Siskin Subacute West

In the surveyor’s words

From the most serious findings on record at Siskin Subacute West, in the surveyor’s own words.

• Immediate jeopardy, widespreadF656Oct 29, 2023

  41291 41782 45837 Based on facility policy review, medical record review, observation, and interview, the facility failed to update residents' care plans after a fall with new and appropriate interventions for 3 residents (Residents #1, #86 and #93), and the facility's failure resulted in the potential for harm for Resident #1 by failing to develop and implement appropriate interventions after a fall with major injury on 8/5/2022, and resulted in actual harm when Resident #86 sustained a right hip fracture after a fall on 10/6/2023, Resident #93 sustained a close head injury after a fall on 10/18/2023, and Resident #93 fell again on 10/19/2023 and was sent to the Emergency Department (ED) for Altered Mental Status (AMS). […]

• Immediate jeopardy, widespreadF689Oct 29, 2023

  Based on facility policy review, medical record review, facility investigation review, hospital documentation review, interview, and observation, the facility failed to follow it's falls prevention policy for 3 residents (#86, #93, and #1); failed to develop and implement interventions to prevent falls for 3 residents (#86, #93, and #1,); failed to complete fall risk assessments for 3 residents (#86, #93, and #1); failed to provide adequate supervision to prevent falls for 1 resident (#93); and failed to complete a thorough investigation to determine a root cause analysis of falls for 3 residents (#86, #93, and #1) of 4 residents reviewed for accidents. […]

• Immediate jeopardy, widespreadF835Oct 29, 2023

  Based on facility policy review, medical record review, review of facility documentation, observation and interview, the Administration failed to provide effective leadership and oversight to ensure effective systems were in place to address falls which resulted in fall with injuries for Residents #1, #86, and #93. The Administration's failure to identify serious outcomes related to falls, address the concerns in QAPI, ensure direct care staff members had access to the care planned falls interventions , and ensure fall investigations were reviewed and complete resulted in an immediate jeopardy for Resident #1, #86, and #93 and had the potential or likelihood to affect all 40 residents of the facility. […]

• Immediate jeopardy, widespreadF837Oct 29, 2023

  Based on medical record review, review of facility documents, observation and interviews, The facility's governing body failed to provide effective leadership, oversight to the Administrator, establish, develop, revise and implement an effective fall program to include CNA (Certified Nursing Assistant) access to care plans to include fall interventions, and failed to oversee and maintain an effective QAPI (Quality Assessment Performance Improvement) program. The facility's failure placed Resident #1, #86, and #93 in immediate jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) and had the potential or likelihood to affect all 40 residents… […]

• Immediate jeopardy, widespreadF867Oct 29, 2023

  Based on facility policy review, facility documentation review, medical record review, observation and interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to reassess, monitor ongoing concerns, and perform a root cause analysis related with falls for Residents #1, #86, and #93. The facility failed develop an effective QAPI program that recognized concerns to ensure systems and processes were in place and consistently followed by staff to prevent falls for Residents #1, #86, and #93. The failure of the QAPI Committee to ensure a safe environment and develop corrective action plans for falls resulted in an immediate jeopardy for Resident #1, #86, and #93 and had the potential or likelihood to affect all 40 residents of the facility. […]