Valley Grande Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain a written, signed and dated order from the attending physician for 1 of 3 residents (Resident #1) whose records were reviewed for physician services.The facility failed to obtain a physician's order for Resident #1 to be in the secured unit.This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records.The findings included:Record review of Resident #1's admission Record dated 03/20/26 revealed a [AGE] year-old-female, having had an original admission date of 12/06/22 and readmission date of 08/01/25 with diagnoses of liver cirrhosis (late stage of chronic liver disease), history of Transient Ischemic Attack (a temporary blockage of blood flow to the brain AKA a mini stroke), dementia, schizoaffective disorder (a serious mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations 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 observation, interviews and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices. The facility must maintain medical records on each resident that are complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for clinical records.The facility failed to document a change in condition or progress note to reflect the placement of the Wander Guard (A discreet wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area) on Resident #1. The facility failed to document a change in condition or progress note to reflect the placement of Resident #1 in the secured unit (a unit that is designed to provide specialized, dementia-specific skilled nursing care to adults with Alzheimer's disease or related disorders).These failures could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were free from misappropriation and exploitation of property for 1 of 6 residents reviewed for misappropriation of property. (Resident #2) The facility failed to protect Resident #2 from misappropriation/exploitation by allowing housekeeping to take money from Resident #2 for housekeeping's own well-being and personal expenses, exact date unknown. This failure could place residents who resided in this facility at risk of misappropriation of property. Findings included: Record review of a face sheet dated 1/30/26 reflected Resident #2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included vascular dementia (a decline in thinking, memory, and reasoning skills caused by reduced blood flow to the brain, which damages or kills brain cells), and muscle wasting and atrophy (when muscles waste away). Record review of the MDS assessment dated [DATE] reflected Resident #2 had a BIMS score of 4 which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from chemical restraints that were not required to treat the residents' medical symptoms for 1 (Resident #1) of 3 residents reviewed for unnecessary medications. The facility failed to have an adequate indication for the use of the medication Zyprexa (Olanzapine- atypical antipsychotic) for Resident #1. This failure could put residents at risks of receiving unnecessary psychotropic medications.Findings include: Record review of Resident #1's admission Record dated 01/29/26 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. The admission record revealed Resident #1 had diagnoses of Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple tasks), vascular dementia (a decline in thinking, memory, and reasoning skills caused by reduced blood flow to the brain, which damages or kills brain cells).…

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 drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (wound care cart) of 7 medication carts. The facility failed to ensure that the wound care cart was secured and lock when it was left unattended by LVN A. These failures could place residents at risk of injury to other residents if medication left unsecured were consumed. Findings included: During an observation on 01/29/2026 at 02:20 PM revealed the wound care medication cart was left unlocked outside room [ROOM NUMBER]. During the observation LVN A came out of the room and surveyor informed her wound care medication cart was unlocked and LVN A secured the cart by locking it. During an interview on 01/29/2026 at 02:25 PM with LVN A revealed she was responsible for the wound care medication cart that was left unlocked. She stated she was expected to lock the wound care medication cart when she walked away from it. She…

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 reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 3 (Resident #4, Resident #11, and Resident #13) of 10 residents reviewed for MDS assessment.Resident #4's quarterly MDS assessment dated [DATE] failed to indicate Resident #4 had falls on 07/28/25 that resulted in major injury, on 09/09/25 that resulted in minor injury, and on 10/02/25 that resulted with no injury.Resident #11's quarterly MDS assessment dated [DATE] failed to indicate Resident #11's behavior of physical aggression that occurred on 09/23/25.Resident #13's quarterly MDS assessment dated [DATE] failed to indicate Resident #13's behaviors of delusions and refusal of care that occurred on 09/16/25.Resident #13's quarterly MDS assessment dated [DATE] failed to indicate Resident #13 had a fall that resulted in minor injury that occurred on 10/13/25.This deficient practice could place residents at risk for inadequate care and services to meet their needs based…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 (Resident #4) of 5 residents reviewed for care plans.The facility failed to develop a comprehensive person-centered care plan for Resident #4 to address the use of a fall mat.This failure could place the residents at risk of not receiving appropriate interventions and care to meet their current needs.Record review of Resident #4's face sheet dated 10/21/25 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included: dementia (decline in cognitive abilities), generalized muscle weakness, other lack of coordination, mood disorder (impacts emotional state), type 2 diabetes (high levels of sugar in blood), and chronic kidney disease. Record review of Resident #4's fall risk…

