River's Bend Health & Rehab Center

Based on facility policy review, observations, and staff interview, it was determined that the facility failed to maintain a safe, clean, comfortable and home-like environment in two of eight hallways observed. Findings include: Review of facility policy, titled General Routine Environmental Cleaning and Disinfection Policy last reviewed July 2, 2026, read, in part, Proper cleaning and disinfecting of environmental surfaces is necessary to break the chain of infection. Cleaning refers to the removal of visible soil from surfaces through the physical action of scrubbing with detergents/surfactants and rinsing with water. Household surfaces should be cleaned on a regular basis, when spills occur, and when surfaces are visibly soiled (floors, tabletops, resident care areas, dining rooms, common areas, shared shower rooms and bathrooms, hair salons, activities, etc). Observation in Resident 8's room on March 9, 2026, at 12:53 PM; March 10, 2026, at 12:56 PM, and March 11, 2026, at 10:18 AM; revealed his tray table was dirty and had spilled liquid, and his floor was dirty and had 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 facility policy review, clinical record review, review of facility provided documentation, and staff interviews, it was determined that the facility failed to provide written notice of a resident's transfer to the resident and the resident's representative for two of six residents reviewed for hospital transfer (Residents 10 and 56); failed to send notice of a residents transfer to a representative of the Office of the State Long-Term Care Ombudsman for two of six residents reviewed for hospital transfers (Residents 10 and 56); and failed to provide a written copy of the facility's bed-hold policy for three of six residents reviewed (Residents 8, 10, and 56).Findings include: Review of facility policy, titled Discharge Planning Policy, last reviewed February 3, 2026, revealed, in part, Transfers and discharges will meet regulatory requirements. Further review of the policy failed to reveal the requirement that a resident and their representative, as well as a representative of the Office of the State Long-Term Care Ombudsman, were to be provided with written notice 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.

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident's comprehensive care plan was implemented for one of 31 residents reviewed (Resident 10).Findings include: Review of facility policy, titled Comprehensive Care Planning Policy, reviewed February 24, 2026, revealed, in part, All staff caring for the resident will be familiar with the resident's plan of care. Review of Resident 10's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), muscle weakness, and lack of coordination. Review of Resident 10's care plan revealed a focus of Behavioral Symptoms Resident experiences wandering activity throughout hallways and occasionally into resident rooms, with a start date of January 27, 2026. Interventions included, but were not limited to, Provide visual deterrents such as stop signs, warning signs, arrows, or do not enter signs on…

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

Based on facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good grooming and personal hygiene for one of seven residents reviewed for ADLs (Resident 51). Findings Include:Review of the facility policy, titled AM Care Policy last reviewed September 16, 2025, read, in part, Morning care will be offered each day to promote resident comfort, cleanliness, grooming, and general wellbeing. Showers and baths are scheduled two times weekly or more or less according to resident preference. Provide shaving as desired by resident.Review of Resident 51's clinical record revealed diagnoses that included age-related osteoporosis (a bone disease characterized by weak and fragile bones, increasing the risk of fractures), hypertension (high blood pressure), and abnormalities of gait and mobility (unusual patterns of walking or movement caused by injuries, neurological, musculoskeletal, or…

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 facility policy reviews, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 31 residents reviewed (Resident 66).Findings include: Review of facility policy, titled Administration of an Intermittent Infusion, with a last revised date of June 1, 2021, revealed, in part, Flush vascular access device with prescribed flushing/locking agent(s) to maintain patency between intermittent infusions. Review of facility policy, titled Short Peripheral Intravenous Catheter (PIVC) Dressing Change, with a last revised date of June 2024, revealed, in part, Transparent dressings are changed with each site rotation every seven days, or sooner if the integrity of the dressing is compromised (wet, loose or soiled). Assessment of peripheral catheter site is performed: 5.3 Before 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 facility policy review, observations, clinical record review, and staff interviews, it was determined the facility failed to ensure a resident receiving enteral feeding received appropriate care and services to prevent complications for one of one resident reviewed for tube feeding (Resident 115). Findings include: Review of facility policy, titled Enteral Feeding Tube Policy last revised April 1, 2016, read, in part, Licensed clinicians with demonstrated competence may administer enteral feedings and provide tube/site care. Review of Resident 115's clinical record revealed diagnoses that included gastrostomy status (refers to the presence of an artificial opening in the stomach for feeding patients who cannot ingest food orally), unspecified protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), and dysphagia (difficulty chewing and/or swallowing). Review of Resident 115's physician orders revealed an order for Enteral: Pump Feeding up at 6:00 PM Special Instructions: At 6:00 PM hang (Isosource 1.5- tube…

