Siskin Subacute West

Inspectors wroteBased 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.

Inspectors wroteBased 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). [...]

Inspectors wroteResident #86 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Right Hip Fracture (10/7/2023), Dementia, Osteoarthritis, and Lumbar Compression Fractures. Review of Resident #86's baseline care plan dated 9/26/2023, showed the Safety section of the care plan was blank. Continued review showed Cognition .Orientation .to person .to place .Therapy Services .Physical (PT) .Occupational (OT) . Review of Resident #86's comprehensive care plan dated 9/26/2023, showed .ALTERATION IN SAFETY; RISK FOR INJURY (ACTUAL) .Related to: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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 in the facility. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.