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 interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 (Resident #4 and Resident #13) of 10 residents reviewed for accuracy of records.LVN E failed to document Resident #4's change of condition for a fall on 09/05/25.LVN F failed to document Resident #13's change of condition for aggressive behavior on 10/10/25.LVN D failed to document Resident #13's vital signs correctly on the change of condition form on 10/14/25 for a fall that occurred on 10/13/25.The DON failed to document Resident #13's vital signs correctly on the change of condition form on 10/21/25 for an incident of aggressive behavior that occurred on 10/10/25.These failures could place residents at risk for errors in care due to inaccurate or incomplete documentation and records. 1. Record review of Resident #4's face sheet dated 10/21/25 reflected a [AGE] year-old female admitted on [DATE] with diagnoses…

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 1 of 4 residents (Resident #1) reviewed for infection control practices, in that: CNA A used cleansing wipe multiple times when performing incontinent care for Resident #1.This failure place residents who use cleansing wipes during incontinent care at-risk for urinary tract infections due to cross contamination. The findings were: Record review of Resident #1's electronic face sheet dated 11/20/25 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnosis included type 2 diabetes mellitus (a chronic disease in which glucose levels in the blood were higher than normal because the body does not make enough insulin or use it the way it should), muscle weakness, muscle wasting and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that described the services to be provided to attain or maintain the residents' highest practicable physical, mental, and psychosocial needs, for 1 (Resident #88) of 4 residents reviewed for care plans in that: The facility failed to implement individualized interventions to address Resident #88's behaviors of aggression toward other residents from 01/24/25 through 06/28/25. This failure could place residents at risk of injuries and their medical, physical and psychosocial needs not being met. Record review of Resident #88 Face Sheet dated 07/24/25 revealed she was a [AGE] year-old female admitted to facility on 10/24/24 with diagnoses of Alzheimer's disease, anxiety disorder, unspecified psychosis and major depressive disorder, recurrent, severe with psychotic symptoms. Record review of Resident #88's quarterly MDS dated [DATE] revealed Resident #88 was usually understood 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 3 (Resident #6, Resident #96, and Resident #66) of 7 residents reviewed for infection control, in that:1) The facility failed to ensure that LVN D performed hand hygiene for at least 20 seconds prior to and after medication administration for resident #6. 2) The facility failed to ensure that CNA H and CNA I followed the Enhanced Barrier Precautions (EBP) when they did not wear a gown while providing perineal/foley care to Resident #96.3) The facility failed to ensure that LVN G and LVN J put on PPE when they entered Resident #66's room who was on isolation precautions. These failures could place residents at risk for healthcare associated cross-contamination and infections. Findings included: Record review of Resident #6's face…

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, 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 preference for 1 (Resident #6) of 9 residents reviewed for call lights. The facility failed to ensure Resident #6 had the call light within reach in the morning while in bed.This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency. Record review of Resident #6's face sheet dated 07/23/25 reflected a [AGE] year-old-female with an initial admission date of 12/06/22. Diagnoses included Encephalopathy (damage or disease that affect the brain), dysphasia (difficulty swallowing) following cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced), muscle wasting and atrophy (a decrease in muscle size and strength, often resulting from disuse, nerve damage, or certain diseases), history of falling, and lack…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #100) of 8 residents reviewed for Advance Directives. The facility failed to ensure Resident #100's OOH-DNR was completed. The OOH-DNR form did not have the physician's signature. This failure could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes. The findings were: Record review of Resident #100's electronic face sheet dated [DATE] reflected the resident was a [AGE] year-old male originally admitted to the facility on [DATE], and readmitted to the facility on [DATE]. His diagnoses included: Respiratory Failure, Metabolic Encephalopathy (any disease or disorder of the brain, characterized by changes in brain function or structure), Type 2 Diabetes Mellitus, Hypertension (high blood pressure), Acute Kidney Failure. Resident #100's electronic face sheet reflected…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency for 1 of 2 Residents (Resident #1) who were reviewed for misappropriation of property in that: The facility failed to report when Resident #1 gave CNA T money to buy gift cards. This failure could place residents at risk for potential abuse/misappropriation of property/exploitation due to not having allegations reported as required. Findings were: Record review of Resident #1's admission Record dated 07/24/25 reflected a [AGE] year-old female admitted on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move for 1 of 4 (Resident #105) reviewed for notifying the LTC Ombudsman of the residents' discharge, in that: Resident #105 was discharged to family member who was traveling to [NAME] and was planning to admit to another LTC facility on 05/15/2025 without a notice to the LTC state ombudsman. This failure could place residents at risk of not knowing their rights and receiving the services of the state LTC Ombudsman. Record review of Resident #105's electronic face sheet dated 07/24/2025 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and a discharge date of 05/15/2025. His diagnoses included Osteoarthritis (a condition that causes joint pain and stiffness due to the breakdown of cartilage), Major Depressive…