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 policy review, medication administration observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (4 errors in 25 observations, 15.38%).Findings include: Review of facility policy, titled General Dose Preparation and Medication Administration, revised November 15, 2024, revealed that prior to administering medication the nurse should verify that the medication to be administered is the correct medication, at the correct dose, for the correct resident. Review of Resident 66 current physician orders revealed medication orders for Cyanocobalamin (Vitamin B-12) 1000 mcg daily, starting on March 6, 2026. Observation on March 10, 2026, at 9:41 AM, revealed Employee 1 (Licensed Practical Nurse- LPN) was observed administering Cyanocobalamin 500 mcg to Resident 66. Review of Resident 93's current physician orders revealed medication orders for Cyanocobalamin (Vitamin B-12) 4000 mcg daily, starting October 1, 2025; Aspirin 81 mg chewable tablet, starting October 1, 2025;…

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 policy review, personnel file review, and staff interviews, it was determined that the facility failed to ensure that residents were protected from the potential for abuse by failing to obtain information from previous employers and/or current employers for five of five employee files reviewed (Employees 2, 3, 4, 5, and 6). Findings include: Review of facility policy, titled Pennsylvania Resident Abuse, with a last review date of April 9, 2024, revealed that the The facility will do the following prior to hiring a new employee: generally, attempt to obtain references from 2 prior employers for an applicant. Review of personnel file of Employee 2 revealed that the Employee was hired on January 2, 2025. Further review of their personnel filed failed to reveal any reference checks from previous and/or current employers. Review of personnel file of Employee 3 revealed that the Employee was hired on December 23, 2024. Further review of their personnel filed failed to reveal any reference checks from previous and/or current employers. Review of personnel file of Employee…

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 clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber in a timely manner for four of 33 residents reviewed (Residents 49, 62, 70, and 119). Findings include: Review of facility policy, titled Medication Regimen Review, revised June 1, 2024, revealed, 1. If an irregularity is not time-sensitive but should be addressed before the consultant pharmacist's next monthly MMR, the facility staff and the consultant pharmacist will confer on the timeliness of attending physician/prescriber responses to identified irregularities based on the specific resident's clinical condition. 2. The attending physician/prescriber should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident per facility policy, or applicable state and federal regulations. Review of Resident 49's clinical record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for two of 30 residents reviewed (Residents 85 and 125). Findings Include: Review of Resident 85's clinical record revealed diagnoses that included dysphagia (difficulty swallowing), gastro-esophageal reflux disease (when stomach acid backs up into your esophagus, the tube connecting your stomach to your mouth), and hypertension (high blood pressure). Review of Resident 85's clinical record revealed she had a weight measure of 202.8 pounds on October 7, 2024, that reflected a significant weight loss from the previous weight measure. Review of Resident 85's Quarterly MDS (Minimum Data Set- assessment tool utilized to identify residents' physical, mental and psychosocial needs) with ARD (assessment reference date- last day of the assessment period) of October 7, 2024, revealed Section K - Swallowing/Nutrition Status, did not reflect her most…

