included: 1. Review of the medical record revealed Resident #82 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, respiratory failure, iron deficiency anemia, kidney disease, non-ST elevation myocardial infarction, diabetes, pulmonary edema, diabetic neuropathy, hypertension, glaucoma, hyperlipidemia, insomnia, and anxiety disorder. Review of the wound evaluation note dated 11/21/24 at 2:14 P.M. revealed Resident # 82 was admitted with a Stage III pressure ulcer to the sacrum. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 did not have a pressure ulcer. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a comprehensive care plan to include hearing loss and monitoring the correct dialysis access for Resident #44, constipation and diarrhea for Resident #71, and oxygen use for Resident #67. This affected three residents (#44, #67, and #71) of 26 resident records reviewed. The facility census was 89. Findings include: 1. Review of the medical record for Resident #67 revealed an admission date of 05/24/24 with diagnoses including pulmonary embolism, heart failure, hypertension, and type two diabetes mellitus. Review of the physician's orders for February 2025 identified no orders for oxygen use or maintenance of oxygen equipment. Review of Resident #67's care plan, last reviewed 12/10/24, revealed there was no plan of care for oxygen use. On 02/03/25 at 11:04 A.M., observation of Resident #67 revealed he was receiving oxygen via nasal cannula. On 02/03/25 at 11:06 A.M., interview with Licensed Practical Nurse (LPN) #384 confirmed Resident #67 was…

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, record review, and facility policy review, the facility failed to ensure Resident #55's doorway was free from potential fall hazards. This affected one (#55) resident of three residents reviewed for accidents. The facility census was 89. Findings include: Review of medical record for Resident #55 revealed an admission date of 06/15/23. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), unspecified dementia, malignant neoplasm of bladder (bladder cancer), benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (enlarged prostate), and major depressive disorder. The resident was at moderate risk of falling. Review of Resident #55's quarterly Material Data Set (MDS) assessment revealed the resident was severely impaired cognitively; exhibited inattention behavior, which was continuously present and did not fluctuate; rejected care daily; used a walker and could walk up to 150 feet with supervision or touch assistance from staff; and had no falls since prior assessment. Further review of Resident #55'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, interviews, record review, manufacturer's instructions, and facility policy review, the facility failed to ensure Resident #42 received nectar thick liquids as ordered. This affected one resident (#42); however, it had the potential to affect seven residents (#1, #30, #35, #42, #43, #50, #63) the facility identified as being on a thickened liquids. The facility census was 89. Findings include: Review of medical chart for Resident #42 revealed an admission date of 07/26/23. Diagnoses included altered mental status, oropharyngeal dysphagia (difficulty swallowing), dementia, schizophrenia (a mental health condition which may result in a mix of hallucinations, delusions, disorganized thinking and behavior), and legal blindness. Review of speech therapy evaluation and plan of treatment for Resident #42, signed 05/15/24, revealed the resident had been referred to speech therapy due to coughing/choking during oral intake, pneumonia, prolonged mastication with solids, and signs/symptoms of dysphagia. Clinical bedside assessment of swallowing revealed Resident #42…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure Resident #67 had physician's orders for oxygen use, oxygen tubing was dated at the time it was changed, and administration of oxygen was documented in the medical record at the time of each administration and Resident #2's oxygen cannula was stored properly. This affected two residents (#2 and #67) of three residents reviewed for respiratory care. The facility census was 89. Findings include: 1. Review of the medical record for Resident #67 revealed an admission date of 05/24/24 with diagnoses including pulmonary embolism, heart failure, hypertension, and type two diabetes mellitus. Review of Resident #67's care plan, last reviewed 12/10/24, revealed there was no plan of care for oxygen use. Review of the physician's orders for February 2025 identified no orders for oxygen use or maintenance of oxygen equipment. Review of the medication administration record, vital signs, assessments, and progress notes for February 2025 revealed…

