AdviniaCare Summit Commons, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and staff and resident interview, the facility failed to provide a qualified dietitian for 4 of 4 residents reviewed who did not receive dietary consultations to evaluate individual nutritional needs, Resident ID #s 1, 2, 3, and 4.Findings are as follows:Record review of a community reported complaint submitted to the Rhode Island Department of Health on 9/30/2025, alleged concerns with the quality of care provided.A. Record review revealed Resident ID #1 was admitted to the facility in July of 2025 with a diagnosis of progressive Multiple Sclerosis (MS, a disease of the central nervous system).Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.Record review of a care plan initiated on 7/21/2025 revealed that the resident has a potential for impaired nutritional status due to a diagnosis of MS. Record review revealed a physician's order…

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

Based on clinical record review and residents and staff interview, the facility failed to ensure ongoing monitoring of residents' weights to accurately assess weight status and identify potential health concerns related to weight changes for 1 of 1 resident reviewed who experienced a significant weight gain, Resident ID #1.Findings are as follows:Record review of a facility policy titled Weights, dated August 2015, states in part, .residents/patients are weighted weekly X4: Newly admitted .Thereafter, residents will be weighed monthly, unless clinically indicated.weights are documented in the resident's/patient's medical record .Record review revealed Resident ID #1 was admitted to the facility in July of 2025, with a diagnosis of progressive Multiple Sclerosis (MS, a disease of the central nervous system).Record review of a care plan dated 7/21/2025 revealed, the resident has a potential for impaired nutrition status due to the diagnosis of MS.Record review of the resident's electronic medical record revealed the following weights had been obtained:- 7/14/2025 -192.4 pounds (lbs.)-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to ensure a resident had the right to refuse medications and treatments for 1 of 1 resident reviewed who refused medications, Resident ID #2.Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on 12/6/2025, alleged that Resident ID #2 had reported that a staff member held him/her down by the shoulders and grabbed his/her mouth to give him/her medications.Record review of a facility policy titled Informed Consent - Resident Refusal of Treatment dated April of 2015, states in part, .It is the residents right to refuse recommendations for medications and treatments including dietary made by the physician, consultants or interdisciplinary team.Record review revealed Resident ID #2 was admitted to the facility in October of 2025 with diagnoses including, but not limited to, myxedema coma (a serious complication of severe caused by an underactive thyroid) and dysphasia…

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 surveyor observation, and resident and staff interviews, it has been determined that the facility failed to maintain a safe temperature range of 71 to 81 degrees Fahrenheit (°F) in the facility as the 5th floor of the facility reached a temperature of 88 °F and the 3rd floor reached a temperature of 85 °F. Findings are as follows: Record review of a facility policy titled, HOT WEATHER EMERGENCY FAILURE OF AIR CONDITIONER states in part, .If the ambient air temperatures in resident areas are 82 degrees or higher, all personnel within the facility will be assigned duties aimed at reducing the exposure and/or effects of excessive heat and humidity. Room changes will be made necessary to decrease danger to fragile residents . Record review of two community reported complaints received by the Rhode Island Department of Health on 6/24/2025 alleged that the facility has no air conditioning. Record review revealed that the weather in Providence, Rhode Island on 6/25/2025 was 93°F. During surveyor observations…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that a person-centered comprehensive care plan was developed for 1 of 1 resident reviewed for nutrition where significant weight loss had occurred, Resident ID #3. Findings are as follows: Record review revealed that the resident was originally admitted to the facility in April of 2025, with diagnoses including, but not limited to, end stage renal disease and dysphagia (difficulty swallowing). Record review of a physician's order dated 4/10/2025 revealed a diet order for a mechanical soft, ground texture with nectar thick liquids. Record review of a Care Area Assessment (CAA), dated 4/16/2025 revealed that the resident required a therapeutic and mechanically altered diet. The CAA further revealed that the above was triggered on the Minimum Data Set Assessment and will proceed to the care plan. Record review of the resident's comprehensive care plan failed to reveal evidence of a focused CAA for nutrition, including a person specific approach with descriptive individual 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 record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for 1 of 1 resident reviewed, who experienced actual weight loss, Resident ID #3. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 6/19/2025 alleges that the resident is a dialysis patient and when s/he arrived for treatment s/he had an uncovered bleeding wound to his/her elbow and that s/he had severe malnutrition per the dialysis's Registered Dietician (RD). The RD at the dialysis center noted severe wasting of the thigh and calf muscles, which worsened since the last treatment. Additionally, the report alleges that the resident stated, .[s/he] was not being cared for .[s/he] is not being given protein supplements that the RD had requested . During a surveyor interview on 6/24/2025 at 10:51 AM with the complainant and the dialysis center's RD they revealed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to ensure that adequate pain management was provided to a resident who required such services, consistent with professional standards of practice, and the resident's goals and preferences for 1 of 1 resident reviewed for pain, Resident ID #4. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 6/18/2025 alleged in part that Resident ID #4 was discharged from a hospital and admitted to the facility on [DATE]. S/he returned to the hospital on 6/18/2025 because s/he did not receive his/her medications as prescribed. S/he alleges that s/he waited approximately 5.5 hours and then was informed s/he was already given them and then later told that the facility did not order them from the pharmacy. Record review revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, left knee osteomyelitis (an infection in 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 record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly) receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident reviewed for communication with the dialysis center, Resident ID #3. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 6/19/2025 alleges that the resident is a dialysis patient and when s/he arrived for treatment s/he had an uncovered bleeding wound to his/her elbow and that s/he had severe malnutrition per the Registered Dietitian (RD). The RD a the dialysis facility noted severe wasting of the quadriceps and calf muscles, which worsened since last treatment. Additionally, the report alleges that the resident stated, .[s/he] was not being cared for .[s/he] is not being…

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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen and 3 of 3 kitchenettes observed. Findings are as follows: 1. Record review of Rhode Island Food Code, 2018 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 . During the initial tour of the main kitchen's walk in coolers in the presence of a Cook, Staff K on 3/10/2025 at 8:15 AM, revealed the following: - eight turkey and cheese sandwiches on white bread without a label or date - three sheet pans approximately 15 inches () x 21 full of cooked…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly) receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents reviewed for fluid management, Resident ID #s 42 and 51, and for 2 of 3 residents reviewed for communication with the dialysis center, for Resident ID #s 42 and 79. Findings are as follows: 1. Review of a facility policy titled Hemodialysis, states in part, .Fluid Balance .If resident/patient is placed on fluid restriction, monitor intake . 1a. Record review revealed that Resident ID #42 was admitted to the facility in January of 2025, with a diagnosis including, but not limited to, end stage renal disease (ESRD). Record review for Resident ID #42 revealed that s/he receives dialysis three times a week. Record review revealed a physician's order…

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

Based on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every nurse aide (NA), at least once every 12 months, for 6 of 6 NA personnel records reviewed, Staff E, F, G, H, I and J. Findings are as follows: Record review of the personnel records failed to reveal evidence that an annual performance evaluation was completed for the following NA's: -Staff E, hired in March of 2015 -Staff F, hired in November of 2011 -Staff G, hired in August of 2022 -Staff H, hired in February of 2020 -Staff I, hired in August of 2023 -Staff J, hired in October of 2023 During a surveyor interview with the Director of Nursing Services on 3/13/2025 at 12:41 PM, she was unable to provide evidence that performance evaluations were completed to their entirety for Staff E, F, G, H, I and J within the last 12 months.

Based on record review and surveyor interview, it has been determined that the facility failed to ensure the QAPI/QAA (quality assurance performance improvement/quality assessment and assurance) committee includes the required committee members consisting at a minimum of, the Director of Nursing Services (DNS), the Medical Director, Infection Preventionist and at least three other members of the facility staff. Findings are as follows: Review of a policy titled Policy & Procedure Manual Quality Assessment and Assurance Committee states in part, .The Committee will be composed of staff who understand the characteristics and complexities of the care and services delivered in each unit and/or department. The QAA committee will be composed of, at a minimum .The Director of Nursing or Assistant Director of Nursing .The Infection Preventionist .The infection preventionist must be a member of the QAA committee and report to the committee on the infection prevention and control program . Record review revealed the QAPI/QAA committee met on the following dates in 2024/2025: - 4/11/2024 -…

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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide residents with the right to personal privacy and confidentiality of his/her personal and medical records relative to the posting of past survey results. Findings are as follows: During a surveyor observation of the main lobby area on 3/12/2025 at 2:16 PM, revealed a Survey History Binder. Record review of the Survey History Binder revealed copies of previous surveys including the resident/staff rosters which contain identifying information of residents from the following survey dates: - Resident/Staff Roster form dated 4/12/2022 with one resident identified. - Resident/Staff Roster form dated 6/14/2022 with one resident identified. - Resident/Staff Roster form dated 7/18/2022 with four residents identified. - Resident/Staff Roster form dated 7/27/2022 with one resident identified. - Resident/Staff Roster form dated 8/11/2022 with three residents identified. - Resident/Staff Roster form dated 8/30/2022 with two residents identified. - Resident/Staff Roster…

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 surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure residents who are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed for a continuous feeding via a gastrostomy tube (G-tube, a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine), Resident ID #102. Findings are as follows: Review of a facility policy titled Enteral Feeding [feeding provided via an alternative method via a G-tube] states in part, .Check physician order for formula, rate and water flushes . Record review revealed that Resident ID #102 was readmitted to the facility in January of 2025, with a diagnosis including, but not limited to, gastrostomy status. Record review revealed a progress note authored by the dietitian, dated 3/10/2025 at 3:38 PM, which revealed that the resident's weight has trended down since last review. It further revealed that the resident is currently on Jevity 1.2 cal (calorically dense,…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician for 1 of 1 resident reviewed for significant weight loss, Resident ID #28. Findings are as follows: Record review of a facility's policy titled, WEIGHTS states in part, .Weight [sic] are documented in the resident's/patient's medical record and/or the weight book. If a significant weight loss/gain is identified (>[greater than] 5% in 30 days or >10% in 6 months), the IDT [interdisciplinary Team], dietician, physician and family are notified. All residents with a significant weight loss are reviewed by the interdisciplinary team and the resident/responsible party and interventions implemented as appropriate and are monitored weekly . Record review revealed that Resident ID #28 was readmitted to the facility in September of 2024, with diagnoses including, but not limited to, dementia and dysphagia (difficulty swallowing). Review of a care plan last revised on 1/30/2025 revealed, the resident is at risk for malnutrition due…

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 surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that medical records are accurately documented for 2 of 3 residents reviewed for enhanced barrier precautions (EBP - refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities), Resident ID #s 13 and 217. Findings are as follows: 1. Record review revealed Resident ID #13 was admitted to the facility in January of 2025 with a diagnosis including, but not limited to, congestive heart failure. Record review revealed a physician's order dated 2/3/2025 for EBP, related to his/her wounds. Review of the February 2025 Medication Administration Record (MAR) revealed the EBP order was signed off as completed from 2/3 - 2/28/2025. Review of the March 2025 MAR revealed the EBP order was signed off as completed from 3/1 - 3/12/2025. Record review revealed the resident had a wound which was resolved on 2/13/2025. Surveyor observations 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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to enhanced barrier precautions (EBP- refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact resident care activities), for 1 of 3 residents reviewed with a history of Methicillin-Resistant Staphylococcus Aureus (MRSA), Resident ID #217. Findings are as follows: Review of a facility policy titled, Enhanced Barrier Precautions Policy states in part, .It is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms .important MDROs may include, but are not limited to: Methicillin-resistant Staphylococcus aureus (MRSA) .Enhanced barrier precautions require the use of a gown and gloves for certain residents during specific…

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

Based on record review and staff interviews it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed for Levothyroxine (a medication used to treat hypothyroidism, an underactive thyroid), Resident ID #3. Findings are as follows: Record review revealed the resident was readmitted to the facility in January of 2025 with a diagnosis including, but not limited to, cerebral infraction (stroke). Record review revealed a physician's order with a start date on 1/24/2025 for Levothyroxine Sodium oral tablet, 100 micrograms (MCG) one time a day, for thyroid disease. Record review revealed a progress note dated 1/24/2025, which revealed that the resident's laboratory work up was reviewed by the Nurse Practitioner (NP) and a new order was obtained to decrease the Levothyroxine to 87.5 and recheck his/her labs in 6 weeks. Record review revealed the following physician's orders with a start date of 1/25/2025: - Levothyroxine Sodium Oral Tablet 100 MCG one time a day for thyroid disease. - Levothyroxine…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from significant medication errors for 1 of 3 residents reviewed for medication administration, Resident ID #1. Findings are as follows: Record review revealed Resident ID #1 was admitted to the facility in December of 2024 with diagnoses including, but not limited to, nontraumatic subarachnoid hemorrhage (bleeding in the brain) and essential hypertension (high blood pressure). Record review revealed a physician's order for Nimodipine (a medication prescribed to treat high blood pressure) 30 MG (milligrams), give 2 tablets orally every 4 hours. Record review of the resident's Medication Administration Record for January 2025 revealed that s/he had not received his/her Nimodipine every 4 hours as ordered by the physician on the following dates: - 1/2/2025 s/he missed 6 doses, indicating that s/he did not receive any Nimodipine - 1/3/2025 s/he missed 5 doses - 1/4/2025 s/he missed 2 doses - 1/7/2025 s/he missed 1 dose - 1/10/2025 s/he missed 2 doses -…

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

Based on record review and staff interview, it has been determined that the facility failed to document all required components of the facility-wide assessment. Findings are as follows: Review of a facility provided document titled, Facility Assessment, reviewed and approved on 8/7/2024, failed to reveal that the facility developed and maintained a plan to maximize recruitment and retention of direct care staff as required. During a surveyor interview on 1/3/2025 at approximately 4:00 PM with the Administrator, he acknowledged that the facility assessment failed to develop and maintain a plan to maximize recruitment and retention of direct care staff.

Based on record review, and staff interview, it has been determined that the facility failed to maintain medical records that are complete in accordance with professional standards and practices for 1 of 2 residents reviewed for blood sugar parameters for insulin administration, Resident ID #1. Findings are as follows: Record review revealed that Resident ID #1 was admitted to the facility with a diagnosis including, but not limited to, diabetes. Further record review revealed the resident requires the administration of insulin to manage this diagnosis. Record review revealed the resident has a physician order dated 12/31/2024 for NovoLog (a fast-acting insulin with an onset of effect within approximately 15 minutes, peak effect in approximately 30-90 minutes and duration of approximately 3-7 hours) Injection Solution 100 unit/milliliter (ML), inject as per blood sugar sliding scale and to contact provider if blood sugar is more than 351 milligrams per deciliter (mg/dL). Review of the resident's January 2025 Treatment Administration Record (TAR) revealed the resident's blood sugar…

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

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician's orders relative to using an insulin pen injector to administer insulin, Resident ID #6. Findings are as follows: Record review of the facility's clinical competency titled, Use of Insulin Pen, undated, revealed the nurse should remove the cap from the insulin pen, wipe the top of the pen with an alcohol wipe where the insulin pen needle is to be attached. Additionally, the nurse should then remove the paper pull tab from the Insulin pen needle (BD AutoShield Duo Applicator) and screw it on to the insulin pen until tight. Record review revealed that Resident ID #6 was admitted to the facility with a diagnosis including, but not limited to, diabetes. Further record review revealed the resident requires the administration of insulin to manage this diagnosis. Additionally, record review revealed the resident has a physician's order…

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 surveyor observation, record review and staff interview it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to wound care for 1 of 2 residents reviewed for burns, Resident ID #2. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 9/20/2024 alleges that Resident ID #1 had reported that the facility was not adhering to the medical treatment plan related to his/her bilateral lower extremity wounds. Review of a policy titled Skin Care Non-Pressure Wound Assessment which states in part, .Residents with non-pressure injuries .are assessed, documented and provided appropriate treatment to promote healing .ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. Post op surgical site incisions are evaluated and documented on a least weekly .until it is resolved .documentation of non-pressure ulcers include Location, measurement .type of wound .partial thickness [damage of…

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

Based on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents reviewed for pressure ulcers, Resident ID #2. Findings are as follows: According to the State Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities, revised 8/8/2024 which states in part, A pressure ulcer/injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must .Identify whether the resident is at risk for developing or has a PU/PI upon admission and thereafter .Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors .If a PU/PI is present, provide treatment and services to heal it and to prevent .It is important that each existing PU/PI be identified, whether present on admission or developed…

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

Based on record review and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint received at the Rhode Island Department of Health on 5/15/2024 alleges that Resident ID #1 received Suboxone (a medication that is used to treat pain) in error. Record review of the facility policy titled, MEDICATION ADMINISTRATION BY ROUTE OR DOSAGE, revealed in part, .Sublingual Medications .Procedure Verify medication order on MAR [Medication Administration Record]. Check against physician order. Ask resident his/her name. Record review revealed that Resident ID #1 was admitted to the facility in May of 2024 with diagnoses including, but not limited to, multiple myeloma (a cancer that forms in a type of white blood cell), atrial fibrillation (irregular heartbeat) and chronic obstructive pulmonary disease. Record review of a telehealth evaluation authored by Advanced Practice Nurse, Staff C, dated 5/14/2024 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and staff interview, it has been determined that the facility failed to serve and store food under sanitary conditions relative to food storage in 2 of 3 nursing unit refrigerators, the serving temperature of potentially hazardous cold food in 2 of 3 dining locations. The facility also failed to ensure staff were wearing hair restraints and beard covering in the main kitchen. Findings are as follows: 1. The State of Rhode Island Food Code 2018 Edition 3-501.6 states in part, .Except during preparation cooking or cooling .temperature control for safety shall be maintained at 5 degrees C (Celsius) 41 degrees (Fahrenheit) or less . During a surveyor observation on 4/2/2024 of the 4th floor dining room at approximately 12:05 PM for the lunch meal, the serving temperature of the tuna salad sandwich had a cold holding temperature of 51.2 degrees F. An additional surveyor observation of the 5th floor dining room at approximately 12:15 PM for the lunch meal, the serving temperature of the…

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

Based on record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent the development of infections for 3 of 4 residents reviewed relative to the use of positive airway pressure devices; Continuous positive airway pressure (CPAP) and Bilevel positive airway pressure (BIPAP). These devices provide breathing support which is administered through a face mask or nasal mask, Resident ID #s 5, 21 and 38. Findings are as follows: Review of a facility policy titled CPAP/BIPAP Management dated April 2015, states in part, .Cleaning of equipment: CPAP or BIPAP system/ machine cleaning - wipe machine off twice monthly with damp cloth, replace disposable filters per manufacturer guidelines, clean non-disposable filters weekly and replace when needed, use warm soapy water and let air dry before inserting back into machine. Headgear- wash as needed .masks and nasal pillows- wash daily with mild detergent or white vinegar solution, rinse with warm water and…

