Brentwood Place Four

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (100/200 hall nurses cart) of 3 medication nurse cart reviewed for pharmacy services in that: The facility failed to ensure: 1. LVN K responsible for the 100/200 hall nurses cart , removed medications in unsecure containers from the Nurses Cart. 2. The 100/200 hall nurses cart did not have 1 insulin pen for Resident #19 with no open date. Observation of the pen reflected it was used. These failures could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications, and place residents at risk of not having the medication available due to possible drug diversion. The findings included: Record review and observation on 06/08/25 at 09:53 AM, of Nurses Cart Hall 100/200, with LVN K revealed: - The blister pack for Resident #3's tramadol…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from Misappropriation of property for 1 (Resident # 1) of 8 residents reviewed for misappropriation of property. The facility failed to protect Resident #1 from misappropriation of property from CNA A. CNA A used Resident #1's Debit card for unauthorized transactions. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 08/24/2024 and ended on 09/03/2024. The facility had corrected the noncompliance before the Incident investigation began on 02/04/2025. This failure could place residents at risk of Exploitation/Misappropriation of Property and loss of lifelong earnings. Findings included: Record review of Resident #1's face sheet dated 02/05/2025 revealed he was a [AGE] year-old male with an admission date of 08/21/2024. His diagnoses included mild cognitive impairment of uncertain or unknown etiology (exact cause of the memory/cognitive decline cannot be determined) Primary…

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 implement their written policies and procedures regarding allegations of abuse/neglect for 1(Resident#1) of 8 residents reviewed for abuse/neglect. The facility failed to report a suspicion of misappropriation of property within 24 hours to the state agency as required by their policy. This failure could place all residents at risk of misappropriation of property. Findings included: Record review of Resident #1's face sheet dated 02/05/2025 revealed he was a [AGE] year-old male with an admission date of 08/21/2024. His diagnoses included mild cognitive impairment of uncertain or unknown etiology (exact cause of the memory/cognitive decline cannot be determined) Primary Open Angle Glaucoma, (Increased pressure inside eye which may cause gradual damage to the optic nerve), Hypertension (blood pressure in the arteries is consistently elevated). Record review of Resident #1's MDS assessment dated [DATE] revealed he had a BIMS score of 14,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment have evidence that all alleged violations were thoroughly investigated and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and the alleged violation is verified appropriate corrective action was taken for 1 of 8 residents (Residents #1) reviewed for Misappropriation of property. The facility failed to investigate and submit the results of their investigation within 5 days as per their policy, after Resident #1 reported his debit card was missing on 08/24/2024. This failure could place residents at risk of Misappropriation of property. Findings included: Record review of Resident #1's face sheet dated 02/05/2025 revealed he was a [AGE] year-old male with an admission date 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 interview and record review, the facility failed to immediately consult with the resident 's physician when there was a significant change in the resident 's physical status and a need to alter treatment significantly for two (Residents #17 and #55 ) of ten residents reviewed for notification of changes. 1. ADON C failed to notify the physician and responsible party of Resident #17's change of condition of significant weight loss on 04/28/24. Resident #17's physician was not informed of significant weight loss until 05/06/24. The responsible party for Resident #17 was not notified until 05/07/24. 2. ADON C failed to notify the physician and responsible party of Resident #55's change of condition of significant weight loss on 05/04/24. These failures could place residents at risk for a delay in treatment and diagnosis of new symptoms resulting in serious illness, hospitalization, further decline in the resident's condition, and death. Findings included: 1. Review of Resident #17's quarterly MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene to a resident who is unable to carry out activities of daily living for three of six residents (Resident #536, Resident #4, and Resident #32) reviewed for quality of life. 1. The facility failed to provide Resident #536, who required extensive assistance, with timely incontinence care on 05/7/24 from 6:00 a.m. to 2:20 p.m. 2. The facility failed to provide Resident #4, who required extensive assistance, with timely incontinence care on 05/07/24 from 6:00 a.m. to 2:50 p.m. and failed to consistently shampoo resident's hair. 3. The facility failed to ensure Resident #32 had his fingernails cleaned and trimmed. These failures could place residents at risk of skin breakdown, urinary tract infections, and loss of dignity. Findings included: 1. Record review of Resident #536's Face sheet dated 05/09/24 reflected a [AGE] year-old male with an admission date of 05/06/24. Resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise when the facility failed to implement significant weight loss interventions for two (Residents #17 and #55) of seven residents reviewed for significant weight loss, in that: 1. The facility failed to communicate and follow-up on Resident #17's significant weight loss of 44.8 pounds (20%) from 04/05/24 to 04/28/24 to the facility. Resident #17 was weighed on 05/03/24 revealing Resident #17 had lost 46 pounds (21%) for 1 month period from 04/05/24 to 05/03/24. The facility did not notify physician until 05/06/24 and failed to follow physician guidance to notify Dietitian on 05/06/24. The Dietitian was notified by ADON C after surveyor intervention on 05/07/24. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure enteral feeding physician orders were followed for two (Residents #17 and #55) of six residents reviewed for enteral tube feeding, in that: 1. The facility failed to verify adequate nutrition was provided via enteral tube feeding or PEG tube (surgical placement of feeding tube in the stomach to provide nutrition, hydration and/or medicines) for Resident #17. 2. The facility failed to notify Consultant Dietitian of Residents #17 and #55's significant weight loss to ensure nutritional interventions were in place. 3. The facility failed to administer enteral feedings for Resident #17 as ordered by the physician. 4. The facility failed to administer enteral feedings to Resident #55 as ordered by the physician. These failures could place residents who are completely dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown and overall decline in quality of care. Findings include: 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for two of two (Resident #20 and Resident # 76) residents reviewed for tracheostomy care. 1. The facility failed to ensure the RT performed hand hygiene during tracheostomy (a surgical opening in the neck providing a direct airway through the trachea) care. 2. The RT failed to maintain sterile technique during the suctioning of Resident #20's trach. 3. The facility failed to ensure LVN L performed hand hygiene during tracheostomy care for Resident #76 and changed her gloves and performed hand hygiene before applying a clean trach drainage sponge around Resident #76's trach stoma. These failures could place residents at risk for respiratory infections. Findings included: 1. Review of Resident #20's admission MDS assessment, dated 05/01/24, reflected the resident was a [AGE] year-old…

