Siskin Subacute West

Based on facility policy review, medical record review, observation, and interviews, the facility failed to ensure resident health information remained private and confidential for 1 resident (Resident #5) of 5 residents observed during medication administration, which had the potential to allow unauthorized individuals access to the residents' private health information.The findings include: Review of the facility's policy dated, 4/14/2004, titled, HIPAA [Health Insurance Portability and Accountability Act] Privacy Plan, revealed .The Health Insurance Portability and Accountability Act of 1996 (HIPAA) establishes regulations for the use and disclosure of Protected Health Information (PHI) .will inform and educate all employees with access to PHI .about its various privacy policies and procedures .will establish .appropriate safeguards to prevent PHI from intentionally or unintentionally being used or disclosed . Review of the medical record revealed Resident #5 was admitted to facility on 4/24/2026 with diagnoses including Encounter for Surgical Aftercare following Surgery 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility failed to complete side (bed) rail assessments for the risk of entrapment and failed to obtain consent for side rails for 3 residents (Residents #20, #138, and #235) of 3 residents reviewed for side rails. The findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses including Fracture of Right Fibula, Type 2 Diabetes Mellitus, Morbid Obesity, Congestive Heart Failure, Anxiety, and Tremor. Review of Resident #20's medical record showed no order, entrapment risk safety assessments, or consent for bed rails. Review of Resident #20's comprehensive care plan dated 8/17/2023, showed .ALTERATION IN SAFETY; RISK FOR INJURY .PATIENT WILL NOT EXPERIENCE ANY INJURY OR UNTOWARD EVENTS DURING HOSPITALIZATION .EDUCATE PATIENT AND/OR FAMILY IN METHODS FOR SAFELY USING ASSISITVE DEVICES (WHEELCHAIR, WALKER, NON-SLIP SHOES) AND THE MANAGEMENT OF A SAFE ENVIRONMENT (TRIPPING HAZARDS, SIDE RAILS, ADEQUATE LIGHTING) . Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documentation review, medical record review, observation, and interview, the facility failed to ensure routine and regular scheduled side rail assessments were completed to identify the risk of entrapment for 3 residents (Residents #20, #138, and #235) of 3 residents reviewed for side rails. The findings include: Review the facility's untitled maintenance log used for monthly bed inspections showed the following areas were assessed .Condition of Cords/Plug .Headboard .Foot Rails .Hand Rails .Bed Frame .Electrical Safety Check .Caster Locking Mechanism . Resident #20 was admitted to the facility on [DATE] with diagnoses including Fracture of Right Fibula, Type 2 Diabetes Mellitus, Morbid Obesity, Asthma, Congestive Heart Failure, Paroxysmal Atrial Fibrillation, Obstructive Sleep Apnea, Anxiety, and Restless Leg Syndrome. During an observation on 10/16/2023 at 11:53 AM, Resident #20 was lying on a bariatric bed with an air mattress. There were bilateral ½ upper side rails and ½ left lower side…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, record review, observation and interview, the facility failed to promote care that maintained a resident's dignity, respect, and quality of care when staff failed to provide a privacy bag for 1 resident (Resident #136) of 3 residents reviewed with indwelling urinary catheters. The findings include: Review of the facility's undated policy titled, Subacute Patient's Rights Statement, showed .Patients [residents] in the Subacute Rehabilitation Program have all rights .include at least the following .dignity in an environment that promotes a positive self image .To be free from humiliation . Resident #138 was admitted on [DATE] with a diagnosis of Strep Arthritis to Left Shoulder. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #138 had an indwelling urinary catheter. Review of a hospital Discharge summary dated [DATE] showed Resident #138 had an indwelling urinary catheter in place on 10/5/2023. Review of physician orders dated 10/15/2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation and interview, the facility failed to review the baseline care plan and provide a written summary to 1 resident (Resident #136) of 16 residents reviewed for base line care plans. The findings include: Review of the facility's policy titled, Care plan preparation, long-term care, dated 5/22/2023, showed A care plan is an individualized, written action plan for a resident's care .On completion .the facility must provide .a written summary of the baseline care plan . Review of the facility's undated policy titled, Subacute Patient's Rights Statement, showed .Patients [residents] in the Subacute Rehabilitation Program have all rights .include at least the following .To be involved in all aspects of care including development of care plan . Resident #136 was admitted to the facility on [DATE] with diagnoses including Scoliosis, Hypertension, History of Fracture of Right Femoral Neck and Degenerative Joint Disease. Review of a baseline care plan dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility job description, facility policy review, medical record review, and interview the facility failed to revise the comprehensive care plan after the comprehensive assessment for 3 residents (Residents #18, #20, and #235) of 8 residents reviewed for care plans. The findings include: Review of the facility's job description for the Minimum Data Set (MDS) Coordinator titled, SubAcute Patient Assessment Coordinator, revised on 10/2009, showed .The Patient Assessment Coordinator's .primary job responsibility is to ensure accurate and timely completion and submission of the Resident Assessment Instrument, including MDS .and Care Plans .Completes 5 day, 14 day and 30 day MDS accurately to ensure maximum reimbursement and meet nursing home guidelines .Completes the Care Plan process .Demonstrates an understanding of and adherence to hospital-wide and stated standards including .CMS [Centers for Medicare and Medicaid Services] . Review of the facility's policy titled, Nursing Plan of Care, reviewed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to obtain a Physician's Order for the continued use of an indwelling urinary catheter (a tube inserted in the bladder to drain urine), failed to obtain a Physician's Order for catheter care, and failed to document medical justification for the use of a urinary catheter for 1 resident (Resident #86) of XX residents reviewed for catheter use. The findings include: Review of the facility policy titled, Urinary Incontinence and Indwelling Urinary Catheter (Foley) Management, dated 12/11/18, revealed .A resident who is admitted to the facility without an indwelling urinary catheter [tube inserted in the bladder to drain urine into a bag outside of the body] shall not be catheterized unless there is a valid medical justification .the facility must ensure that residents receive treatment and care in accordance with professional standards of practice . Review of the facility policy titled, Indwelling urinary catheter…

