Sienna Extended Care & Rehab

Inspectors wroteBased on observation, record review, and interview, the facility failed to post the most recent state survey results of the facility in a place readily accessible to residents, family members, and legal representatives of the residents. The administrator identified 68 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the total amount of resident funds in the facility trust account did not exceed the amount covered under the facility surety bond. The DON identified 11 residents in the facility trust account resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had the right to voice grievances to the facility without fear of discrimination or reprisal and failed to promptly resolve grievances the residents had in the resident council group. The administrator identified 68 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident assessments were coded for 2 (#1 and #48) of 19 sampled residents reviewed for accuracy of resident assessments. The administrator identified 68 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to: a. follow EBP during the provision of care for 1 (#14) of 3 sampled residents reviewed for activities of daily living; and b. transport dirty linen appropriately and sanitize their hands between meal set up for different residents on hall 200. The administrator identified 68 residents resided in the facility. The DON identified 18 residents were on EBP.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from misappropriation for 1 (#177) of 3 sampled residents reviewed for abuse. The administrator identified 68 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure: a. an abuse allegation was reported to APS for 2 (#8 and #21); and b. an initial abuse allegation was reported to the state agency within two hours for 1 (#21) of 3 sampled residents reviewed for abuse. The administrator identified 68 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to complete skin assessments as ordered for 3 (#1, 12, and #24) of 5 sampled residents reviewed for non-pressure skin conditions. The administrator identified 68 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to administer a resident's oxygen as ordered for 1 (#12) of 3 sampled residents reviewed for respiratory care. The DON identified seven residents received continuous oxygen in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents' medications were only accessible to qualified staff. The administrator identified 68 residents resided in the facility. The administrator identified the facility had three medication rooms.

Inspectors wroteBased on record review and interview, the facility failed to ensure the dietary manager completed certification as a certified dietary manager within three years of beginning employment per state requirement. The administrator identified 68 residents resided in the facility and 66 residents ate from the cafeteria.

Inspectors wroteBased on record review and interview, it was determined the facility failed to ensure dementia management education was provided to 1 (LPN #2) of 1 staff member who cared for residents with dementia. The administrator identified 18 residents had diagnosis of dementia in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were administered as ordered for one (#1) of one sampled residents reviewed for intravenous medications as order by the physician. Social Services identified 73 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident assessments were accurately coded for three (#27, 45, and # 52) of 18 sampled residents reviewed for resident assessments. The Administrator identified 70 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. medications for administration were not left at the resident's bedside for one (#55) of 24 residents observed during initial pool; and b. medications were administered as ordered for two (#27 and #54) of five sampled residents reviewed for unnecessary medications. The administrator identified 70 residents resided in the facility and no residents with orders to self administer medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food items were dated and labeled appropriately for one of one kitchen observation. The Dietary Manager identified 69 residents who received meals from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff donned personal protective equipment in transmission based precautions room for one (#77) of eight residents observed receiving their meal trays. The Daily Census, dated 12/17/23, identified two residents on isolation precautions for COVID-19.

Inspectors wroteBased on record review and interview, the facility failed to ensure trust account statements were provided quarterly to three ( #2, 5 and #7) of three sampled residents reviewed for trust accounts. The Administrator identified 15 residents in the resident trust account.

Inspectors wroteBased on record review and interview the facility failed to: a. assess bowel sounds post-abdominal surgery for one (#3), b. obtain fingerstick blood sugars as ordered for two (#3 and #4), and c. monitor vital signs every shift as ordered for one (#3) of three sampled residents reviewed for physician orders. The DON identified 21 residents were insulin dependent and 81 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were available for administration for two (#3 and #4) of three sampled residents reviewed for pharmacy services. The DON stated there were 81 residents who resided in the facility.

Inspectors wroteOn 01/06/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure policy was followed regarding allegations of misappropriation of pain medication signed out and not documented as given. On 01/03/23, LPN #1 signed out four narcotic pills for Resident #36, these were not documented as administered on the MAR. Upon interview, Resident #36 stated they did not receive any pain medications on 01/03/23. On 01/04/23, LPN #1 was observed signing out two doses of a narcotic pain medication when the count sheet for Resident #36 count was determined to be inaccurate during shift change. Resident #36 was not in the building at this time. LPN #1 returned to work on 01/04/23 despite the policy stating the employee would be suspended pending an investigation. [...]

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure: a. Thorough skin assessment was conducted on readmission, b. Weekly skin monitoring and/or weekly wound assessments were conducted, c. The physician was notified timely of the new or worsening wound; and d. Adequate wound care/treatment was initiated timely for one (#11) of three sampled residents reviewed for pressure ulcers. This resulted in actual harm to Resident #11 who developed a pressure injury which worsened to an avoidable pressure injury with slough visible. The DON identified 71 residents who were at risk for skin breakdown.

Inspectors wroteBased on observation, record review, and interviews the facility failed to: A. Provide baths/showers to dependent residents for four (#10, 31, 38, and #54), B. Provide incontinent care in a timely manner for one (#11) and, C. Provide nail care for one (#58) of nine sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 01/03/23, documented 71 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to administer medications as ordered for one (#10) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 01/03/23, documented 71 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure medication carts remained locked when staff were not present for two of six medication carts observed. The DON identified six carts which contained medication in the facility.

Inspectors wroteBased on record review, and staff interview, the facility failed to obtain physician ordered labs for two (#10 and #58) of five sampled residents reviewed for laboratory services. The Resident Census and Conditions of Residents report, dated 01/03/23, documented 71 residents resided in the facility.

Inspectors wroteBased on observation, record review and interviews, the facility failed to have an effective administration to ensure: 1. the abuse policy was followed regarding allegations of misappropriation of pain medication signed out and not documented as administered for three (#36, 38 and #54) of five sampled residents reviewed for pain and controlled medication count records were verified by two licensed nurses when removed from circulation and placed into the drawer for controlled medications awaiting destruction for 10 (#11, 36, 43, 48, 66, 70, 127, 128,129, and #130) of 11 sampled residents reviewed for controlled medications awaiting destruction. 2. a resident had necessary intervention, monitoring, and care to prevent the development and worsening of an avoidable pressure injury/pressure ulcer for one (#11) of three sampled residents reviewed for pressure ulcers. 3. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to: a. provide personal care to residents in a manner which prevented cross contamination for four (#2, 11, 57 and #58) of four sampled residents observed during incontinent care, and b. ensure staff wore masks during a COVID-19 outbreak and the facilities community transmission rate was high. The Resident Census and Conditions of Residents report, dated 01/03/23, documented 71 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure: A. resident's family was notified of a change in condition for one (#54) of one resident reviewed for notification of changes and B. the physician was notified in a timely manner of lab results for one (#21) of one resident reviewed for physician notification. The Resident Census and Conditions of Residents, dated 01/03/23, documented a census of 71 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure neuro checks and post fall assessments were completed for one (#41) of one sampled residents reviewed for falls. The Resident Census and Conditions of Residents report, dated 01/03/23, documented 71 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure: A. coordination of care with a third party dialysis center, B. weights obtained as ordered, and C. a resident was assessed after returning from dialysis for one (#38) of one sampled resident reviewed for dialysis services. The Resident Census and Conditions of Residents report, dated 01/03/23, documented five residents received dialysis services.