Villa Siena

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (SR/BR, adjustable rigid bars attached to the side of the bed) for 30 out of 30 residents when:1. There was no documentation that indicated the facility conducted an accurate routine bed inspection following the Food and Drug Administration (FDA, a federal agency within the U.S. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring for safety, comfort, skin integrity, and continued need of the use of physical restraints (devices or techniques used to limit a person's movement or access to their body to ensure safety or manage behavior) were provided for two of three residents (Resident 10 and 28). This failure had the potential to adversely affect the safety and wellbeing of the residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 out of 5 sampled residents (Resident 29) was free from unnecessary psychotropic medication (drug that affects brain activities associated with mental processes and behavior) when Resident 29 received:1. PRN (as-needed) lorazepam (medication to treat agitation or anxiety) 9 times for a condition not as prescribed and without documented evidence of attempted behavioral (or non-pharmacological) interventions prior to its use; and2. PRN lorazepam order for 90 days but it was transcribed as 120 days. These failures resulted in unnecessary psychotropic medication for Resident 29 who received medication outside of the prescribed indication, without attempted behavioral interventions, and longer than prescribed.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately reflect the status of residents in the assessment for 11 (Residents 26, 19, 6, 17, 18, 29, 22, 4, 14, 15, and 7) of 15 residents (residents who used side or bed rails [SR/BR, adjustable rigid bars attached to the side of the bed]) when the Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment for Residents 26, 19, 6, 17, 18, 29, 22, 4, 14, 15, and 7 was coded they used SR/BRs as restraints. This failure increased the potential for inaccurate care to be provided for Residents 26, 19, 6, 17, 18, 29, 22, 4, 14, 15, and 7. For Resident 19:Review of Resident 19's Bed Rail assessment dated [DATE], it indicated the use of SR/BRs to serve as an enabler to promote independence. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive, resident-centered care plans, do timely initial assessment and develop baseline care plan for four out of sixteen sampled residents (Residents 1, 5, 8 and 28), when: 1. For Resident 1, the initial recreational activity assessment was not done in a timely manner and there was no baseline activity care plan; 2. For Resident 5, there was:a. no care plan developed for Resident 5's tardive dyskinesia (TD, an involuntary movement disorder that causes a range of repetitive muscle movements in the face, neck, arms and legs; a condition which sometimes develops as a side effect of long-term treatment with antipsychotic medications) andb. no care plan developed for dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning) care;3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident care plans and assessment were reviewed and updated for effectiveness in two of sixteen sampled residents, (Residents 2 and 22), when: 1. For Resident 2, the activity care plan and hospice care plan were not reviewed and updated quarterly and2. For Resident 22, the activity assessment and activity care plan were also not reviewed and updated quarterly. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being.1. During the lunch observation of Resident 2 on 7/21/25 at 12:32 p.m., she was eating lunch with the assistance of the facility staff. Resident 2 was confused and could not answer questions. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with standards of practice for two out of two residents (Resident 28, and 29) when there was no physician's order, monitoring, and policy for the use of Wander Guard (a monitoring device to alert staff when a resident approaches or exits a designated area). Review of Resident 28's admission record, indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (a decline in mental abilities, severe enough to interfere with daily life), essential hypertension (high blood pressure that does not have a known cause), cataract (a clouding of the natural lens of the eye, which can cause blurred vision and other vision problems). During an interview with Registered Nurse (RN) C, on 7/25/25 at 11:13 a.m., RN C confirmed Resident 28 have wander guard. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage practices and sanitary conditions in the kitchen when three of 13 avocados were wrinkled, soft and dented, and nine of 13 cutting boards had deep cut marks and brown discoloration on their surfaces. These failures had the potential to cause food contamination and spread food-borne illnesses to residents who received their food from the kitchen. During a concurrent observation and interview on 7/21/25 at 8:53 a.m., with the Nutrition Service Director (NSD), the NSD confirmed the three pieces of avocado were wrinkled, soft and dented. The NSD stated the avocados will not be served and will be thrown out. Review of the facility's policy and procedure (P&P), titled Food Receiving And Storage of Cold Foods: Suggested Refrigerated Storage Guidelines, dated 2023, indicated Fruit - check quality. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct the Certified Nursing Assistant's (CNA) Annual Performance Evaluation (a formal, documented review of an employee's work over the past year, assessing their performance against established goals and expectations) for two (CNA E and CNA F) of five sampled employees. This failure did not ensure CNA E and CNA F had the necessary job knowledge and had worked to provide safe resident care. During a review of the facility's randomly selected five employee files on 7/25/2025 at 9:45 a.m., indicated:1. * CNA E's Annual Performance Evaluation from the period 4/16/2023 to 4/16/2024 was completed and there was no Annual Performance Evaluation completed from the period 4/16/2024 to 4/16/2025 in the employee file; and2. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to update the daily nurse staffing information posts for 7/19/2025, 7/20/2025, and 7/21/2025. This failure communicated inaccurate facility staffing information to residents and visitors. During an observation beside the facility's nurse station on 7/21/2025 at 10:15 a.m., a glass covered board was observed and the facility's daily nurse staffing information dated 7/18/2025 was posted (picture taken). During another observation on 7/21/2025 at 3:21 p.m., beside the facility's nurse station, the daily nurse staffing information posting was changed to a new one dated 7/22/2025 (picture taken). During a concurrent interview with registered nurse C (RN C) and photo review on 7/22/2025 at 2:38 p.m., RN C reviewed the pictures of the daily nurse staffing information taken on 7/21/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an expired emergency kit (a kit/box containing medications for immediate use during a medical emergency) and a medication were replaced timely to ensure unexpired medications were available for resident use. During a visit to the medication room on 7/21/25, at 10:21 a.m., with Licensed Vocational Nurse (LVN) B, an emergency kit containing three refrigerated medications was observed in the medication refrigerator. A review of the contents list on the outside of the kit indicated the expiration date for two lorazepam vials (injectable medication to treat seizures and agitation) was 3/2025. Further inspection of the contents inside with LVN B revealed one lorazepam vial had the expiration date of 3/2025 (4 months ago), and another vial expired in 4/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policies for influenza vaccine (known as flu shot, immunization against infection by influenza viruses) and pneumococcal vaccine (vaccine to prevent bacterial pneumonia [infection of the lungs]) when the facility did not offer pneumococcal vaccinations and influenza vaccinations in accordance with the current Centers for Disease Control and Prevention (CDC) recommendations to 22 of 29 residents (Residents 2, 3, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 18, 20, 21, 23, 24, 25, 26, 27, and 181). This failure had the potential to put the residents at risk of acquiring pneumococcal and influenza infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain informed consents for the use of restraints (a specific intervention or device that prevents the patient from moving freely or restricts normal access to the patient's own body) for 13 of 13 sampled residents (2, 3, 5, 7, 8, 9, 15, 17, 18, 20, 24, 26, and 29) who were using a personal safety alarm (a small, noise-making device meant to surprise a potential attacker or draw attention to an individual in distress), floor mat alarm (a mat that is placed on the floor which sounds when it senses that a person is walking over it), and wander/elopement alarm (the person at risk of eloping is provided with a bracelet or anklet that triggers an alarm if they attempt to exit those doors which then alerts staff so they can assist the individual), when 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately assess and complete the Minimum Data Set (MDS, an assessment tool) for 20 of 29 residents (Residents 2, 3, 5, 6, 7, 9, 10, 11, 13, 14, 15, 16, 18, 20, 21, 23, 24, 25, 26, and 29). This failure had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a registered nurse (RN) was on duty for 8 consecutive hours for 8 days during the months of October, November, and December of 2023. This failure had the potential to affect resident's care, health, and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food service operations were carried out according to standards of practice when: 1. The ice machine drain pipe and the floor drainage sink did not have air gaps (an unobstructed vertical space between the water outlet and the flood level of a fixture), 2. A Dietary Aide did not wear a hair net while serving food in the the Skilled Nursing Facility (SNF) kitchen, 