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

Based on facility policy review, Daily Nursing Forms review, observation and interview, the facility failed to post accurate daily staffing for Certified Nursing Assistants (CNA), Licensed Practical Nurses (LPN) and Registered Nurses (RN) for 6 of 33 days reviewed. The findings include: Review of the facility's policy titled, Posting of nurse staffing-Skilled Nursing Services, dated 2003, showed .facility must post the following information on a daily basis .total number .of licensed and unlicensed nursing staff directly responsible for resident care per shift .posting must be updated if staffing changes . Observation on 10/21/2023 at 4:44 AM of the DAILY NURSING FORMS posted by the elevator at the entrance to the facility showed, .DATE:10/20/2023 .CENSUS: 36 . The staff posting showed there were 2 RNs, 2 LPNs, and 4 CNAs working the 7PM - 7AM shift. Based on facility policy review, Daily Nursing Forms review, observation and interview, the facility failed to post accurate daily staffing for Certified Nursing Assistants (CNA), Licensed Practical Nurses (LPN) and Registered Nurses…

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 medical record review, observation, and interview the facility failed to maintain a complete and accurate medical record for 2 residents (Residents #18 and #88) of 25 residents reviewed for medical records. The findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses including Pain due to Internal Orthopedic Prosthetic Devices, Atherosclerotic Heart Disease, Acute Kidney Failure, and Depression. Review of Resident #18's admission Orders dated [DATE], showed .Code Status .FULL . Review of Resident #18's Comprehensive Care Plan dated [DATE], showed .FULL CODE .RESUSCITATE (CPR) FULL CODE . Review of Resident #18's Tennessee Physician Orders for Scope of Treatment (POST) form dated [DATE], showed .CARDIOPULMONARY RESUSCITATION (CPR) .Resuscitate (CPR) .Full Treatment . The form was signed by the physician and a Registered Nurse (RN). The form was not signed by Resident #18. Review of Resident #18's admission Minimum Data Set (MDS) assessment dated [DATE] showed the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, and interview, the facility failed to maintain appropriate infection control practices for 1 resident (Resident #137) of 4 residents observed in Transmission Based Precautions (TBP) and failed to provide hand hygiene assistance for residents prior to the meal on 1 of 5 hallways observed for meal tray distribution. The findings include: Review of the facility's policy titled, Feeding, long-term care, dated 11/28/2022, showed .Before the meal tray arrives, give the resident soap, water, a washcloth, and a hand towel to clean the hands. If needed, assist the resident with handwashing . Review of the facility's policy titled, Transmission Based Precautions, reviewed on 7/13/2023, showed .Contact precautions reduce the risk of transmission .Contact precautions are used for known or suspected infections spread by direct patient contact or by contact with items in the patient's environment. These guidelines must be observed in addition to standard precautions when contact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview the facility failed to assess 2 residents (Residents #1 and #7) for medical contraindications prior to providing the Influenza vaccine of 5 residents reviewed for immunizations. The findings include: Review of the facility's undated policy titled, Immunization (vaccine) guidelines, showed .The influenza immunization will be offered to all residents annually from October 1 of the current year through March 31 of the following year unless immunization is medically contraindicated or the resident has already been immunized during this time period .Before offering the influenza immunization each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization .The residents medical record will include documentation of education provided to the resident/resident representative on the benefits and the potential side effects of influenza immunization and the resident either…

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.