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 given medications by enteral means received appropriate treatment and services to prevent complications for 1 of 2 residents (Resident #90) reviewed for gastrostomy tubes in that: LVN C did not check for residual of Resident #90's gastrostomy tube (G-Tube) prior to administering medications. This failure could place residents with G-tube at risk of medical complications, or a decline in health due to inappropriate G-tube management and not following appropriate procedures. Record review of Resident #90's face sheet dated 07/23/25 revealed the resident had an original admission date to the facility on [DATE], with diagnoses that included Metabolic encephalopathy (brain dysfunction caused by an underlying condition that affects your metabolism), anemia (when your blood doesn't carry enough oxygen to the rest of your body), dysphagia (difficulty swallowing), severe protein-calorie malnutrition (serious health…

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 needs respiratory care was provided such care, consistent with professional standards of practice for 2 of 4 residents (Resident#100 and Resident#52) reviewed for oxygen in that: 1. Resident #100 received oxygen at 2.5 LPM via nasal cannula without a physician's order. 2. The facility failed to ensure that Resident #52 received oxygen as prescribed. These deficient practices could affect the residents who received oxygen continuously and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health. The findings were: 1. Review of Resident #100's face sheet, dated 8/15/18, revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, pneumonia, and hypoxia. Review of Resident #100's electronic chart and paper chart revealed there was no physician order for oxygen. Observation 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 observation, interviews, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 2 of 7 residents (Resident #48 and Resident #93) reviewed for resident records. 1. The facility failed to ensure a physician order was written for isolation precautions for Resident #48 on 07/15/2025. 2. The facility failed to ensure a physician order was written for dietary diet for Resident #93 on 07/19/2025. 1. Record review of Resident #48's electronic face sheet dated 07/22/2025 reflected the resident was a 77 -year-old female admitted to the facility on [DATE] with an original admission date of 11/27/2020. Resident #48 had diagnoses which included the following: COVID-19, Unspecified Dementia, Muscle Weakness, Type 2 Diabetes Mellitus (high blood sugar levels), Immunodeficiency due Conditions Classified Elsewhere (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 interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 5 residents (Resident#1) reviewed for abuse and neglect, in that: The facility failed to implement their Abuse Neglect Exploitation (ANE) policy when the facility failed to ensure Resident #1, who required 2 or more staff per her care plan was provided with the appropriate number of staff while in the shower chair. As a result, the resident had a fall when she was left unattended and sustained a broken toe. This failure could place residents at risk of abuse and neglect. The findings included: Record review of Resident #1's admission record revealed she was an [AGE] year-old female with an admission date of 01/13/21. Diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 5 residents (Resident #1) reviewed for abuse/neglect. The facility failed to report Resident #1's fall with injury on 02/05/25, where Resident #1 sustained a fractured right great toe. State Survey Agency was not notified of the fall with injury within 2 hours. The incident occurred on 02/05/25 at 10:42 am and was not reported. The facility failed to report Resident #1's FM's allegation of resident neglect related to the Resident #1's fall with injury on 02/05/25, where Resident #1 sustained a fractured right great toe. FM alleged resident neglect. The incident occurred on 02/05/25 at 10:43 am and was not reported. These failures could place all residents at increased risk for potential abuse due to not having…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #1), reviewed for pharmaceutical services, in that: LVN C failed to verify Resident #1's morphine was accounted for when completing a narcotic count on 12/06/24. Resident #1's Morphine Sulfate Oral Solution 20mg/5ml was missing and not found. This failure could place residents at risk for not receiving medication as ordered. The findings included: Record review of Resident #1's face sheet, dated 05/22/25, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: Poly osteoarthritis (when 5 or more joints have arthritis),unspecified, adult osteomalacia (softening of bones), unspecified, osteophyte (bony lumps that grow on the bones in the spine or around joints),…