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 clinical record review, staff interviews, and facility policy review, it was determined that the facility failed to provide the resident and/or resident representative with a summary of the baseline care plan in a format and location developed by the facility for one of three residents reviewed for care planning (Resident 72). Findings include: Review of facility policy, titled Comprehensive Care Planning Policy, last revised March 20, 2025, revealed the policy's statement was, An interdisciplinary plan of care will be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. The aforementioned policy's Procedures section included, The comprehensive care plan will be developed within seven (7) days after completion of the comprehensive assessment (MDS). The comprehensive care plan will be prepared by an interdisciplinary team that includes but is not limited to: The attending physician; A registered nurse with responsibility for the resident; A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observations, clinical record review, as well as resident, resident representative, and staff interviews, it was determined that the facility failed to invite a resident and/or their representative to care plan meetings and failed to have required members of the interdisciplinary team participate in the care plan conference for two of 30 residents reviewed (Residents 14 and 58); and failed to review and revise the resident plan of care for one of 30 residents reviewed (Resident 49). Findings include: Review of facility policy, titled Care Plan Invitation Letter Policy, with a last reviewed date of April 9, 2024, revealed The Executive Director or Administrator will designate a staff member who will be responsible for completing the Care Planning Invitations, for delivering an invitation to the resident prior to the conference date (unless he/she has been legally deemed incompetent), and for mailing an invitation or calling to notify the family/responsible party/representative,…

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 clinical record review and staff interviews, it was determined that the facility failed to ensure a physician's discharge summary was completed for two of four residents reviewed for discharge (Residents 57 and 137). Findings include: Review of Resident 57's clinical record revealed diagnoses that included congestive heart failure (disease process of the heart that results in a decreased ability of the heart to effectively pump blood throughout the body) and type two diabetes mellitus (decreased ability of the body to produce and/or utilize insulin for the transport of glucose from the blood stream into the cells for nourishment). Review of Resident 57's clinical record revealed that Resident 57 was admitted to the facility on [DATE], for rehabilitation after increased weakness. Resident 57 was subsequently discharged to home on February 5, 2025, after reaching rehabilitation goals for activities of daily living and strength. Review of Resident 57's clinical record revealed that as of March 26, 2025, no…

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

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 30 residents reviewed (Residents 61 and 105). Findings include: Review of Resident 61's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), generalized osteoarthritis (degeneration of joint cartilage and the underlying bone, causing pain and stiffness, especially in the hip, knee, and thumb joints), and hypertension (high blood pressure). Review of Resident 61's clinical record physician orders revealed an order for Resident to be out of bed to low Broda chair (a tilt-in-space positioning chair which prevents skin breakdown through reducing heat and moisture) with padded back support, pressure reducing cushion, dycem (a non-slip pad) underneath…

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, policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of 33 residents reviewed (Residents 79). Findings include: Review of facility policy, Splint Issuance, last revised March 11, 2022, read, in part, splints shall be issued with a provider's order and therapist must evaluate patient to determine need for splint, fit and issuance. Splint schedule will be communicated to the multidisciplinary team and documented in the care plan. Clinical record review for Resident 79 documented diagnoses that included contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity, and rigidity of joints) of multiple muscles, depression (feelings of severe despondency and dejection), dementia (a condition characterized by progressive loss of intellectual functioning,…

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, clinical record review, facility document review, and resident and staff interviews, it was determined that the facility failed to ensure residents receive adequate supervision and assessment after an accident for one of five residents reviewed for falls (Resident 72). Findings include: Review of facility policy, titled Neurological Checks Policy, last revised July 9, 2024, revealed the policy stated, Neurological checks are indicated to monitor for potential irregularities in neurological status in the event of a known or unknown head trauma as the result of a resident event, change in resident condition, or physician's order. Review of the procedures section of the policy revealed it included, A licensed clinician will perform an initial neurological check for all residents who have sustained a witnessed, unwitnessed, alleged, reported, or suspected head trauma following an unusual occurrence or change in resident neurological condition .When triggered by a qualifying event, a neurological check observation in the electronic health record will be initiated to…

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

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one resident reviewed for dialysis (Resident 54). Findings Include: Review of facility policy, titled Hemodialysis Care Policy, with an effective date of June 16, 2017, and a last reviewed date of April 9, 2024, revealed the Pre-dialysis process: Document assessment in the Dialysis Communication Tool. Assessment includes vital signs, pre-treatment weight (unless performed at dialysis), medications administered before treatment, time of last meal, fluid intake, any additional information. Print the tool and send with resident to dialysis (if off-site). Review of Resident 54's clinical record revealed diagnoses that included Parkinson's disease (a movement disorder of the nervous system that worsens over time) and end stage renal disease (a condition where the kidneys have permanently lost most of their ability to function). Review of Resident 54's current physician orders…

