Sienna Nursing and Rehabilitation

Inspectors wroteBased on interview, and observation, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis. The facility failed to ensure they employed a full time or interim DON from 02/25/2026 through present date of exit 04/23/2026. This failure could place all residents at risk of not receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents right to personal privacy and confidentiality of his or her personal and medical records for 8 of 10 staff (LVN C, LVN M, MA N, MA O, RN H, LVN P, RN Q, RN G). The facility failed to ensure LVN C, LVN M, MA N, MA O, RN H, LVN P, RN Q, and RN G did not use their personal laptops to access residents' medical records and document care provided without any safeguards in place to ensure security of residents' confidential information. This deficient practice placed residents at risk for having their sensitive patient health information disclosed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals for 3 of 3 residents (Resident #58, #68, #77) reviewed for respiratory care. - The facility failed on 04/21/2026 to ensure Resident #68's oxygen concentrator was turned on for 3 and a half hours as per vitals collected at 1:30 PM by LNV C.-The facility failed on 04/21/2026 to ensure Residents #58, #68, and #77 had an oxygen in use signage on the doorway entry. This failure placed residents at risk of not receiving respiratory care or the hazards of machine malfunction or accelerating the spread of fire associated with oxygen usage.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 4 items served on a sample tray (cold items) reviewed for food and nutrition services. -The facility failed on 04/22/2026 to provide a pudding dessert and tossed salad below 41 F. This failure places residents at risk of food-borne illnesses, decreased appetite, and overall meal dissatisfaction.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage. -The facility failed on 04/21/2026 to ensure a moldy tomato was not stored in the walk-in fridge.- The facility failed on 04/21/2026 to ensure different produce were not stored in the same bag (tomato with green onions).- The facility failed on 04/21/2026 to ensure a bag of green onions, bologna sandwiches, and hardboiled eggs in the walk-in fridge were labeled.- The facility failed on 04/21/2026 to ensure a box of chicken thighs was not leaking fluids, labeled, and was stored to maintain a temperature below 41 F. This failure had the potential to place residents at risk for foodborne illness.