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 prepare, store, distribute, and serve foods in accordance with professional standards for food service safety in the facility's only kitchen. Dietary Aide A failed to effectively restrain her hair while getting snacks in the kitchen. This failure placed the 92 residents, who received their meals from the facility's only kitchen, at risk for food contamination and food borne illness. Findings included: Observation on 5/20/25 at 4:10 p.m. revealed Dietary Aide A was getting snacks from the kitchen and was not wearing a hairnet. During an interview on 5/20/25 at 4:20 p.m. Dietary Aide A stated that she was late, and she entered the kitchen through the back door and forgot to use a hair net. Dietary Aide A stated that she knew she had to use a hair net when entering the kitchen. Dietary Aide A stated that by not using the hair net the food could get infected or a hair could fall into the food. During an interview on 5/20/25 at 4:30 p.m. the DM stated that all staff knew that a hair net was required when entering…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal pharyngeal ulcers for 1 of 1 resident (Resident #2) reviewed for gastrostomy feedings in that: The facility did not transcribe and initiate Resident #2's enteral feeding order of 65ml for 22 hours, leading to 6 pound weight loss between 10/11/24 and 12/09/24. This failure placed resident at risk for not receiving their required daily nutritional intake placing the resident at risk for weight loss. The findings included: Record review of Resident #2's face sheet dated 02/18/25 revealed a [AGE] year-old- female who was initially admitted to the facility on [DATE]. Resident diagnoses included the following: cerebral infarction (decreased blood flow to the brain), dysphagia (difficulty in swallowing)…

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 interviews and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 4 residents (Resident #1 and Resident #3) reviewed for comprehensive care plans. 1. The facility did not include Resident #1's rash on her care plan. 2. The facility did not include Resident #3's rash on her care plan. This failure could place residents at risk for not receiving appropriate treatment and services. The findings included: 1. Record review of Resident #1's face sheet, dated 02/21/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (memory loss, cognitive decline, language problems, behavioral changes and difficulty with daily tasks), unspecified, Anxiety disorder, unspecified (intense,…

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 maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for medical records accuracy, in that: The facility failed to ensure Resident #1's skin observation tool documentation accurately reflected Resident #1's rash. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. The findings included: Record review of Resident #1's face sheet, dated 02/21/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (memory loss, cognitive decline, language problems, behavioral changes and difficulty with daily tasks), unspecified, Anxiety disorder, unspecified (intense, excessive, and persistent worry and fear about everyday situations), dysphagia…

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 to ensure all residents had the right to formulate an advance directive for three (Residents #30, #3, and #57) of 24 reviewed for advanced directives, in that: 1. The facility failed to ensure Resident #30's OOH-DNR was completed correctly. The OOH-DNR form did not have the physician's signature in the appropriate place. 2. The facility failed to ensure Resident #3''s OOH-DNR was completed correctly. The OOH-DNR form did not hat the physician's signature in the appropriate place. 3. The facility failed to ensure Resident #57's OOH-DNR was completed correctly. The OOH-DNR form did not have the signature for witness 2 in section E. These failures could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes. The findings were: 1.Record review of Resident #30's admission Record dated [DATE] revealed Resident #30 was an [AGE] year-old male admitted 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 interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 25 residents who receive insulin services. The facility failed to keep an updated calibration log documenting the control solution testing results for the facility's blood glucose meters. This failure could result in not determining if the glucometers were functioning properly and/or obtaining false glucometer readings. The findings included: Record review of the facility's Resident Matrix dated 5/13/24 revealed the facility had 25 residents who were insulin dependent. Record review of the facility's Blood Glucose Monitoring System User's Guide for Control Solution Testing revealed that the intended use for the control solution is as a quality control check to verify the accuracy of blood glucose test results. Use Control Solution: Before testing with the system for the first time. When you open a new bottle of test strips.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to establish procedures to ensure that water was available to essential areas when there is loss of normal water supply. The facility failed to ensure the emergency water supply was readily available and stored in a safe and sanitary manner. The facility's emergency water supply was stored two blocks from the facility in a warehouse. This failure could place residents at risk of serious risk for complications from water that might be contaminated due to poor sanitary conditions. In an interview on 05/14/24 at 3:00 PM, The DM said the emergency water supply was across the street in the laundry department. The kitchen has a 7-day supply of food and once hurricane season starts she would order extra supplies of foam plates, cups, utensils and would order extra food supplies. On 05/16/24 at 9:21 AM, Surveyor conducted an observation of the laundry department located 0.2 miles from the facility. The water supply was in a warehouse type building. The laundry 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 interview and record review, the facility failed to notify the resident's representative of a transfer or discharge and the reasons for the move in writing and in a language and manner they understand and failed to send a copy of the notice to the Office of the State Long-Term Care Ombudsman, for 1 Resident (Resident #97) of 24 residents reviewed for hospitalizations. The facility failed to send a written notice of a transfer to Resident #97's RP and to the Office of the State Long-Term Care Ombudsman as soon as practicable after Resident #97 was transferred to the hospital. These failures could place residents at risk of not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Record review of Resident #97's physician's orders revealed R#97 was admitted to the facility on [DATE] and readmitted on [DATE]. R#97's diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions),…

