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🔎 Siskin Subacute West

Inspection Results


Inspection Overview

Siskin Subacute West has been cited for a total of 18 deficiencies since we began saving each survey.

In Tennessee, the average facility has **18.90 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2023-10-29
Correction Date: 2023-11-28
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2023-10-29
Correction Date: 2023-11-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: K

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-10-29
Correction Date: 2023-11-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2023-10-29
Correction Date: 2023-11-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: K

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-10-29
Correction Date: 2023-11-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2023-10-29
Correction Date: 2023-11-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Survey Date: 2023-10-29
Correction Date: 2023-11-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Post nurse staffing information every day.

Survey Date: 2023-10-29
Correction Date: 2023-11-28
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: K

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Survey Date: 2023-10-29
Correction Date: 2023-11-28
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: K

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Survey Date: 2023-10-29
Correction Date: 2023-11-28
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2023-10-29
Correction Date: 2023-11-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: K

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2023-10-29
Correction Date: 2023-11-28
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2023-10-29
Correction Date: 2023-11-28
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2023-10-29
Correction Date: 2023-11-28
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Survey Date: 2023-10-29
Correction Date: 2023-11-28
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: C

The resident has the right to receive notices in a format and a language he or she understands.

Survey Date: 2020-02-20
Correction Date: 2020-03-31
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2020-02-20
Correction Date: 2020-03-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2019-01-16
Correction Date: 2019-02-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**