Inspectors wroteBased on interviews and record review, the facility failed to employ a qualified social worker on a full-time basis with a facility of more than 120 beds for 1 of 1 Social Workers reviewed. -The facility failed to ensure social services were directed by a qualified individual on 4/23/26 in a facility with 138 total capacity. This failure placed residents at risk of receiving services from a staff member not qualified to identify as a social worker.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 walk-in fridge cooling system and 7 of 10 employees (LVN C, LVN M, MA N, MA O, RN H, LVN P, RN Q) not having access to facility issued laptops and desktops.-The facility failed to ensure water was not pooling under the walk-in fridge cooling system.-The facility failed to ensure laptops intended for nursing staff use were working. This failure placed residents at risk for delay in care and foodborne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately inform the resident's physician and their representative when there was a significant change in the resident's physical, mental or psychosocial status for 1 of 3 residents (Resident #68 reviewed for change in condition. -The facility failed to ensure LVN C reported Resident #68's oxygen being disconnected for unknown number of hours and oxygen saturation of 86% to the physician on 04/21/2026. This failure places residents at risk for experiencing a worsening condition and leaving the resident without appropriate treatment following a change in condition.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain evidence demonstrating the result of all grievances for a period no less than 3 years from the issuance of the grievance decision for 1 of 1 grievance binders reviewed. The facility failed to maintain evidence demonstrating the results of grievances prior to 2/13/2026. This failure could place residents at risk of not having their grievances properly resolved, tracked, and documented for future review.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 3 residents (Resident #12) reviewed for ADL care. -The facility failed on 04/21/2026 to ensure Resident #12's fingernails were trimmed. This failure could place residents who required assistance with ADL's at risk for unmet needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 1 (Resident #6) of 8 residents reviewed for falls. The facility failed to ensure Resident #6 was assessed by a nurse immediately after her fall on 03/13/2026. This failure could affect residents by placing them at risk of potential medical complications related to changes in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #10) reviewed for infection control in that; CNA A failed to change her gloves after they became contaminated during incontinent care while assisting Resident #10. These failures could place resident's at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation and interview the facility failed to ensure the daily nursing staffing was posted as required for 3 of 3 days in that, The facility did not post the daily staffing in a prominent place readily accessible to residents and visitors. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post, in a form and manner accessible and understandable to residents and, resident representatives: a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, and the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit for 2 of 5 (400-hall/Male Memory Care Unit, and 500-hall/Female Memory Care Unit) halls reviewed for posting of required information. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents had the right to examine the results of the most recent survey of the facility and the facility failed to post the results of the most recent survey in a place that is readily accessible to residents, family members, legal representatives of residents, and the public for 1 of 1 survey results binder reviewed. -The facility failed to ensure the annual survey results binder was accessible for residents, family members, and staff on 04/22/2026 at 11:30 AM. This failure placed residents, family members, and legal representatives of the residents at risk of not being informed of the facility's survey and investigation results causing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (Resident #1) of four residents reviewed for nutrition. The facility failed to ensure Resident #1 maintained acceptable parameters of nutritional status as demonstrated by Resident #1 experiencing a 11.47% weight loss in 80 days. He had an active decline in his weight from 12/1/25 - 02/18/26. This failure could place residents at risk for decreased nutritional status, decline in health, malnutrition, or hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the resident's right to be free from abuse and neglect for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 18 residents reviewed for abuse and neglect. 1. The facility failed to prevent Resident #1 from abusing Resident #3 on Hall 400 (male secured locked unit) that led to an emergency room visit resulting in head laceration requiring 3 staples for Resident #3 on 05/25/2025. 2. The facility failed to ensure Hall 400 (male secured locked unit) had sufficient staffing to prevent Resident #1 from abusing Resident #4 that led to hospitalization of Resident #1 and a fall resulting in a skin tear to Resident #4's left elbow, while Resident #1 was supposed to be on 1:1 monitoring on 05/25/2025. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 18 residents reviewed for resident-to-resident altercations. 1. The facility failed to prevent supervision of Resident #1 from abusing Resident #3 on Hall 400 (male secured locked unit) that led to an emergency room visit resulting in head laceration requiring 3 staples for Resident #3 on 05/25/2025. 2. The facility failed to ensure Hall 400 (male secured locked unit) had sufficient supervising staff to prevent Resident #1 from abusing Resident #4 that led to hospitalization of Resident #1 and a fall resulting in a skin tear to Resident #4's left elbow, while Resident #1 was supposed to be on 1:1 monitoring on 05/25/2025. 3. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 5 (Resident #1, Resident #2, Resident #4, Resident #5, and Resident #6) of 18 residents reviewed for sufficient staffing related resident-to-resident altercations and 1:1 monitoring. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents for 9 (06/04/25, 06/05/25, 06/06/25, 06/13/25, 06/14/25, 06/15/25, 06/16/25, 06/18/25, 06/19/25) of 20 days reviewed for DON coverage. The facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on 06/04/25, 06/05/25, 06/06/25, 06/13/25, 06/14/25, 06/15/25, 06/16/25, 06/18/25, and 06/19/25. This failure leaves residents without the nursing administrative oversight that only the DON can provide.

Inspectors wroteBased on interview, and record review, the facility failed to review and revise resident's comprehensive care plans by the interdisciplinary team after each assessment for 3 (Resident #1, Resident #2, and Resident #3) of 18 residents reviewed for comprehensive care plans. The facility failed to update or add interventions to Resident #1's care plan regarding aggressive and physical behaviors towards other residents since 12/13/2024. The facility failed to update or add interventions to Resident #2's care plan regarding physical behaviors towards other residents since 11/18/2024. The facility failed to update or add interventions to Resident #3's care plan regarding wandering since 02/21/2024. These failures could result in residents not receiving the care that they need.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat residents with respect, dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 11 of 11 residents in the confidential group interview. Staff used cell phones in residents' presence causing residents to feel disrespected. (11 residents in the Resident Council Meeting) This failure could place residents at risk of a diminished quality of life a loss of self-esteem and increased isolation.