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

Based on record review and staff interview, it has been determined that the facility failed to obtain laboratory services to meet the needs of its residents for 1 of 1 resident reviewed for a valproic acid level (a laboratory test that is monitored when a patient is receiving Depakote) Resident ID #83. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2023 with diagnoses including, but not limited to, bipolar disorder and violent behaviors. Record review revealed that the resident is prescribed Depakote (a drug used for those with bipolar disease or a seizure order. A person receiving this medication must have labs drawn to ensure appropriate therapeutic levels. Record review revealed a new order dated 3/5/2024 to check the resident's valproic acid level in 2 weeks, indicating that the lab should be drawn on 3/18/2024. Record review failed to reveal evidence that the lab was obtained as ordered. During a surveyor interview with Licensed Practical Nurse, Staff A, on 4/3/2024 at 10:38 AM, she acknowledged that the lab had not been…

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 surveyor observation, record review, and staff interview it has been determined the facility failed to maintain all patient care equipment in safe operating condition for 1 of 1 wheelchairs reviewed, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/21/2023 alleges in part, A technician from [his/her] [outpatient center] confirmed [s/he] arrived to [his/her] appointment in a broken wheelchair . Record review revealed the resident was admitted to the facility in December of 2023 with diagnoses including, but not limited to, end stage renal disease (a condition where the kidney reaches advanced stage of loss of function) and polyneuropathy (damage to multiple peripheral nerves). Record review of a document from an outpatient service provider titled, Continuity of Care Consultation and Referral Form dated 12/20/2023 states in part, please do not use this wheelchair for any patient any longer because .it lacks brake which can cause a lot of injury to the patient . During a surveyor…

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 surveyor observation, record review and staff interview, it has been determined the facility failed to provide care in accordance to a resident's plan of care for 1 of 4 residents relative to falls, Resident ID #34, and 3 of 7 residents reviewed relative to Abnormal Involuntary Movement Scale (AIMS, a tool used to assess the presence and the severity of abnormal movement of the face, limbs and body), Resident ID #s 34, 35, and 36. Findings are as follows: 1A. Record review for Resident ID #34 revealed s/he was admitted to the facility in September of 2017 with a diagnosis including, but not limited to, dementia with psychotic disturbance. Record review revealed the resident has a care plan dated 5/10/2019 and revised on 12/19/2022 which states in part, .at risk for falls secondary to Previous History of falls and weakness 12/18/22 s/p [status post] fall . This care plan has interventions including, but not limited to, .low bed .Non skid safety strips [to the floor] on door side of bed .Safety strips added to floor in front of toilet . During surveyor observations 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 surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 2 of 3 residents review related to wanderguard use, Resident ID #s 32 and 37. Findings are as follows: Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients. Review of the facility policy titled, WANDERING MANAGEMENT SYSTEM dated April 2015, states in part, .Procedure .Check every shift for placement and document .Check function of on a daily basis . Record review revealed Resident ID #37 was re-admitted to the facility in October of 2022 with diagnosis including, but not limited to, dementia, and delirium. Record review revealed a physician's order with a start date of 5/11/2022 which states in part, wander guard right ankle at all times…