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 clinical records review and staff interview, it was determined that the facility failed to provide documentation of actual disposition of medications and method of disposition for one of three residents reviewed (Resident 136). Findings include: Review of Resident 136's clinical record revealed diagnoses that included end stage renal disease (a condition where the kidneys have permanently lost most of their ability to function) and hypertension (high blood pressure). Review of Resident 136's clinical record revealed a discharge summary completed on February 15, 2025, that Resident 136 was found unresponsive and passed away on that day due to cardiac arrest. Further review of the discharge summary revealed Resident 136's disposition of medications went with the Resident. Review of Resident 136's clinical record revealed there was no medication disposition form completed or any progress notes indicating a disposition of medications has been completed for Resident 136. During an interview with the Director of Nursing on March 27, 2025, at 10:34 AM, revealed they were unable to…

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

Based on observations, review of facility policy, and interviews, it was determined that the facility failed to clean and store dishes in accordance with professional standards for food safety in the dish machine area in the kitchen area for one of one meal observed. Findings include: Review of facility policy, Dish Machine Use, last revised May 17, 2021, read, in part, prior to use confirm chemical dispensers are filled and have enough product for the shift. Prior to use verify temperature and/or chemical sanitizer concentration are within specifications provided by dish machine manufacturer. If requirements are not met, immediately discontinue use of the dish machine and notify the person in charge. During use, operator will monitor temperature gauge frequently, if requirements are not met, immediately discontinue use of the dish machine and notify person in charge. The person loading dirty dishes into the dishwasher will not handle the clean dishes unless they wash hands thoroughly before moving from dirty to clean dishes. Observation on March 24, 2025, at 9:44 AM, in the dish…

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 policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for two of three residents reviewed (Residents 1 and 2). Findings Include: Review of facility policy, titled Neurological Checks Policy, revised July 9, 2024, revealed Neurological checks are indicated to monitor for potential irregularities in neurological status in the event of known or unknown head trauma as the result of a resident event, change in resident condition, or physician's order. When triggered by a qualifying event, a neurological check observation in the electronic health record will be initiated to conduct periodic checks and to document the results of the neurological checks. Unless otherwise ordered by the physician, the frequency of neurological assessments will be once every shift for 72 hours post occurrence or change. Review of Resident 1's clinical record revealed diagnoses that…

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 clinical record review, facility document review, and staff interview, it was determined that the facility failed to ensure a system of recording the disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and to ensure an account of all controlled drugs is maintained and periodically reconciled for prompt identification of loss or potential diversion of controlled substance for one of three residents reviewed (Resident 1). Findings include: Review of facility policy, titled 5.3 Storage and Expiration Dating of Medications and Biologicals, last revised August 1, 2024 stated, 18. Controlled Substance Storage: 18.1(2)Controlled medications must be counted with another designated staff member when there is an exchange of keys. Review of Resident 1's clinical record revealed diagnoses that included dementia (progressive, irreversible degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and anxiety disorder (excessive and uncontrollable feelings of worry…

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, facility policy review, and staff interviews, it was determined that the facility failed to store drugs used in the facility in accordance with currently accepted professional principles and the expiration dates for three of three medication carts observed (B Hall, C Hall, and G Hall medication carts). Findings Include: Review of facility policy, titled 5.3 Storage and Expiration Dating of Medications and Biologicals, last revised August 1, 2024, revealed it stated, 2. Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, .3. Facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medication and biologicals are stored .11. Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medication. Facility staff should record the date opened on the primary medication container (ie., vial, bottle, inhaler) when the medication has a shortened…

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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident/resident representative and/or the representative of the Office of the State Long-Term Care Ombudsman of resident transfers, in writing, to include to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman for six of 11 resident records reviewed (Residents 20, 34, 76, 81, 97, and 184). Findings include: Review of facility policy, Resident Discharge/Transfer Letter Policy, last revised April 19, 2023, read, in part, for emergency transfers, signature of administrator/designee will be acquired/obtained as soon as practicable. If signature is obtained after resident transfers, it will be given to resident at that time, if applicable. The policy failed to document…