Inspectors wroteBased on observation and interview, the facility failed to permit only authorized personnel to have access to one of one medication room reviewed for drug storage in that: The facility Medical Records staff member had access to the medication room while unauthorized to be in the medication room unattended. These failures could place clients at risk for drug diversion.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 7 (Residents #17, #49, #60, and #67) residents reviewed for infection control. The facility failed to ensure CNAs A, B, E and D used PPE during incontinent care for Resident #17 and #60 as the residents were on Enhanced Barrier Precautions (EBP). The facility failed to ensure CNA B changed her gloves after they became contaminated during incontinent care while assisting Resident #17. The facility failed to ensure CNAs C, D, E, and F used PPE during transfers for EBP Residents #49, 60, and #67. These failures could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 1 resident (Resident #86) reviewed for intravenous fluids. The facility failed to ensure the dressing on Resident #86's Mid-line intravenous line (a short flexible tube inserted into a vein to administer fluids and medications) was dated and initialed. The failure could affect residents by placing them at risk for infections.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure medical records were complete and accurately documented for 1 of 3 residents (Residents #1) whose assessments were reviewed. The facility failed to ensure Resident #1's Shower log, dated 06/17/2024, correctly documented the resident as receiving showers. This failure could place residents at-risk for inadequate care and services due to an inaccurate assessment.

Inspectors wroteBased on interviews and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of controlled medications for 1 of 4 residents (Resident #1) reviewed for pharmaceutical services. The facility failed to accurately receive and store Resident #1's 45 tablets of the anti-anxiety narcotic schedule IV medication Alprazolam. As a result, the 45 tablets of Alprazolam were diverted. The facility failed to accurately receive and store Resident #1's 60 tables of the narcotic scheduled IV pain medication Tramadol. These failures could place residents at risk of misappropriation of property by drug diversion and could result in increased pain and/or anxiety, and poor quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to medications for 1 of 4 medication carts reviewed for medication storage. The facility failed to ensure that Resident #1's 60 tablets of Tramadol were secured in a double-locked area. This failure could place residents at risk for harm by not receiving the medications due to misappropriation.

Inspectors wroteBased on staff interview and record review, the facility failed to implement the facility's Quality Assessment and Performance Improvement plan and program, in which data was to be gathered and analyzed, and plans of action were to be developed, implemented, and evaluated to address adverse events related to potential deficient practice for 4 of 10 residents (Resident #1, Resident #2, Resident #3, Resident #4) reviewed for quality assurance and performance improvement 1. The facility did not identify a pattern of Resident # 1's behaviors directed toward Resident #2 three times in six (6) months. 2. The facility did not complete incident/accident reports for Resident #3's physical behaviors. 3. The facility did not complete incident/accident reports for Resident #4's physical behaviors. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for kitchen sanitation, in that: The facility failed to ensure [NAME] A prevented cross contamination while preparing food. The facility failed to throw out food within seven (7) days. The facility did not thaw food within a container causing drips on the floor The facility stored food on the floor of the walk-in refrigerator. The facility failed to ensure Dietary Aides B, C, and D had effective hair restraints. The facility failed to ensure pans and dishes were stored face up and uncovered leaving them exposed to contamination from air born contamination. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in the facility's only kitchen. The facility failed to ensure the oven worked consistently. The facility failed to ensure the garbage disposal worked correctly. The facility failed to ensure milk refrigerator's hinge was not rusted and worked. The facility failed to ensure the milk refrigerator's gasket (seal) was black and did not become detached. These failures placed the residents at risk for not receiving a variety in meals as planned and placed residents at risk for foodborne illness.

Inspectors wroteBased on record review and interviews the facility failed to review and revise the comprehensive care plan after assessment of 1 of 5 residents (Resident #70) reviewed for care plan revision. The facility failed to include a care plan for Resident #70's crawling behavior. This failure could place the residents at risk of injury.

Inspectors wroteBased on record review and interviews the facility failed to provide assistive devices to prevent injuries of 1 of 5 residents (Resident #70) reviewed for Quality of Care. The facility failed to ensure Resident #70 receives adequate supervision and assistive devices to prevent accidents relating to her crawling behavior. This failure could place the residents at risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to medications for 1 of 4 medication carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication cart #1 was locked when unattended on 12/13/2023. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions.