Siskin Subacute West

• Star rating

  The CMS overall star rating changed from 2 of 5 to 5 of 5.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 5 of 5.

CMS lists this as a standard inspection.

• Citation F0583. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep residents' personal and medical records private and confidential.

  CMS lists it as corrected on May 21, 2026.

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• Special Focus Facility

  CMS no longer lists this home as a Special Focus Facility candidate.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Special Focus Facility

  CMS now lists this home as a Special Focus Facility candidate.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

CMS lists this as a standard inspection.

• Citation E0037. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Establish staff and initial training requirements.

  CMS lists it as corrected on June 30, 2025.

• Citation K0321. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on May 16, 2025.

• Citation K0781. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have restrictions on the use of portable space heaters.

  CMS lists it as corrected on June 30, 2025.

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• Special Focus Facility

  CMS no longer lists this home as a Special Focus Facility candidate.

• Health citation

  CMS changed citation F0656 from severity L to K. It is from the health inspection on October 29, 2023. Severity K: immediate jeopardy, pattern.

• Health citation

  CMS changed citation F0689 from severity L to K. It is from the health inspection on October 29, 2023. Severity K: immediate jeopardy, pattern.

• Health citation

  CMS changed citation F0835 from severity L to K. It is from the health inspection on October 29, 2023. Severity K: immediate jeopardy, pattern.

• Health citation

  CMS changed citation F0837 from severity L to K. It is from the health inspection on October 29, 2023. Severity K: immediate jeopardy, pattern.

• Health citation

  CMS changed citation F0867 from severity L to K. It is from the health inspection on October 29, 2023. Severity K: immediate jeopardy, pattern.

• Fine

  CMS changed the fine from October 29, 2023 from $144,490 to $93,919.

• Star rating

  The CMS overall star rating changed from 5 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 5 of 5 to 1 of 5.

• Special Focus Facility

  CMS now lists this home as a Special Focus Facility candidate.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

CMS lists this as a standard inspection.

Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

14 of 303 Tennessee homes (5%) got a citation at the immediate jeopardy level in 2023.

• Citation F0656. Severity K: immediate jeopardy, pattern.

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

  CMS lists it as corrected on November 28, 2023.

• Citation F0689. Severity K: immediate jeopardy, pattern.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on November 28, 2023.

• Citation F0835. Severity K: immediate jeopardy, pattern.

  The rule CMS cited: Administer the facility in a manner that enables it to use its resources effectively and efficiently.

  CMS lists it as corrected on November 28, 2023.

• Citation F0837. Severity K: immediate jeopardy, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on November 28, 2023.

• Citation F0867. Severity K: immediate jeopardy, pattern.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on November 28, 2023.

• Citation F0700. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on November 28, 2023.

• Citation F0909. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on November 28, 2023.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on November 28, 2023.

• Citation F0655. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on November 28, 2023.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on November 28, 2023.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on November 28, 2023.

• Citation F0732. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Post nurse staffing information every day.

  CMS lists it as corrected on November 28, 2023.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on November 28, 2023.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on November 28, 2023.

• Citation F0883. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement policies and procedures for flu and pneumonia vaccinations.

  CMS lists it as corrected on November 28, 2023.

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CMS lists this as a standard inspection.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on November 14, 2023.

• Citation E0006. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Conduct risk assessment and an All-Hazards approach.

  CMS lists it as corrected on October 17, 2023.

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CMS fine of $93,919 on October 29, 2023.

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