Siena Skilled Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from sexual abuse, when Resident 2 grabbed Resident 1's breast and buttock without permission on two occasions. This failure had the potential to negatively impact Resident 1's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice to attain and maintain the highest practicable well-being for one of four sampled residents (Resident 1) when Resident 1's change in condition (CIC) was not documented in the clinical record, the physician was not notified of the CIC, and there was no monitoring done related to the CIC.These failures resulted in the delay in the management of Resident 1's change in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure compliance to the professional standards of practice, manufacturer's guidelines, and facility's policy and procedures (P&P) for one out of six sampled residents (Resident 40) and for a census of 90 residents when:1. Resident 40's delayed-release capsule medication (designed to release the active ingredient later than immediately after administration) was opened and its contents were mixed with other powdered medications. 2. Shared glucometers (a device which measures blood sugar using blood from a fingertip) were not sanitized properly after use. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of 18 sampled residents (Resident 20 and Resident 77) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 20 and Resident 77's pain medication orders were not consistently followed. This failure had the potential for Resident 20 and Resident 77 to develop medication dependence (the inability of the individual to function normally in the absence of the drug), overdose, not achieve pain relief, and not attain their highest practicable well-being.

Inspectors wroteBased on interview, and record review the facility failed to ensure safe and effective pharmaceutical services for a census of 90 residents when:1. Resident 6's controlled drug (drug with potential for abuse) uses and removal signed out from the Controlled Drug Record (CDR- a paper log of controlled drug removal for administration to resident) were not documented in their Medication Administration Record (MAR-a legal document that list administered drugs); and,2. Discontinued non-controlled medications (pharmaceutical preparations that can only be obtained through a medical practitioner's prescription and dispensed by a pharmacist but are not considered controlled substances under the Controlled Substance Act) and those which remained in the facility after discharge of the patient were destroyed in accordance with state regulations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in accordance with the facility's policies and procedures (P&P), and accepted professional principles for a census of 90 when:1. A total of three loose pills were found in medication cart A;2. Two opened Trelegy Ellipta inhalers (a prescription medication used to treat airflow obstruction in adults) had no opened date label; and,3. Seven expired lubricating jelly (used to reduce friction during medical procedures involving the insertion of instruments or devices into the body) were stored in station 1 crash cart (a mobile medical cart used to store and transport life-saving equipment and medications for rapid response to critical situations). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of 18 sampled residents (Resident 22) was assisted with nail care as part of his Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when Resident 22 had long and jagged fingernails with sharp edges. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately assess one of four sampled residents (Resident 1) when the most recent MDS (Minimum Data Set, an assessment tool) did not identify the resident had behavior issues during the seven days look-back period. This failure had the potential for ineffective care planning and risk for unmet care needs for Resident 1.

Inspectors wrote2. A review of Resident 23's clinical record indicated Resident 23 was admitted May of 2024 and had diagnoses that included chronic obstructive pulmonary disease (a group of diseases that causes airflow blockage and breathing-related problems), congestive heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body), and dementia (memory loss that interferes with daily functions). A review of Resident 23's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 8/9/24, indicated Resident 23 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 8 out of 15 which indicated Resident 23 had moderately impaired cognition. During a concurrent observation and interview on 9/9/24 at 10:07 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper delivery of respiratory care consistent with the facility's policy and procedures (P&P) and the professional standards of practice for one out of 21 sampled residents (Resident 23) when Resident 23 had no physician's order for the use of oxygen therapy and the oxygen therapy was not care planned. These failures had the potential to result in unsafe delivery of oxygen to Resident 23, and for Resident 23 to not receive appropriate respiratory care and not achieve his highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 21 sampled residents (Resident 25) did not received unnecessary antipsychotic medication (a medication used to treat symptoms of losing touch with reality such as disrupted thoughts and perceptions) when Resident 25 received an antipsychotic medication with no monitoring of disruptive behavior, no monitoring of antipsychotic medication side effects, and the antipsychotic medication care plan was not developed. This failure had the potential for Resident 25 to unsafely receive an antipsychotic medication, and experience overdose (an excessive and dangerous dose of a drug), and/or other side effects of antipsychotic medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an accessible call system for one of 21 sampled residents (Resident 25) when Resident 25's call light button was not within his reach. This failure has the potential to result in the residents' not attaining their needs and not maintaining their highest practicable physical, mental, emotional, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the Responsible Party (RP, a person responsible for a resident) for one of three sampled residents (Resident 1), when Resident 1 sustained skin tears (a wound that happens when the layers of skin peel back) to her right forearm and left lower leg. This failure to notify prevented the RP from being able to advocate for the resident's best interest. Resident 1 was admitted mid-2023 with diagnoses which included heart disease, difficulty breathing, and anemia (a condition where the blood does not have enough healthy red blood cells). Resident 1's Minimum Data Set (MDS, an assessment tool) indicated severe cognitive (thinking, knowing) impairment. Resident 1's children are listed as the RPs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive care plans (plans that summarize specific care needs and treatments) were developed for one of three sampled residents (Resident 1), when skin tears (a wound that happens when the layers of skin peel back) to both legs and right forearm were identified, and care plans were not created. This failure had the potential to result in inadequate care being provided for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored properly when two opened eye medications and an opened inhaler were not labeled with an open date, for a census of 66. These failures had the potential for residents to receive expired medications with decreased effectiveness.

Inspectors wroteBased on interview and record review, the facility failed to ensure a transfer notice was provided to Resident 39 and Resident 39's representative and a copy of the discharge notice was sent to the Office of the State Long Term Care Ombudsman as required, for a census of 66. This failure had the potential to result in residents not being protected from unnecessary transfers and not having access to an advocate who can inform them of their options and rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure quality of care was provided for two residents (Resident 40 and Resident 27) for a census of 66 when: 1. Resident 40's tube feeding order was not clarified with the physician, and, 2. Resident 27 did not recieve treatment and care for a wound on his right foot in accordance with the plan of care and professional standards. These failures had the potential for Resident 40 to not receive an adequate amount of nutrition as ordered and had the potential for the worsening of Resident 27's wound on his right foot.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to maintain Resident 59's medical records in accordance with professional standards when there was no documentation Resident 59 was discharged from the facility. The facility must maintain medical records on each resident that are complete and accurately documented. This failure could interfere with the ability of staff to respond to the changing status, needs, and the after care of the resident.