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 record review, review of the facility's dialysis contract, and interview, the facility failed to monitor vital signs and weights before and after dialysis for Residents #52 and #239, and failed to maintain adequate communication with the outside dialysis center for Resident #239. This affected two residents (#52 and #239) of three reviewed for dialysis. The facility census was 89. Findings include: 1. Review of the medical record for Resident #52 revealed an admission date of 01/17/24 with diagnoses including end-stage renal disease, type two diabetes mellitus, dependence on renal dialysis, and heart failure. Review of the physician's orders for February 2025 identified orders for hemodialysis three times weekly on Monday, Wednesday and Friday at the in-facility dialysis center. Review of the dialysis communication reports for Resident #52 revealed pre-dialysis vital signs were not documented on 03/20/24, there was no dialysis communication form for 04/08/24, post-dialysis vital signs were not documented on 04/19/24, pre-dialysis weight and post-dialysis weight were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure narcotic pain medications were provided according to physician orders and non-pharmacologic pain relief interventions were encouraged prior to medication administration. This affected one resident (#14) of five residents reviewed for unnecessary medications. The facility census was 89. Findings include: Review of medical record for Resident #14 revealed an admission date of 10/27/20. Diagnoses included end stage renal disease (ESRD) with dependence on dialysis, muscle weakness, spondylolisthesis of thoracolumbar region( a condition where a vertebra slips out of alignment and presses on the vertebra below it which can put pressure on nerves around spine and cause back pain), osteoarthritis (a condition where the protective cartilage that cushions the end of bone wears down over time which can cause pain) of right knee, hydronephrosis with renal and ureteral calculous obstruction ( a condition where urine builds up in 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, review of the medical record and interview with staff the facility failed to ensure multi-dose insulin pens were dated as to when they were first accessed. This affected three residents (Resident #11,#25 and #242) of 24 residents prescribed insulin. Findings included: 1. Observation of medication administration with Licensed Practical Nurse (LPN) #385 on 02/05/25 at 7:45 A.M. revealed a humulin 70/30 multi-dose Kwikpen for Resident # 242 and a Lantus multi-dose SoloStat pen for Resident #25 that were not dated as to when they were first accessed. On 02/05/25 at 7:50 A.M. an interview with LPN #385 verified the multi-dose insulin pens were not dated as to when the insulin were first accessed. 2. Observations of medication administration with LPN #384 on 02/05/25 at 8:05 A.M. revealed a Novolin 70/30 multi-dose FlexPen for Resident #11 was not dated as to when it was first accessed. On 02/05/25 at 8:15 A.M. an interview with LPN #384 verified there was no dated as to when the multi-dose insulin pen was first accessed. Review of the undated facility policy…

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 medical record review and interview, the facility failed to ensure a physician order was written prior to obtaining a laboratory test. This affected one (Resident #71) of five residents reviewed for medication use. Findings include: Review of Resident #71's medical record revealed diagnoses including type two diabetes mellitus and stroke. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was usually able to understand others and was cognitively intact. Review of Resident #71's physician orders revealed medication orders for the management of the diabetes mellitus. On 09/28/24 an order was written for metformin Extended Release 1000 milligrams (mg) twice a day. An order dated 12/18/24 was written for insulin NPH isophane and regular suspension pen 70/30 with a concentration of 100 units per milliliter. Ten units were ordered every day. A pharmacy recommendation dated 07/26/24 revealed a request for monitoring HgbA1c (laboratory test that measured the average amount of sugar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. On 02/03/25 at 1:49 P.M., Resident #71 reported she had problems with constipation and sometimes went four to six days before she was able to have a bowel movement . Resident #71 stated this was not a new problem. While at home she used a little round pill. Review of Resident #71's medical record revealed diagnoses including cerebral infarction, type two diabetes mellitus, depression, migraine, hypertension, hyperlipidemia, hypothyroidism, anxiety disorder, delusional disorder, osteoporosis, and constipation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #71 was cognitively intact and able to make herself understood. During review of bowel movement records from 01/07/25 to 02/05/25 with the Director of Nursing (DON) on 02/10/25 at 10:09 A.M., the DON verified although there were periods of time greater than three days (01/08/25-01/12/25) when there was no evidence of Resident #71 having a bowel movement, the records were incomplete as there was one shift on 01/08/25, 01/10/25…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, self-reported incident (SRI) review and interview, the facility failed to ensure medications were not misappropriated. This finding affected two (Residents #20 and #28) of three residents reviewed for medication administration. Findings include: Review of Resident #20's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic pulmonary edema, disorganized schizophrenia and chronic respiratory failure with hypercapnia. Review of Resident #20's physician orders revealed an order dated 02/20/24 for oxycodone oral tablet (narcotic) 5 milligrams (mg) give one tablet by mouth every six hours as needed for pain. Review of Resident #28's medical record revealed the resident was admitted on [DATE] with diagnoses including end stage renal disease, diabetes and chronic gout. Review of Resident #28's physician orders revealed an order dated…

