Williamsburg Post Acute & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide influenza and pneumococcal vaccines for 5 residents (Residents #124, #125, #274, #275, and #276), in a survey sample of 5 residents reviewed for immunizations. The findings included: 1. The facility staff failed to provide education of the risks/benefits about influenza immunization, and offer flu vaccines for Residents #125, #274, #275, and #276. On 10/18/2023, clinical record reviews were performed and revealed the following: Residents #125, #274, #275, and #276, had no immunization information under the immunization tab of their clinical record. The miscellaneous tab and progress notes were reviewed, and revealed no evidence of the residents' immunization status regarding the flu and had no evidence that education had been provided or the vaccine offered. On 10/19/2023 at 4:28 p.m., Surveyor C met with the Director of Nursing (DON), who was also the facility's Infection Preventionist.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer COVID-19 vaccines for 4 residents (Residents #125, #274, #275, and #276) in a survey sample of 5 residents reviewed for immunizations and 5 staff (Staff #1, #2, #3, #4 and #5). The findings included: 1. For Residents #125, #274, #275 and #276, the facility staff failed to provide COVID-19 immunization, to include education of risks/benefits about COVID-19 immunization. On 10/18/2023, a clinical record review was conducted of each of the residents' clinical charts. There was no information noted that indicated the residents' current COVID-19 immunization status, no evidence they had been educated on the risk/benefits of immunization, and no evidence they had been offered the COVID-19 immunization. On 10/19/2023 at 4:28 p.m., an interview was conducted with the Director of Nursing (DON) who accessed the clinical records for Residents #125, #274, #275, and #276 and verified…

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, resident interview, staff interviews, facility documentation review, and clinical record review, the facility staff failed to assess and determine if a resident was safe to self-administer medications, for one resident (Resident #14) in a survey sample of 39 residents. The findings included: For Resident #14, who had medications stored in their room, the facility staff failed to assess if Resident #14 was safe to self-administer medications. On 10/17/2023 at approximately 12:40 p.m., observations were conducted of Resident #14's room. Resident #14 was not present in the room. It was noted that Resident #14 had a basket on the bed that contained two blister packets of medications. There was also a 3-drawer plastic storage unit against the wall that had clear drawers and it was observed there was a bottle of Tylenol and 2 cans of jock itch spray present. On 10/17/2023 at 1:33 p.m., Resident #14 was visited in her room. When asked about medications, Resident #14 said, the facility staff give…

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, resident interview, facility staff interview, clinical record review, and facility documentation review, the facility staff failed to accommodate the needs of 2 residents (Residents #274 and #70) in a survey sample of 39 residents. The findings included: 1. For Resident #274, who was unable to get out of bed without assistance, the call bell was not in reach; therefore, leaving the resident with no way to call facility staff for assistance. On 10/17/2023 at 1:45 p.m., Resident #274 was visited in his room. The resident was noted to be alert, oriented x4 and a good historian upon interview. The resident was observed lying in bed, was noted to be a bilateral amputee of lower extremities. Resident #274 said, his call bell is the only way he can call for assistance and frequently it is out of reach or has fallen behind the bed. He said he frequently has to get his roommate to use his call bell to get assistance to the room. Resident #274 reports he does not get out of bed. On 10/17/2023 at 1:49 p.m., an interview was conducted with CNA B. CNA B was asked about the…

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

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to notify the physician and family of a resident's change in medications and change in condition for one resident (Resident #14) in a survey sample of 39 residents. The findings included: For Resident #14, who had a medication change which was not communicated to the family, there was a noted increase in sleeping and she was difficult to arouse following the start of an antipsychotic medication. The facility staff failed to notify the doctor and family member of the change until prompted by survey team. On 10/17/2023, Resident #14 was visited in her room by Surveyor C. Resident #14 was awake, able to engage in conversation with no difficulty, and appeared to have some memory loss. There was no obvious significant hearing deficit noted. On 10/18/2023, Surveyor C visited Resident #14's room on 3 occasions, once mid-morning, once early afternoon, and lastly around 3:30 p.m. Each time, Surveyor C knocked on the resident's room door, entered the room, and called the…