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, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and nutrition services. 1. The facility failed to ensure Dietary Aide ZB wore effective hair restraints to cover his hair and facial hair on 05/07/24 while cleaning dishes and using the dish machine. 2. The facility failed to ensure 1 of 3 freezers were free of ice accumulation on the bottom of freezer. These failures could place residents at risk for food-borne illness and food contamination. Findings included: Observation on 05/07/24 at 10:35 AM with Dietary Aide ZB revealed he did not wear a hair restraint to cover the 2.5 inches of back of hair along with ½ inch near his ear not covered with cap. Dietary Aide ZB had facial hair not covered with no facial hair restraint while doing dishes. Interview on 05/07/24 at 10:50 AM with Dietary Aide ZB stated he knew he should have been wearing a hair restraint while doing dishes to cover his facial hair along…

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 maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of sixteen residents (Resident #536, Resident #38, and Resident #32) observed for infection control. 1. The facility failed to ensure that CNA K and CNA G performed hand hygiene while providing incontinence care to Resident #536 on 05/07/24 2. CNA G failed to prevent cross contamination with the residents foley catheter bag. 3. The facility failed to ensure that CNA H changed her gloves and performed hand hygiene while providing incontinence care to Resident #38 on 05/08/24. 4. The facility failed to ensure that CNA U changed her gloves and performed hand hygiene while providing incontinence care to Resident #32 on 05/07/24. These failures could place the residents at risk of cross-contamination and development 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.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one laundry room reviewed for environment. 1. The facility failed to properly dispose and maintain the lint accumulation in the facility dryers in a timely manner. 2. The facility failed to properly maintain sanitary handwashing area in the laundry room hand washing station and for the laundry employee restroom. This failure could put residents at risk for an unsafe and unsanitary environment. Findings included: Observation on 05/09/2024 at 9:00 AM of facility's laundry room revealed there were three (3) dryers that were in use at that time. Observation of the lint collector area beneath two (2) dryers revealed a layer of thick lint about 2 inches thick accumulated on the top of lint trap and on the bottom of the lint trap. Observation of third dryer revealed a thick accumulation of lint about 2 inches thick on the top side of the lint filter and a clump of lint about 6 inches wide and 12 inches long on the floor of the lint…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 (Resident #486) of 6 residents reviewed for resident rights. The facility failed to ensure Resident #486's call light was placed within their reach. This failure could place residents at risk of injuries and unmet needs. Findings include: 1. Record review of Resident #486 Comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old male admitted [DATE]. Resident #486 had diagnoses which included traumatic brain injury (brain dysfunction due to injury to head), Methicillin Susceptible Staphylococcus Aureus infection (antibiotic resistant bacterial infection), and anemia (low iron) with a blank BIMS score. Record review of Resident #486's care plan reflected resident was at risk of falls, with 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 observations, interviews, and record review, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #486) of 6 residents reviewed for quality of care. The facility failed to ensure Resident #486 wore a helmet, as ordered by physician, to prevent possible injury when ambulating. This failure could result in residents to experience accident, injuries, and diminished quality of life. Findings included 1. Record review of Resident #486 Comprehensive MDS dated [DATE] reflected a [AGE] year-old male admitted [DATE]. Resident #486 had diagnoses which included traumatic brain injury (brain dysfunction due to injury to head), Methicillin Susceptible Staphylococcus Aureus infection (antibiotic resistant bacterial infection), and anemia (low iron) and BIMS score was blank. Record review of Resident #486's care plan reflected resident was at risk of falls, with the goal to be free of falls dated 05/02/2024 with a target date 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 observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of two residents (Resident #38) reviewed for catheter care. The facility failed to ensure CNA H provided catheter care and appropriate perineal care for Resident #38 when she failed to clean the resident's penis, scrotum, and buttocks on 05/08/24. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings included: Record review of resident #38s quarterly MDS assessment, dated 02/12/24, reflected an [AGE] year-old male with an admission date of 04/20/23. He had a BIMS score of 4 which indicated he was severely cognitively impaired. He was dependent of care for all ADL. He had a foley catheter and colostomy (an opening into the colon from outside of the body). Active diagnoses included dementia, chronic respiratory failure,…