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.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interview, record review, and facility investigation review the facility failed to prevent Resident #18 from exiting the facility unsupervised. This affected one resident (Resident #18) of three residents reviewed for accidents. The facility census was 102. Finding include: Review of the medical record for Resident #18 revealed an admission date on 12/05/23. Diagnoses included dementia severe with other behavioral disturbance, Alzheimer's Disease, anxiety disorder, and a need for assistance with personal care. Review of Resident #18's admission Minimum Data Set (MDS) Assessment, dated 12/11/23, revealed the resident had severe cognitive impairment, did not have any behaviors and had no impairments to his upper and lower extremities. The assessment indicated the resident was independently able to sit, stand, and use the restroom. The resident required supervision or touch assistance for walking 10 feet in a room, corridor, or smaller…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the facility fall log, resident medical record and staff interview, the facility failed to ensure Resident #98's physician and family were timely notified of a change in resident condition including falls and hospital transfer. This affected one resident (#98) of three residents reviewed for falls. The facility census was 98. Findings include: Review of the facility fall and accident log for the last 30 days (11/12/23- 12/12/23) revealed Resident #98 had four falls on 11/29/23. Review of Resident #98's closed medical record revealed an admission date of 02/18/19 with diagnoses that included chronic obstructive pulmonary disease and hypertension. Resident #98 was transferred to the hospital on [DATE] and did not return to the facility. Review of the resident's nursing progress notes revealed the first nursing progress note completed on 11/29/23 was an entry dated 11/29/23…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of facility fall log, review of resident photographs, medical record review and staff interview, the facility failed to implement comprehensive, individualized and effective interventions to decrease the risk of falls for Resident #98. This affected one resident (#98) of three residents reviewed for falls. The facility census was 98. Findings include: Review of Resident #98's closed medical record revealed an admission date of 02/18/19 with diagnoses that included chronic obstructive pulmonary disease and hypertension. The resident was transferred to the hospital on [DATE] and did not return to the facility. Review of Resident #98's care plan dated 09/29/22 revealed the resident was at risk for falls related to decreased strength and endurance and history falls. Fall prevention interventions included walker within reach, call light within reach, keep bed in lowest position,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure the comprehensive Minimum Data Set (MDS) 3.0 assessments were completed accurately. This affected five residents (Residents #10, #29, #34, #40, and #61) of six residents reviewed for pain and anxiety medication usage. The facility census was 102. Findings Include: 1. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure, cardiogenic shock, diabetes, heart disease, and partial paralysis of the left side after a stroke. Review of the physician's orders for Resident #10 revealed an order dated 08/31/23 for Oxycodone (a narcotic pan medication) 5 milligrams (mg) every eight hours as needed for pain. Attempt and document non-pharmacological interventions dated 08/31/23. Review of the comprehensive 5-day MDS assessment for Resident #10, dated 09/08/23, section J Health Conditions revealed the pain assessment section was not completed. Interview with the Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and staff education, the facility failed to document why as needed pain medications were being administered and what non-pharmacological interventions were attempted prior to administering pain medication. This affected six residents (Residents #10, #29, #45, #61, #65 and #97) of six residents reviewed for pain medication documentation. The facility census was 102. Findings Include: 1. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure, cardiogenic shock, diabetes, heart disease, and partial paralysis of the left side after a stroke. Review of the physician's orders for Resident #10 revealed an order dated 08/31/23 for Oxycodone (a narcotic pan medication) 5 milligrams (mg) every eight hours as needed for pain and to attempt and document non-pharmacological interventions. Review of the Medication Administration Record (MAR) for Resident #10 for August and September 2023 revealed the prompts for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and pharmacy dispensing records the facility failed to implement a gradual dose reduction for psychotropic anxiety medication as ordered. This affected one resident (Resident #84) of six residents reviewed for controlled substance usage. The facility census was 102. Findings Include: Medical review revealed Resident #84 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, dementia without behavioral disturbance, arthritis, autistic disorder, bipolar disorder, anxiety, and glaucoma. Review of the physician's orders for Resident #84 revealed an order dated 08/09/21 for Ativan (a psychotropic anti-anxiety medication) 0.5 milligrams (mg) orally every evening at bedtime. On 08/07/23 an order was written to decrease the dosage to 0.25 mg every evening at bedtime. Review of the August 2023 Medication Administration Record (MAR) for Resident #84 revealed the Ativan 0.25 mg dosage was administered at bedtime from 08/07/23 through the end of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure fall prevention interventions were in place as ordered for Resident #12. This affected one resident (#12) of three residents reviewed for falls. The facility census was 99. Findings include: Review of the medical record for Resident #12 revealed an admission date of 07/03/23. Diagnoses included right side paralysis, hypertension, dementia, depression and anxiety. Review of the plan of care dated 07/03/23 revealed Resident #12 was at risk for falls due to a history of falls at home and cognitive impairment. Interventions included ensuring the call light was in reach, mats to the floor on both sides of the bed and ensuring needed items were within reach. Review of the fall risk assessment dated [DATE] revealed Resident #12 was at high risk for falls. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 was moderately cognitively impaired. Resident #12 required limited assistance from one person 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 interview and review of personnel files, the facility failed to ensure employees did not have a finding entered into the State of Ohio Nurse Aide Registry. This had the potential to affect all 93 residents residing in the facility. Findings include: Review of personnel files revealed Licensed Social Worker #116 hired on 08/03/22, Business Office Manager #176 hired on 06/02/22, Licensed Practical Nurse (LPN) #183 hired on 04/03/17, LPN #186 hired on 05/20/22, Housekeeper (HSK) #137 hired on 06/10/22, HSK #169 hired on 08/26/20 and Registered Nurse #112 hired on 01/10/17 lacked evidence they were checked through the State of Ohio Nurse Aide Registry to determine if they had a finding of abuse, neglect, exploitation, mistreatment of residents or their property. Interview with Human Resource/Personnel Manager #192 on 10/06/22 at 11:30 A.M. verified there was no evidence in the personnel file provided but indicated the administrator handled that portion. The records were requested. On 10/06/22 at 3:52 P.M. the facility provided evidence they used a computer system that searched…