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

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide a proper Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to 2 residents (Residents #43 and #70) in a survey sample of 3 residents reviewed for such notices. The findings included: For Residents #43 and #70, the facility staff failed to utilize a CMS approved SNF ABN form, which provided the option for the resident to select/choose to continue services and pay for the care without Medicare being billed. On 10/17/2023, the facility Administrator was asked to provide a listing of residents who were discharged from Medicare Part A services, prior to exhausting their benefit days. From this listing, a sample of 3 residents was selected, which included Residents #43 and #70. The notices issued to these residents was requested and received. Review of the SNF ABN forms revealed the following: 1. For Resident #43, the facility staff provided a SNF ABN notice on 09/11/2023, which indicated therapy services were ending. The form provided Resident #43 with 2…

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, clinical record review, and facility documentation, the facility staff failed to ensure freedom from abuse and neglect for 1 resident (Resident #54) in a sample of 39 residents. The findings included: For Resident #54, the facility staff failed to ensure the resident was not verbally abused by a CNA who threatened to, and did in fact, neglect the resident's needs. Resident #54 is a [AGE] year-old resident with diagnoses of, but not limited to, bradycardia, chronic kidney disease Stage 3, chronic obstructive pulmonary disease, history of falls, hypertension, muscle weakness, unsteady on feet, muscle wasting and atrophy. On 10/17/2023, a review of the facility grievance log revealed that on 07/20/2023, Resident #54 was threatened by CNA who stated, If you ring that call bell, I am NOT going to answer it. This grievance was written in the grievance book by the Social Worker (Employee F). A review of the complaint/grievance report read as follows: Resident was wanting air conditioner turned up…

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 resident interview, facility staff interview, clinical record review, and facility documentation review, the facility staff failed to protect one resident (Resident #14) from misappropriation of property in a survey sample of 39 residents. The findings included: For Resident #14, the facility staff failed to protect the resident from a known perpetrator, who had been identified by the facility as a verbal abuser and who had previously financially exploited the resident. The facility staff continued to permit unsupervised and unrestricted access to Resident #14 and her personal possessions by the known perpetrator, which allowed the perpetrator to gain access to Resident #14's bank cards when she had no legal right to possess the items. On [DATE] in the afternoon, Resident #14 was visited in her room. During the interview/conversation, cognitive impairment and difficulty with memory recall was noted. The resident did acknowledge she had been to visit her daughter earlier in the day. Resident #14's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, facility staff interview, clinical record review, and facility documentation, the facility staff failed to implement the abuse, neglect, and exploitation policy for 2 residents (Residents #54 and #14) in a survey sample of 39 residents. The findings included: 1. For Resident #54, the facility staff failed to implement the abuse/neglect policy when Resident #54 reported to the Social Worker an allegation of abuse/neglect. Resident #54 is a [AGE] year-old resident with diagnoses of, but not limited to, bradycardia, chronic kidney disease Stage 3, chronic obstructive pulmonary disease, history of falls, hypertension, muscle weakness, unsteady on feet, muscle wasting and atrophy. On 10/17/2023, a review of the facility grievance log revealed that on 07/20/2023 Resident #54 was threatened by CNA who stated, If you ring that call bell, I am NOT going to answer it. This grievance was written in the grievance book by the Social Worker (Employee F). A review of the complaint/grievance report…