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 clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure that the resident and resident representative received written notice of the facility bed-hold policy at the time of transfer for seven of 11 resident records reviewed (Residents 20, 34, 59, 76, 81, 97, and 184). Findings Include: Review of facility policy, Bed Hold Letter, revised September 26, 2020, read, in part, Business Office or designee will complete the Medicaid Bed Hold Letter and sent to the appropriate parties, certified/return receipt requested or provided directly to the responsible party, and a copy will be maintained in the Resident's financial file. Review of Resident 20's clinical record revealed diagnoses that included chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle, and the ventricle cannot contract normally when the heart beats), chronic obstructive pulmonary disease (COPD - a type of progressive lung disease…

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 clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for two of 26 residents reviewed (Residents 77 and 87). Findings Include: Review of Resident 77's clinical record revealed diagnoses that included vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults), delusional disorder (type of psychotic disorder; a delusion is an unshakable belief in something that is untrue), and depression. Review of Resident 77's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (ARD-last day of the assessment period) of September 2, 2023, revealed in Section N. Medications at subsection N0450. Antipsychotic Medication Review that the Resident was receiving an antipsychotic medication on a routine basis, had not had a gradual…

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 facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for seven of 29 residents reviewed (Resident 20, 36, 42, 59, 77, 81, and 97). Findings include: Review of facility policy, titled Comprehensive Care Planning Policy, with a revision date of March 2, 2021, revealed F) The Comprehensive Care Plan is reviewed and updated at least every 90 days by the interdisciplinary team. J) 2. Residents who have returned from the hospital in the past week. Their previous MDS and Care Plan must be reviewed and updated and section W) Care Plans are to be maintained with the current Medical Record. Review of Resident 20's clinical record revealed diagnoses that included chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle, and the ventricle cannot contract normally when the heart beats), chronic obstructive pulmonary disease (COPD - a type 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 observations, policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 29 residents reviewed (Resident 97). Findings include: Review of facility policy, titled Central Vascular Access Device (CVAD) Dressing Change, with a revision date of June 01, 2021, read, in part, Consideration: 1. Central vascular access devices (CVADs) include: 1.1 Peripherally inserted central catheter (PICC) . Guidance: 1. Perform sterile dressing changes using Standard- ANTT: 1.2 At least weekly, 1.3 If the integrity of the dressing has been compromised (wet, loose, soiled) . 7. Assessment of the vascular access site is performed: 7.3 Before and after administration of intermittent infusion . 24. Documentation in the medical record includes but is not limited to: 24.1 Date and time, 24.2 Site assessment, 24.3 Length of external catheter, 24.4. Arm circumference, 24.5 Reason for dressing…

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 policy review, observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for four of four residents reviewed for respiratory care/oxygen services (Residents 7, 34, 41, and 45). Findings include: Review of Resident 7's clinical record revealed diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and hypertension (high blood pressure). Review of Resident 7's physician orders revealed an order to administer oxygen 2 LPM (liters per minute) via nasal cannula PRN (as needed) for shortness of breath, every shift, with a start date of March 26, 2024. Further review of Resident 7's physician orders also revealed an order to clean oxygen concentrator and filter, change tubing weekly on Sunday, with a start date of March 26, 2024. Further review of Resident 7's physician orders revealed an order for CPAP unit at bedtime as needed for obstructive…

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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of 26 resident's reviewed (Resident 87). Findings include: Review of facility policy, titled Social Services Policy, last revised March 1, 2024, read, in part, The facility provides social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, and/or psychosocial well-being .[Social services is] responsible for assessing and ensuring residents who are trauma survivors receive culturally competent, trauma-informed care/approaches. Including: Psychiatric referrals as needed, identifying triggers and implementing approaches/interventions to help reduce risk of re-traumatization, considering resident's experiences and cultural preferences, values…