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, record and activity calendar review, the facility failed to provide an ongoing activities program for the residents on the secured dementia unit to improve boredom, loneliness and frustration that could result in distress or agitation. This affected three of three residents (#8, #63, and #73) reviewed for activities with the potential to affect all 23 residents on the secured dementia unit in a facility of 93 residents. Findings include: Observations on the secured dementia unit on 10/03/22 at 9:50 A.M. revealed eight residents asleep in the dining room. At 10:23 A.M. the same eight residents were in the dining room with nothing going on. Interview with Licensed Practical Nurse (LPN) #153 and State Tested Nurse Aide (STNA) #146 reported activity staff did not come onto the unit a lot. Meal service began at 11:21 A.M. and continued through 12:35 P.M. Activity Aide (AA) #167 arrived on the unit with a beach ball at 12:28 P.M. but residents were in the middle of meal service, 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 observations, interviews, review of activity calendars, review of staffing patterns and review of the facility assessment, the facility failed to have sufficient quantity of staff to provide the necessary behavioral health, psychosocial and dementia care to residents with consideration of the number, acuity, and diagnoses of the residents. This affected all 23 residents (#7, #8, #14, #26, #30, #34, #40, #41, #44, #48, #55, #59, #61, #62, #63, #68, #69, #70, #73, #74, #75, #130, and #131) on the secured dementia unit out of 93 residents. Findings include: Observations on the secured dementia unit on 10/03/22 at 9:50 A.M. revealed eight residents asleep in the dining room. The remainder of the residents were in their rooms for the entire day. The posted activities were not being delivered. There was one Licensed Practical Nurse (LPN) #153 and one State Tested Nurse Aide (STNA) #146 for 23 residents. LPN #153 and STNA #146 were observed physically running to respond to alarms sounding and call lights. Interview with LPN #153 and STNA #146 on 10/03/22 at 10:30 A.M. reported 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 observation, medical record review, interview, and review of product information, the facility failed to properly disinfect equipment being removed from a resident's room who had a diagnosis of clostridium difficile. This had the potential to affect eight residents (#18, #19, #28, #80, #184, #186, #230, and #280) of 93 residents. Findings include: Review of Resident #35's medical record revealed she was in isolation for clostridium difficile. On 10/03/22 at 11:02 A.M. two staff were observed donning personal protective equipment and entering Resident #35's room. At 11:04 A.M., an unidentified staff member pushed a mechanical lift into the hallway and wiped it down with a ReadyKleen wipe. At 11:05 A.M. State Tested Nurse Aide (STNA) #172 exited the room pushing a reclining dialysis chair into the hall. After changing her mask and performing hand hygiene, STNA #172 returned and stated she had to disinfect the chair using ReadyKleen wipes. Review of the label for the ReadyKleen wipes did not indicate it was effective against clostridium difficile. Interview on 10/03/22 at 3:02…