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, clinical record review, and facility documentation, the facility staff failed to report an allegation of abuse/neglect within 24 hours, if the events do not result in serious bodily injury, for 1 resident (Resident #54) in a survey sample of 39 residents. The findings included: For Resident #54, the facility staff failed to identify, investigate, and report allegations of abuse to the Administrator. Resident #54 is a [AGE] year-old resident with diagnoses of, but not limited to, bradycardia, chronic kidney disease Stage 3, chronic obstructive pulmonary disease, history of falls, hypertension, muscle weakness, unsteady on feet, and muscle wasting and atrophy. On 10/17/2023, a review of the facility grievance log revealed that on 07/20/2023 Resident #54 was threatened by CNA who stated, If you ring that call bell, I am NOT going to answer it. This grievance was written in the grievance book by the Social Worker (Employee F). A review of the complaint/grievance report read as follows: Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and facility documentation, the facility staff failed to investigate an allegation of abuse for 1 resident (Resident #54) in a survey sample of 39 residents. The findings included: For Resident #54, the facility staff failed to identify, report, and investigate an allegation of abuse made to the Social Worker on 07/20/2023. Resident #54 is a [AGE] year-old resident with diagnoses of, but not limited to, bradycardia, chronic kidney disease Stage 3, chronic obstructive pulmonary disease, history of falls, hypertension, muscle weakness, unsteady on feet, muscle wasting and atrophy. On 10/17/2023, a review of the facility grievance log revealed that on 07/20/2023, Resident #54 was threatened by CNA who stated, If you ring that call bell, I am NOT going to answer it. This grievance was written in the grievance book by the Social Worker (Employee F). A review of the complaint/grievance report read as follows: Resident was wanting air conditioner turned up and felt like he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to complete resident assessments/Minimum Data Set (MDS) in a timely manner for 6 Residents (Residents #1, #33, #36, #39, #68 and #274) in a survey sample of 39 residents. The findings included: 1. For Residents #1, #33, #36, #39, #68 and #274, the facility staff failed to ensure the timely completion of MDS assessments. On 10/19/2023 at 8:50 a.m. during the completion of the survey process, clinical record reviews were conducted of Residents #1, #33, #36, #39, #68 and #274's MDS assessments with particular attention to the date(s) the assessments were completed. The following was noted: a. Resident #1 had a quarterly MDS with an Assessment Reference Date (ARD) of 08/27/2023. The assessment was completed on 09/11/2023. b. Resident #33 had a quarterly MDS with an ARD date of 09/08/2023. The assessment was completed on 09/30/2023. c. Resident #36 had a quarterly MDS with an ARD of 09/01/2023. The…

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

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and implement a comprehensive care plan for three residents (Residents #125, #70, and #21) in a survey sample of 39 Residents. The findings included: 1. For Resident #125, facility staff failed to implement and/or monitor for changes in behavior related to the use of psychotropic medications and/or dementia. On 10/17/2023 at 12:30 p.m., Resident #125 was observed in bed lying flat on his back. The resident was picking at the bed linens and pulling on his hospital gown repeatedly. The surveyor asked him if he needed help, and he replied in a stream of disjointed words in a rambling response.The surveyor asked Resident #125 his name, and other questions, the resident did not look up or respond to the surveyor. He simply kept picking at the gown, pulling it up, and attempting to disrobe. Review of the physician's orders in the clinical record revealed Resident #125 was currently receiving the following 3 psychotropic medications: 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.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow standards of practice affecting one resident (Resident #14) in a survey sample of 39 residents. The findings included: For Resident #14, the facility staff failed to monitor for changes in condition, and for medication interactions, following the implementation of an antipsychotic medication. On 10/17/2023, Resident #14 was visited in her room by Surveyor C. Resident #14 was awake, able to engage in conversation with no difficulty, and appeared to have some memory loss. There was no obvious significant hearing deficit noted. During the interaction and observations of the room, it was noted by the Surveyor that Resident #14 had multiple over-the-counter medications in the room. They included 2 foil blister packets on the bed, a bottle of Tylenol, and 2 cans of jock itch spray. On 10/18/2023, Surveyor C visited Resident #14's room on 3 occasions, once mid-morning, once early afternoon, and again around 3:30 p.m. Each time, Surveyor C knocked on the…

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

Based on observation, resident interview, facility staff interview, clinical record review, and facility documentation review, the facility staff failed to provide assistance to one resident (Resident #274), who was dependent upon staff for activities of daily living, in a survey sample of 39 residents. The findings included: For Resident #274, the facility staff failed to provide baths to include hair care, which resulted in the resident's hair becoming matted and having to be cut. On 10/17/2023 at 1:58 p.m., Resident #274 was visited in his room. Observations revealed that Resident #274's hair appeared uncombed, and it being matted in the back of his hair was noted. Resident #274 was asked about baths and showers, and he stated he had not been out of bed since his admission, which was 09/27/2023. On 10/18/2023 at 11:14 a.m., Resident #274 was visited in his room again. It was noted that his hair still appeared uncombed, and the resident said he had asked to be shaved and said, They said if they can't get to it today, they will do it tomorrow. Later in the afternoon, Surveyor C…