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 facility policy, employee files review, and staff interviews, it was determined that the facility failed to ensure that nursing staff with the appropriate competencies and skills sets to provide nursing and related services was provided to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three of three nursing staff reviewed (Employees 6, 12, and 13). Findings include: Review of facility policy, titled Nursing Staff Orientation Process, last revised July 14, 2021, revealed, in part, Licensed nurses and certified nursing assistants will receive general orientation and complete skills and competency checklists prior to assuming an independent assignment. 1a. Certified nursing assistants will receive 1-3 days of general orientation (including skills and competencies checklist. 1b. Licensed nurses will receive 1-5 days of general orientation (including skills and competencies checklist). 3. Certified nursing assistants will receive a minimum of 2-3 days orientation on 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 facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to ensure that residents were protected from the potential for abuse by failing to perform a FBI criminal history background check prior to hire for one of five personnel files reviewed (Employee 6). Findings Include: Review of facility policy, titled Pennsylvania Resident Abuse, with a last revised date of August 30, 3023, revealed, in part, 1. a. The facility will do the following prior to hiring a new employee: .iv. Conduct a criminal background check in accordance with State law and Facility policy. Review of facility policy, titled Employee Background Screening Policy, with a last revised date of February 16, 2024, revealed, in part, Part 2: Criminal Background Check A. Each facility shall conduct a criminal background check of all employees, as required by law upon hire. The HR department shall oversee and monitor the process .Pennsylvania-if the applicant has not been a Pennsylvania resident for two consecutive years before application, they will need to…

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

Based on clinical record review and staff interview, it was determined the facility failed to develop a discharge summary to anticipate resident needs for one of three residents reviewed (Resident 132). Findings Include: Review of Resident 132's clinical record revealed diagnoses that included hypertension (high blood pressure) and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Continued review of Resident 132's clinical record revealed he was discharged home with his daughter on February 10, 2024. Continued review of Resident 132's clinical record revealed no documentation of staff documenting a recapitulation of the Resident's stay, a final summary of the Resident's status, a reconciliation of all pre-discharge medications with the Resident's post-discharge medications, a post-discharge plan of care developed with Resident participation to assist Resident 132 to adjust to his living environment, or documentation of arrangements to be made for his follow-up care 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 clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders and care plan for two of 26 residents reviewed (Residents 41 and 92). Findings include: Review of Resident 41's clinical record revealed diagnoses that included Pneumonia (An infection of the air sacs in one or both the lungs. Characterized by severe cough with phlegm, fever, chills and difficulty in breathing), asthma (a long-term inflammatory disease of the airways of the lungs), and vitamin D deficiency. Review of Resident 41's physician orders revealed an order for an antibiotic amoxicillin-pot clavulanate tablet; 875-125 mg; Amount to Administer: 1 tablet; oral, with a start date of March 13, 2024, and a completed date of March 22, 2024. Further review of Resident 41's physician orders revealed an order for a prednisone tablet once a day by mouth every morning for seven days, with a start date of March 22, 2024, and a completed date of March 28, 2024. Review…

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 facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice for one of one resident reviewed for dialysis (Resident 59). Findings include: Review of facility policy, titled Central Vascular Access Device (CVAD) Dressing Change, with a revision date of June 01, 2021, read, in part, Consideration: 1. Central vascular access devices (CVADs) include: 1.3 Tunneled catheters . 7. Assessment of the vascular access site is performed: 7.4 At least once every shift when not in use. Review of Resident 59's clinical record on April 9, 2024, at 12:03 PM, revealed diagnoses that included end stage renal disease (condition in which kidneys cease functioning) and dependence on renal dialysis (treatment that removes extra fluid and waste products from the blood when the kidneys are not able to). During an interview with Resident 59 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of medications for two of three closed records reviewed (Residents 132 and 133). Findings include: Review of facility policy, titled Disposal/Destruction of Expired or Discontinued Medications, dated 2023, read, in part, Facility should destroy non-controlled medications in the presence of a registered nurse and witnessed by one other staff member, in accordance with facility policy or applicable law. Facility should enter the following information on a drug destruction form when medications are destroyed: Residents name, name and strength of medication, prescription number, amount of medication, date of destruction, signature of staff destroying medications, signature of witnesses, and method of disposition, including donation as permitted by…