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 facility self reported incident review, resident interview, medical record review and staff interview. The facility failed to ensure residents were treated with dignity and respect by staff members. This affected three (Residents #50, #52 and #230) of three residents reviewed for staff treatment. The facility census was 93. Findings include: Review of facility self reported incident (SRI) #227326 created and reported on 09/27/22 indicated State Tested Nurse Aide (STNA) #104 had reported to administrative staff, STNA #214 was rude and inappropriate with Resident #230. STNA #104 indicated STNA #214 was rude and inappropriate towards Resident #230 by telling the resident she would not respond to verbal calls for assistance, and she would only respond to call light use. Further review of the SRI revealed facility staff interviewed Resident #230 and other residents in the facility which found Residents #50 and #52 also had concerns related to rude and inappropriate treatment by STNA #214. Interview with Resident #230 on 10/04/22 at 12:55 P.M. indicated a staff member was very…

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, electronic narcotic dispense records, policy review, schedule review and staff interview, the facility failed to ensure narcotic medications were dispensed appropriately and not misappropriated by staff members. This affected two (Residents #15 and #31) of six residents reviewed for medications. The facility census was 93. Findings include: 1. Review of Resident #15's medical record revealed an admission date of 12/24/20 with admission diagnoses that included cerebrovascular accident with hemiplegia and hemiparesis, congestive heart failure and osteoarthritis. Review of physician's orders indicated the use of oxycodone/acetaminophen (narcotic analgesic pain medication) 5/325 milligrams (mg) every six hours as needed. Review of the electronic narcotic dispense records revealed on 09/06/22 at 5:38 P.M. and 09/24/22 at 3:54 P.M. the Director of Nursing withdrew the above narcotic medications from the Alixa electronic medication dispensing machine (electronic machine which stores narcotics and other medications for staff retrieval and disbursement to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident and resident's representative in writing of the reason for transfer/discharge to the hospital and send a copy of the notice to the Long-Term Care Ombudsman. This affected one of two residents (#81) reviewed for hospitalization. Findings include: Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including respiratory failure. Review of the progress note dated 08/02/22 at 4:08 A. M, revealed Resident #81 had a sudden change in condition and was sent to the hospital for hypoxia, sepsis and hypothermia. On 08/10/22 at 7:00 A. M. he again had a change in condition and was sent to the hospital. There was no evidence in the record the resident/representative were notified of the transfer and the reason for the move in writing nor a copy of the notice sent to the Long-Term Care Ombudsman. Interview with the Director of Nursing on 10/05/22 at 1:45 P.M. indicated the facility had changes…

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 notify the resident and/or the resident's representative of the facility policy for bed hold, including reserve bed payment. This affected two residents reviewed for hospitalization (#35 and #81) of 93 residents in the facility. Findings include: Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including respiratory failure. Review of the progress note dated 08/22/22 at 4:08 P.M. indicated Resident #81 had a sudden change in condition and was sent to the hospital where he was diagnosed with hypoxia, sepsis and hypothermia. He was sent to the hospital again on 08/10/22 at 7:00 A.M. for a change in condition for respiratory issues. There was no evidence the resident/representative were notified of bed hold days remaining. Interview with the Director of Nursing on 10/05/22 at 1:45 P.M. indicated between staffing changes with the business office and social services, bed hold notes were never sent.…