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, clinical record review, and facility documentation, the facility staff failed to provide proper foot care to 1 resident (Resident #67) in a survey sample of 39 residents. The findings included: For Resident #67, the facility staff failed to have her seen by podiatry for cutting her toenails as she is diabetic and on an anti-coagulant medication for history of Transient Ischemic Attack (TIA). On 10/17/2023 at approximately 2:00 p.m., Resident #67 was observed in the hall sitting in her wheelchair wearing open toe sandals. Her toenails were clearly visible, and they were jagged and at least 1/4 inch long. Resident #67 has a Brief Interview of Mental Status (BIMS) score of 0/15 and could not follow the line of questions. On 10/18/2023 at approximately 11:00 a.m., an observation was made of Resident #67 sitting in her wheelchair in her room and she was not wearing shoes or socks. Her toenails were clearly visible and had not been trimmed. On 10/19/2023 at approximately 2:00 p.m., an interview was conducted with CNA C who was asked if residents get their…

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

Based on observation, staff interviews, and facility documentation review, the facility staff failed to ensure 1 of 2 nursing units was safe and free of accident hazards. The findings included: The facility staff failed to ensure that one resident unit was free of accident hazards/over-the-counter medications, which were accessible to residents who are confused and wander. On 10/17/2023 at approximately 12:30 p.m., Surveyor C made observations on one of the nursing units. It was noted in Resident #14's room, multiple items were observed that could pose as a safety hazard to confused residents. The items included over-the-counter medications, Mucinex, Nauzene, Tylenol, and jock itch spray. During the above observation, it was noted there were residents who wander ambulating independently within the hall. During residents' interviews, Resident #38 verbalized there is a resident who wanders into her room and takes her items. On 10/18/2023 during mid-morning, observations were made in Resident #14's room. During this observation, the Mucinex, Nauzene, Tylenol, and jock itch spray were…

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, clinical record review, and facility documentation, the facility staff failed to provide medications as ordered by the physician to 1 resident (Resident #53) in a survey sample of 39 residents. The findings included: For Resident #53, the facility staff failed to administer Gabapentin as ordered by the physician. On 10/29/2023 during clinical record review, it was found that the facility staff failed to acquire the medication, Gabapentin, for administration to Resident #53. Resident #54 had an order for Gabapentin as follows: Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth at bedtime related to OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY (G90.09) -Start Date 10/05/2023. The following excerpts are from the progress notes for Resident #53 regarding the Gabapentin: 10/13/2023 9:35 PM Gabapentin Oral Capsule 100 MG Give 1 capsule by mouth at bedtime related to OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY Medication on order from the pharmacy, signed prescription…

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 facility documentation, the facility staff failed to appropriately label medication with accepted professional principals in 1 of 2 medication refrigerators. The findings included: For the medication refrigerator located on the skilled unit, the staff failed to date when opened a multi-use vial of Tubersol solution used for Tuberculin testing. On 10/19/2023 at approximately 4:00 p.m., an inspection of the medication room and refrigerator was conducted. LPN F was asked what was missing on the multi-use vial of Tubersol found in the refrigerator. LPN F looked at the bottle and stated the date should have been placed on the label when the vial was opened. When asked why that should happen, LPN F stated, The vial is only good for 30 days. If you do not label it, you do not know when it was opened and therefore you will not know when the expiration date is. According to the manufacturer instructions on the product: Sanofi Pasteur - TUBERSOL® Package Insert. A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. On…

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

Based on observation, resident interview, facility staff interview, and facility documentation review, the facility staff failed to ensure a functioning call bell was present for one resident (Resident #59) in a survey sample of 39 residents. The findings included: For Resident #59, the facility staff failed to ensure a call bell was present and functioning in the bathroom. On 10/17/2023 at 1:49 p.m., an interview was conducted with CNA B. CNA B was asked about the call bells, to explain their purpose, where they are located, etc. CNA B stated, The call bell is how the residents let us know if they need something. On 10/18/2023 at 8:30 a.m., an interview was conducted with Resident #59. During this interview, Resident #59 said that her call bell in the bathroom does not work. She did acknowledge she has had falls previously in the bathroom. Surveyor C went to the bathroom and pulled the string/pull cord, which did not engage the call bell/light and auditory alarm for staff. Resident #59 reported the call bell had not worked for about a month, which was the length of time she had…

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.