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, facility policy review, and staff interviews, it was determined that the facility failed to discard expired medications in one of three medication carts (Cart A); and failed to properly label drugs in one of two medication rooms observed (Station 1). Findings Include: Review of facility policy, titled 5.3 Storage and Expiration Dating of Medications, Biologicals, with a last revised date of August 7, 2023, revealed, in part, 4. Facility should ensure that medications and biologicals that:(1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier; 5) Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to the expiration dates for opened medications. Facility should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened…

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 policy review, observations, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety for one walk-in refrigerator in the kitchen and one of three nourishment pantries on the nursing units. Findings include: Review of facility policy, Frozen Food Storage, revision date March 9, 2024, read, in part, date pulled from the freezer will be marked on the food item when placed in the refrigerator to thaw. Review of the facility's Use By Guide- Quick Reference, not dated, read, in part, thickened juices must be used within 10 days of opening, thicken milk within three days, and thawed nutritional shakes within 14 days of thawing. Observation in the walk-in refrigerator on April 8, 2024, at 9:30 AM, revealed the following nutritional shakes were thawed and not date marked when pulled from the freezer: 3/4 of a case vanilla shakes, 1/4 of a case orange cream shakes, and 1/4 of a case chocolate shakes. The aforementioned products were good for 14 days once thawed. During an interview…

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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for one of 30 residents reviewed and failed to provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident ' s medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary for four of four resident's reviewed (Residents 1, 3, 4 and 5). Findings include: Review of facility policy titled Interim/Baseline Care Planning Policy with a last revision date of August 11, 2020, revealed that the facility…

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

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to develop a comprehensive person centered care plan to meet a resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs for six of six records reviewed (Residents 1, 2, 3, 5, 6, and 7). Findings include: Review of facility policy, titled Comprehensive Care Planning Policy, with a last review date of July 19, 2019, revealed [in part]: H. A Facility Resident Care Plan Coordinator (must be a nurse appointed and supervised by the Director of Nursing) is responsible for the Resident Assessment, the Resident Care Plan, and the Resident Care Plan Conference; . J. Residents scheduled for the Resident Care conference include: 1) New admissions who MDS [MDS-Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs] was completed within the previous seven days. 2) Residents who have returned from the hospital in the past week.…

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 policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure each resident the right to personal privacy and confidentiality of his/her personal and medical records for one of one resident reviewed (Resident 2). Findings Include: Review of the facility policy, titled Release of Information, with a last revision date of December 12, 2023, revealed It is the responsibility of the Facility to protect the privileged information contained within the record. Review of Resident 1 clinical record revealed that they were in the process of applying for Medical Assistance. Based on document review, it was revealed that Resident 1's responsible party was sent a Medical Assistance application with another reident's information on it. Email communication received from the Nursing Home Administrator (NHA) on December 27, 2023, at 10:33 AM, indicated that the business office is responsible for sending/mailing Medicaid applications. She indicated that there was never an instance where a Medicaid application was mailed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, clinical record review, document review, and staff interviews, it was determined the facility failed to ensure that the hospice services were established in a timely manner for one of one residents receiving Hospice services reviewed (Resident 3). Findings include: Review of facility policy, titled Hospice Care Policy, with a last revised date of May 24, 2023, revealed the following: the hospice services and those providing them will meet professional standards and be provided timely . ii. Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC (long term care facility) before hospice care is furnished to any resident. Review of Resident 3's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply)…

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 clinical record review and staff interviews, it was determined that the facility displayed past non-compliance in its failure to provide routine drugs to its residents and ensure procedures to assure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for eight of 10 residents reviewed (Residents 1, 2, 3, 4, 5, 6, 7, and 8). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and osteoporosis. Review of Resident 1's Medication Administration (MAR) dated July 2023, revealed Resident 1 was ordered medications including, but not limited to: alendronate (used to treat or prevent osteoporosis) 70 mg every Friday; calcium carbonate (calcium supplement) 500 mg daily; cefuroxime axetil (antibiotic) 500 mg twice daily for seven days; Vitamin D3 25 mcg, three tablets daily; eszopiclone (Lunesta-used to treat insomnia) 2 mg at bedtime; Florastor (probiotic) 250 mg twice a day; magnesium oxide 400 mg, take three times a day for low magnesium;…

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.