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 medical record review and staff interview, the facility failed to ensure pre-admission screening and resident review was resubmitted after a significant change with new updated mental illness diagnosis. This affected two (Resident #31 and #64) of two residents reviewed for pre-admission screening and resident review. The facility census was 93. Findings include: 1. Review of Resident #31's medical record revealed an admission date of 09/19/18 with admission diagnosis that included multiple sclerosis. Review of the Pre-admission Screening and Resident Review (PASRR) revealed PASRR completed on 07/16/18 which indicated no evidence of serious mental illness. Further review of the medical record revealed on 12/08/21 a new diagnosis of schizoaffective disorder was added by the physician. Interview with Licensed Social Worker (LSW) #116 on 10/05/22 at 9:50 A.M. verified a PASRR was not resubmitted for review after a new serious mental illness diagnosis was added for Resident #31. 2. Review of the medical…

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 resident interview, observation, medical record review and staff interview, the facility failed to ensure residents dependent upon staff assistance with meals were provided assistance as indicated. This affected one (Resident #31) of three residents reviewed for assistance. The facility census was 93. Findings include: Interview with Resident #31 on 10/03/22 at 9:30 A.M. revealed staff members did not assist him with meals. Observation of Resident #31 for the lunch meals on 10/03/22, 10/04/22 and 10/05/22 revealed no evidence of staff assistance with meals. Resident #31 was independently feeding himself while having significant hand and arm tremors resulting in difficulty eating and a large amount of food debris on the chest of the resident. Review of Resident #31's medical record revealed an admission date of 09/19/18 with admission diagnosis that included multiple sclerosis. Further review of the medical record including the quarterly Minimum Data Set (MDS) 3.0 assessment with a reference date of 08/16/22 indicated Resident #31 had an independent cognition level 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, interview and record review, the facility failed to reassess and implement interventions for Resident #8's nutritional status following an identification of poor intake resulting in a significant weight loss. This affected one resident (#8) out of three residents (#40 and #284) reviewed for nutrition. Findings include: Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including respiratory failure, diabetes with neuropathy, hypothyroidism, dementia, reflux, major depressive disorder, hyperlipidemia, pneumonia, sepsis, esophagitis, esophageal obstruction and schizophrenia. Review of the admission comprehensive assessment dated [DATE] indicated Resident #8 was severely cognitively impaired and required the extensive assistance of one person for eating. Review of Resident #8's plan of care related to altered nutrition indicated to monitor/report swallowing issues, monitor meal intake percentages, periodically obtain weight, and provide…