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 provide to the resident and the RP a written a notice of bed-hold policy before, or at the time of transfer for 1 Resident (Resident #97) of four residents reviewed for transfers. The facility did not provide written information on the facility's bed-hold policies to Resident #97 or to his RP when resident was sent to the hospital. This failure could place residents at risk for not receiving a notice of the facility's bed hold policy before/upon transfer and not having the necessary information to decide on whether to incur bed hold payments and have the opportunity for the resident to return to the facility. The findings were: Record review of Resident #97's physician's orders revealed R#97 was admitted to the facility on [DATE] and readmitted on [DATE]. R#97's diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), encephalopathy (a group of conditions that cause brain dysfunction),…

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 reviews the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs and describes the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #40), reviewed for care plans. The facility failed to ensure Resident #40's comprehensive care plan dated 04/17/2024 reflected she had an order for O2 at 2 Lpm via N/C continuously. These deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and no having personalized plans developed to address their specific needs. The Findings included: 1. Record review of Resident #40's face sheet dated 05/15/2024 revealed the resident was an [AGE] year-old female with an admission date of 01/06/2024. Resident #40's relevant diagnoses included:…

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 needs respiratory care was provided such care consistent with professional standards of practice for 2 of 6 residents (Resident #40, and Resident #3) reviewed for oxygen in that: 1. Resident #40's oxygen was administered at 2.5 Lpm instead of 2.0 Lpm via nasal cannula as ordered by physician. 2. Resident #3's oxygen was administered at 4 Lpm instead of 2 Lpm via nasal cannula as ordered by the physician. This failure could place residents who received oxygen at risk of developing respiratory complications and a decreased qualify of care. The findings included: 1. Record review of Resident #40's face sheet dated 05/15/2024 revealed the resident was an [AGE] year-old female with an admission date of 01/06/2024. Resident #40's relevant diagnoses included: chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), transient ischemic attack (a short period 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, interviews, and record review, the facility failed to establish and 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 2 of 2 Residents (Resident #17, and Resident #11) that were reviewed for infection control and transmission-based precautions policies and practices, in that: The facility failed to ensure CNA K performed proper pericare (incontinent care) for Resident #17 and #11. The facility failed to ensure CNA K performed hand hygiene during incontinent care on Resident #17. The facility failed to ensure CNA L performed hand hygiene during incontinent care on Resident #11. These deficient practices could place residents in the facility at risk for infections due to improper incontinent care and lead to the spread of infection to residents, resident illness, and/or resident distress. Findings included: 1.Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5 residents (Resident #4) reviewed for resident rights, in that: The facility failed to ensure consent forms were properly completed or signed by a responsible party prior to administration of an antipsychotic medication (Nuplazid) for Resident #4. This failure could place residents who received psychoactive medications without informed consents and placed additional 27 residents who received psychoactive medications at risk of receiving treatments without informed consent. Findings include: Record review of Resident #4's admission Record dated 04/25/24, revealed a [AGE] year old female, admitted to facility on 01/11/24. Her diagnoses included: Dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life) with other behavioral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for one resident (Resident #3) of five residents reviewed for abuse, neglect, and exploitation. The facility failed to conduct an investigation of Resident # 3's transfer by a mechanical life when the straps tore, and Resident #3 was placed at potential of injury. This deficient practice could place residents at risk for abuse, neglect, and not having their needs met. The findings included: Record review of Resident #3's admission Record dated 04/25 /2024 revealed she was a [AGE] year-old female originally admitted to the facility 03/19/20 with a most recent admission date of 02/16/24. Resident #3's diagnosis included benign neoplasm of the brain ( non-cancerous tumor ), diabetes, hyperaldosteronism (endocrine disorder that causes high blood pressure), morbid obesity (body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 6 residents (Resident #4) reviewed for abuse/neglect. The facility failed to report Resident #4 had an unwitnessed fall on 09/03/23. Resident #4 sustained a laceration to right eyebrow and acute fifth metacarpal neck fracture (little finger fracture). The facility failed to report Resident #4 was observed on 09/28/23 with redness to right forehead and right eyelid with no mention of how the redness occurred. The facility failed to report Intake #477220 to State Survey Agency within 24 hours for Resident #4's injury of unknown origin. Incident occured on 01/10/2024 at 7:30 p.m. Facility emailed report on 01/16/2024. This failure could place all residents at increased risk for potential abuse to unreported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews and interviews, the facility failed to thoroughly investigate allegations of abuse and neglect for 1 of 5 residents (Resident #3) reviewed. The facility did not have evidence a thorough investigation was completed for Resident #3 who had an incident during a transfer with the use of a mechanical lift. This failure could place residents at risk of incidents not being thoroughly investigated. The findings included: Record review of Resident #3's admission Record dated 04/25 /2024 revealed she was a [AGE] year-old female originally admitted to the facility 03/19/20 with a most recent admission date of 02/16/24. Resident #3's diagnosis included benign neoplasm of the brain ( non-cancerous tumor ), diabetes, hyperaldosteronism (endocrine disorder that causes high blood pressure), morbid obesity (body mass index of 40 or higher ), major depressive disorder, anxiety disorder, drug induced polyneuropathy (damage or disease affecting peripheral nerves), and lymphedema (condition 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 ensure drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 2 of 4 residents (Resident #1 and Resident #2) being reviewed for pharmacy services. The Facility did not ensure that Resident #1 and Resident #2's narcotics were reconciled as being given from the resident's eMAR to the resident's narcotic reconciliation form on the medication cart. This failure could place residents at risk of not receiving their narcotic medications and drug diversion. The findings included: Record review of Resident #1's face sheet dated 12/13/2023 reflected she was a [AGE] year-old female who was admitted on [DATE]. Relevant diagnosis were right ankle contracture, muscle wasting and atrophy, muscle weakness, lack of coordination, speech and language deficits, vascular dementia (brain damaged caused by multiple strokes), tube feeding, and Alzheimer's disease. Record review of Resident #1'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 interview, and record review, the facility failed to ensure medical records were accurately documented, for one Resident (Resident #1) of 3 residents reviewed for accuracy of medical records. The facility failed to document Resident #1's discoloration to her outer lower left leg in the Progress Notes. This failure could place all residents with discoloration of not receiving adequate care and services. The findings were: Record review of Resident #1's face sheet dated 12/13/2023 reflected she was a [AGE] year-old female who was admitted on [DATE]. Relevant diagnosis were right ankle contracture, muscle wasting and atrophy, muscle weakness, lack of coordination, speech and language deficits, vascular dementia, and Alzheimer's disease. Record review of Resident #1's quarterly MDS dated [DATE] reflected her: Hearing was moderate difficulty Speech clarity was unclear Sometimes understood/understand Vision was moderately impaired BIMS score of 00 (severely impaired) Functional limitation in range of motion:…

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 FACILITY Medication Storage and Labeling Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used within the facility were labeled and stored in accordance with currently accepted professional standards, which included the appropriate cautionary instructions with the expiration date, for 4 of 6 medication storage locations (nurse medication cart D wing, nurse medication cart A wing, nurse medication cart C wing, and back station medication storage room). 1. The facility failed to prevent nurse medication cart D wing from containing 3 (three) expired dicyclomine (used to treat certain types of intestinal problems such as irritable bowel syndrome) capsules 10 milligrams (mg) in an opened bag with an expiration date of 09/2022. 2. The facility failed to prevent nurse medication cart A wing from containing 1(one) bottle of opened clonidine (used to treat high blood pressure) 0.1 milligram (mg) tablets with expiration date 06/30/22. 3. The facility failed 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.