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

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food that was palatable, attractive, and at a safe and appetizing temperature for one of one meal reviewed. 1.The facility failed to ensure hot food was maintained at 135 degrees while on the steam table. 2. The facility failed to maintain a food temperature log to ensure hot foods were maintained at 135 degrees since July 13, 2023 The deficient practice could affect the residents who received their meals from the kitchen by contributing to poor intake of nutrition, weight loss, and illness. Findings included: Observation on 08/11/23 at 12:41 pm revealed the facility was serving broccoli, fried breaded shrimp, and mac and cheese. DA D was taking the food from the steam table and placing it onto residents' plates that were taken out of the kitchen. An interview with DA A on 08/11/23 at 12:45 pm revealed he had not cooked any of the food. DA A stated he was asked to serve the food by [NAME] U. DA A revealed he had not completed any temperature checks 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 observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #38, Resident #55, Resident #67) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #38 had his fingernails trimmed and cleaned. 2- Resident #55 had his fingernails trimmed and cleaned. 3- Resident #67 had her fingernails cleaned This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Review of Resident #38's Comprehensive MDS assessment dated [DATE] reflected Resident #38 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), contracture muscle of the left hand, muscle weakness, and elevated…

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

Based on observations, interviews, and record reviews, the facility failed to provide food that was palatable, attractive, and at an appetizing temperature, and prepared by methods which conserved the nutritive value, flavor, and appearance for one of one meals (03/22/23 lunch) reviewed for dietary services. The facility failed to ensure residents on regular diet received beans that were not burnt and overcooked for lunch on 03/22/23. This deficient practice placed residents at risk for poor food intake and nutrition. Findings included: Interview on 03/21/22 at 10:45 AM with Resident #41 revealed the food at times was overcooked and was burnt often. Interview on 03/21/23 at 11:13 AM with Resident #29 revealed the food was of poor quality, terrible taste and food was overcooked especially the vegetables. Observation on 03/22/23 at 12:56 PM of Lunch test tray of regular diet revealed charro beans tasted burnt and bitter taste. Observation and Interview on 03/22/23 at 1:03 PM with Dietary Manager revealed she tasted the charro beans and told surveyor they tasted burnt. She stated if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 1 (Resident #23) of 4 residents reviewed for privacy and confidentiality. The facility failed to ensure LVN D logged out of his computer and protected Resident#23's Medication Administration Record. This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others. Findings included: Record review of Resident #23's Comprehensive MDS assessment, dated 01/20/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (problem in the brain. It is caused by a chemical imbalance in the blood), quadriplegia (paralysis of all four limbs), and tracheostomy (an incision in the windpipe made to support breathing). During an observation on 03/22/2023 at 12:30 PM, LVN D stepped…

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 assure that medications were secure and inaccessible to unauthorized staff and residents for 1 (nurses medication cart) of 3 medication carts reviewed for medication storage. The facility failed to ensure: The medication supplies were secured or attended by authorized staff when the nurses' cart in hall 400 was left unlocked and unattended in the hallway 400. This failure could place residents at risk to access and ingest of medications leading to a risk for harm and could lead to missing medication. The findings include: During an observation on 03/22/2023 at 12:30 PM, LVN D stepped away from the medication cart, he entered Resident #23 room to administer medication through the G-tube (a surgically placed device used to give direct access to the stomach). LVN D left the nurses medication cart in hallway 500, by room [ROOM NUMBER], unlocked. The lock was in the out position and the drawers were able to be opened, leaving the medications…

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.