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 medical record review, policy review, review of pharmacy delivery records, and interview, the facility failed to ensure ordered medications were available for administration. This affected one (Resident #181) of five residents reviewed for medication use and one additional resident (Resident #185) who addressed a concern during initial review. Findings include: 1. On 10/03/22 at 11:20 A.M., Resident #185 stated she was concerned she had not received her thyroid medication for three days. Review of Resident #185's medical record revealed an admission date of 09/18/22. Diagnoses included hypothyroidism. Review of the September 2022 Medication Administration Record (MAR) revealed an order for [NAME] thyroid tablet 90 milligrams (mg) to be administered once every other day starting 09/20/22 and an order for [NAME] thyroid 60 mg to be administered once every other day starting 09/21/22. Review of a pharmacy packing slip dated 09/18/22 revealed four of each of the [NAME] thyroid doses were delivered to 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, policy review, manufacturer guidelines review, and interview, the facility failed to properly sanitize a glucometer. This had the potential to affect five of five residents (Residents #42, #51, #72, #73, #79) who were ordered glucometer testing on the East Hallway of the facility. Facility census was 84. Findings include: Observation on 10/02/19 at 11:11 A.M. revealed Licensed Practical Nurse (LPN) #11 performing an ordered, routine blood glucose test for Resident #42 on the East hall. Following the procedure, LPN #11 returned to the medication cart and removed a Sani-Cloth bleach wipe from a container and began wiping the glucometer for approximately 30 seconds. She then placed the glucometer in the top drawer of the medication cart. During interview at this time, LPN #11 revealed she usually wiped the entire glucometer for 30 seconds to one minute, however, she was not sure of the specific contact time required by the Sani-Cloth manufacturer for proper sanitization. Review of the manufacturer guidelines for the Sani-Cloth bleach wipes revealed the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to timely implement the restorative nursing programs (RNP) for Resident #81. This affected one of two residents reviewed for RNP. Findings include: Record review revealed Resident #81 was admitted to the facility on [DATE] with diagnoses which included cerebral infarct and muscle weakness. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident needed extensive assistance with activities of daily living (ADL). Review of the physical therapy and occupational discharge summaries revealed the resident was discharged from skilled therapy on 09/12/19 and was to receive a RNP to maintain and/or improve her ADL. Review of the restorative rehabilitation program recommendation revealed it was not signed as completed until 09/23/19 and indicated the program start date was 09/25/19 for transfers and range of motion. The recommendation was signed by Physical therapy assistant (PTA) #12. On 10/03/19 at 7:40 A.M., interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident interview, family interview, facility policy review and staff interview, the facility failed to timely identify, assess and document resident wounds. This affected two (Resident #77 and #63) of three residents reviewed for non-pressure skin conditions. The facility also failed to provide appropriate care and services for constipation for one (Resident #24) of five residents reviewed for medications. The facility census was 84. Findings include: 1. Observation of Resident #77 on 09/30/19 at 3:24 P.M. revealed a scabbed area to the right shin below the knee. The wound appeared nearly a week old. Resident #77 was also observed attempting to remove a bandage and wrap that had been applied to the wound. Interview with Resident #77's husband at the time of observation revealed the wound had been present for about a week. Review of Resident #77's medical record revealed an admission date of 08/26/19 with diagnoses that included fracture of the right humerus 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 medical record review, policy review, and interview, the facility failed to ensure a fall intervention was in place for Resident #12. This affected one (Resident #12) of three residents reviewed for falls. Findings include: Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dizziness, and history of falls. Review of the resident's Fall Risk Assessment, dated 08/20/19, revealed the resident was at a risk for falls, indicated by a score of 20. Review of Resident #12's Care Plan revealed fall interventions, initiated on 05/23/19, for non-skid footwear and to follow the facility fall protocol. Review of Resident #12's Minimum Data Set (MDS) 3.0 Assessment, dated 08/14/19, revealed the resident required extensive, one-person assistance for transfers in her room. Review of Resident #12's nursing progress note, dated 09/18/19 at 6:11 A.M., revealed the resident was found lying on the floor, on her left side, during morning rounds.…

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 a comprehensive and individualized bladder program was in place to ensure Resident #81 remained as continent as possible. This affected one of one resident reviewed for bladder incontinence. This facility identified 36 residents on the restorative scheduled toileting program. Findings include: Record review revealed Resident #81 was admitted to the facility on [DATE] with diagnoses which included overactive bladder, urinary incontinence and difficulty walking. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact but needed extensive assistance of at least two staff for transfers and toileting and one staff for hygiene. The resident was not steady moving on or off the toilet but was stabilized with staff assistance. The resident used a walker or a wheelchair for mobility. The resident was on a toileting program but was frequently incontinent of bladder. Review of the current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the antibiotic stewardship program was implemented for Resident #81, who received an antibiotic (ATB) for an urinary tract infection (UTI) that did not meet the McGreer criteria the facility used for ATB stewardship. This affected one of one resident reviewed for ATB use. The facility had five residents receiving antibiotics. Findings include: Record review revealed Resident #81 was admitted to the facility on [DATE] with diagnoses which included urinary incontinence and history of UTI's. The resident was re-admitted from the hospital on [DATE] on antibiotics for a UTI. Review of the resident's current care plans revealed no care plan for recurrent UTI's. Review of the nursing notes dated 09/15/19 through 09/18/19 revealed there were no signs or symptoms to suggest the resident may have had a UTI requiring antibiotics. Review of the urinalysis dated 09/18/19 revealed the resident had bacteria in her urine which was sensitive to Ciprofloxacin.…

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.