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

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status for 3 of 11 residents reviewed, Resident ID #s 37, 45, and 73. Findings are as follows: Record review of a facility policy titled Weights dated August 2015, states in part, The following residents/patients are weighed weekly X[times]4: .Newly admitted residents/patients .Residents/patients with an unanticipated, unplanned weight loss of >[less than]5% in one month .Residents with an MD [physicians] order for weekly weights .The same scale should be used for each weighing of a particular resident/patient to ensure consistency and more accurate weights .All weight loss/gain of 3 pounds or more on a resident weighing 100 pounds or less and weight loss/gain of 5 pounds or more on a resident weighing 100 pounds or more requires a reweigh for verification. A reweigh is done on the same scale, with a licensed nurse present .If a significant weight loss/gain is identified (>5% in 30 days or >10% in 6 months), 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 surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to staff wearing appropriate personal protective equipment (PPE) for 4 of 4 residents reviewed for transmission-based precautions Resident ID #s 1, 39, 51, 61 and 1 of 3 wound dressings preformed, Resident ID #11. Findings are as follows: Review of the facility policy titled, Precautions to Prevent Transmission of Infectious Agents dated 7/17 states in part, Transmission-Based Precautions are for patients who are known or suspected to be infected or colonized with infectious agents .Transmission-Based Precautions are used empirically, according to the clinical syndrome and the likely etiologic agents at the time, and then modified when the pathogen is identified or transmissible infectious etiology is ruled out .Droplet precautions are intended to prevent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from abuse for 1 of 5 resident's reviewed, Resident ID #8. Findings are as follows: Review of the facility policy, titled Abuse Prohibition Policy, states in part, .Procedure .Identifying events, occurrences, patterns and trends of potential abuse for residents .Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment . Record review reveals that Resident ID #28 (perpertrator) and Resident ID #8 (victim) are roommates. Review of the record for Resident ID #28 revealed that s/he was admitted to the facility in March of 2017 with diagnoses including, but not limited to, Alzheimer's disease, vascular dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) Assessment, dated 11/11/2022, revealed a Brief Interview for Mental Status (BIMS) score of 9 of 15, which indicates moderately impaired cognition. Review…

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

Based on surveyor observation, record review and staff interview, it has been determined the facility failed to provide care to a resident who is unable to carry out activities of daily living (ADLs) and receives the necessary services to maintain personal hygiene for 1 of 6 residents reviewed, Resident ID #62. Findings are as follows: Record review for the resident revealed s/he was admitted to the facility in May of 2022 with diagnoses including, but not limited to, cognitive communication deficit and cerebrovascular accident (CVA/stroke). Record review revealed the resident has a care plan dated 5/9/2022, revised on 11/17/2022 for .has ADL deficit r/t [related to] Hemiparesis [weakness of one entire side of body] following CVA and muscle weakness . This care plan has interventions including but not limited to, .2 assist with adl's . During surveyor observations on the following dates and times, the resident was observed with all of his/her fingernails extending approximately 0.5 centimeters past the fingertips and with black matter under the middle and pointer fingernails 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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from developing for 1 of 6 residents reviewed who is at risk for developing pressure ulcers or who have actual pressure ulcers, Resident ID #37. Findings are as follows: 1. Review of a facility policy titled, Pressure Injury/Non-Pressure Wound Risk Management dated 7/2017 states in part, .Maintain activity and mobility as follows for immobile patients: .When in bed, turn and reposition approximately Q2 [every two] hours or more frequently based upon resident's condition and specific needs . Record review revealed Resident ID #37 was admitted to the facility in November of 2020 with diagnoses including, but not limited to, fracture of the right femur and adult failure to thrive. Review of a Norton Plus assessment dated [DATE] revealed a score of 8…

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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to assess the resident for risk of entrapment from bed rails for 1 of 1 residents reviewed for use of bed rails, Resident ID #17. Findings are as follows: Record review revealed a policy titled, Bed Rails last revised August 2018, that states in part, .Evaluation is completed to identify potential benefits from utilizing side rails and minimize risks . Record review revealed Resident ID #17 was admitted to the facility in December of 2015 with diagnoses including, but not limited to, Alzheimer's disease and lack of coordination. Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident requires extensive assistance of two or more staff with bed mobility and is totally dependent on two or more staff to transfer out of bed. Review of the care plan revealed an intervention with a revision date of 7/21/2022 that states in part, 2 quarter side rails for mobility…

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

Based on record review and staff interview, it has been determined the facility failed to ensure that the monthly pharmacy recommendations were acted upon for 1 of 9 residents reviewed, Resident ID #68. Findings are as follows: Record review for the resident revealed s/he was admitted to the facility in October of 2022 with diagnoses including, but not limited to, depression and mood disorder. Record review revealed the resident has a physician order dated 10/18/2022 for Senna -Docusate Sodium [treat constipation] Tablet 8.6-50 MG [milligrams] .Give 1 tablet by mouth twice daily . Record review of the Medication Regimen Review documentation dated 11/3/2022 revealed a Consultant Pharmacist Recommendation which indicates, .Currently receiving Senna 1 tablet twice daily for constipation. Consider switching to Senna 2 tablets at bedtime for equal efficacy at greater ease of administration . Further review of the above document revealed that on 11/30/2022, the resident's physician documented that s/he was in agreement with the recommendation. Further record review failed to reveal…

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 surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 1 of 3 medication carts observed. Findings are as follows: Review of a policy titled, Medication Storage Room/Medication Cart Policy dated February 2018, states in part, .Medication carts will be cleaned at least weekly and daily as needed. All spills will be cleaned immediately . During a surveyor observation on 12/21/2022 at 9:31 AM of the 4th floor med tech medication cart in the presence of Certified Medication Technician, Staff I, revealed the third drawer with brown liquid spilled in the bottom and medication bottles sticking to the substance. During a surveyor interview directly following the observation with Staff I she acknowledged the drawer was dirty and that she was unsure when the drawer had been last cleaned. During a surveyor interview on 12/21/2022 at 12:05 PM with the Director of Nursing Services she revealed that she would expect the staff to clean the medication…

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 surveyor observation and staff interview, it has been determined that the facility failed to provide food and drinks that are palatable, attractive, and at a safe and appetizing temperature relative to 1 of 18 resident reviewed, Resident ID #17. Findings are as follows: Record review revealed that Resident ID #17 was admitted to the facility in December of 2015. Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident required extensive assistance of staff to eat. Surveyor observation of the lunch meal on 12/20/2022 at 12:30 PM revealed Resident ID #17 had his/her meal tray but staff were not assisting him/her with eating the meal. Further observation revealed the resident started to receive assistance with his/her meal at 1:18 PM, 48 minutes after the tray was delivered. Surveyor observation of the breakfast meal on 12/22/2022 at 8:38 AM revealed a breakfast meal was delivered to his/her room. At this time a test tray was requested by the surveyor. 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 surveyor observation and staff interview, it has been determined that the facility failed to assure that residents receive and consume food in the appropriate form for 1 resident observed, Resident ID #17. Findings are as follows: Review of the record for the resident revealed that s/he was admitted to the facility in December of 2015 with a diagnosis including but not limited to dysphagia (difficulty or discomfort in swallowing). Further review of the record revealed a dietary order dated 12/12/2020 for .Puree Consistency-Dysphagia Level 1 texture . Review of the care plan, revised on 12/13/2022, revealed in part, .Provide puree diet . Surveyor observation on 12/22/2022 at 8:38 AM revealed a breakfast meal was delivered to the resident's room and at 9:11 AM Certified Nursing Assistant (CNA) Staff H was preparing to assist the resident with eating. Surveyor observations of the breakfast meal revealed the meal was mechanical soft consistency, not pureed consistency. During an interview with Staff H immediately following this observation it was indicated that she was unaware…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it has been determined that the facility failed to maintain medical records for each resident that are complete and accurately documented, in accordance with accepted professional standards and practice for 2 of 4 residents reviewed for skin evaluations, Resident ID #s 1 and 4. Findings are as follows: 1. Record review revealed Resident ID #1 was admitted to the facility in December of 2015 with diagnoses including, but not limited to, Alzheimer's Disease and weakness. Record review of the physician's orders revealed a current treatment order dated 1/6/2023 which states in part, Cleanse coccyx (tailbone) wound with wound cleanser, pat dry, apply skin prep to peri (around) wound apply Medihoney (wound treatment) to wound bed . Record review of the Pressure Injury [localized injury to the skin and underlying tissue usually over a boney prominence as a result of pressure] Evaluation documents revealed the following documentation relative to the resident's pressure injury…

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.