3. The temperature of the resident's refrigerator in the activity room was not recorded two times each day. These failures could potentially expose 29 residents to harmful contaminants that could cause foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement care plans for one of 13 sampled residents (Resident 8) when a care plan for a fall was not developed. This failure had the potential to not meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care in accordance with professional standards of practice for one of one sampled resident (Resident 27) when: 1. Resident 27's nasal cannula (NC, flexible tubing inserted into the nostrils and attached to an oxygen source) and humidifier were outdated; 2. The licensed nurses failed to document when oxygen was administered to Resident 27; 3. Resident 27's physician order for oxygen did not have an indication for use. These failures had the potential to compromise Resident 27's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician admission orders for two of 29 residents (Resident 1 and 17). These deficient practices had the potential for unauthenticated and inaccurate treatment orders.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician's order for a PRN (as needed) psychotropic medication (medication capable of affecting the mind, emotions, and behavior) was limited to 14 days for one of five sampled residents (Resident 27). This failure had the potential to result in the resident receiving the medication for an excessive length of time and experiencing adverse medication side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage for three out of 29 residents (Residents 6, 13, 27) when expired or discarded medications were stored, not put away. This failure had the potential for residents to receive medications with unsafe and reduced potency from being used past their expiration date, which could lead to unsafe medication for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store and label the food brought from outside the facility by the family for one of one sampled residents (Resident 24). This failure had the potential for unsafe storage and might result in foodborne illness.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure infection prevention practices were followed when: 1. For Residents 2, 12, and 22, staff did not clean the glucometer machine according to the manufacturer guidelines; and 2. For Resident 29, staff did not perform hand hygiene during a wound treatment procedure. These failures had the potential to spread infection in the facility.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food safety when: 1. An ice machine was not kept in a sanitary condition; and 2. The certified nursing assistant G (CNA G) assisted two residents (Resident 8 and 5) in then dining room without performing hand hygiene. These failures had the potential to cause cross-contamination of food (cross-contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness), the growth of microorganisms, and foodborne illness for the 29 residents eating at the facility.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to implement infection control practices when the licensed vocational nurse D (LVN D) did not perform hand hygiene prior to donning (putting on) gloves during medication administration for three of five randomly selected residents (Residents 1, 25, and 3). This failure put residents and staff at risk of possible spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services were provided to meet the professional standard of practice for 5 of 12 sampled residents (Residents 4, 19, 3, 13 and 1) when: 1) Licensed vocational nurse D (LVN D) did not check Resident 4, 19 and 3's blood pressure (BP) and pulse rate (PR) or heart rate (HR) prior to administration of antihypertensive (a type of medication used to lower blood pressure) medication. 2) documentation of pacemaker (implanted device for a heart condition, a battery-powered device implanted inside the heart to restore a normal heartbeat.) information in residents' medical records were lacking for Residents 1, 4 and 13. 3) No pacemaker care was included in Resident 4's care plan. These failures had the potential to jeopardize the residents' health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for two of 12 sampled residents (Residents 26 and 27) when: 1. For Resident 26, nursing staff did not apply Posey boot (heel protector) to left foot as ordered; and 2. For Resident 27, there was no proper supervision in the dining room and a nutrition care plan was not updated. These failures had the potential to affect the residents care and jeopardize their health and well-being.

Inspectors wroteBased on interview, and record review the facility failed to ensure residents were seen by their attending physicians for two of 12 sampled residents (Residents 11 and 9). These failures had the potential to affect residents' care, health, and wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a registered nurse (RN) for at least 8 hours a day to 29 residents. This failure had the potential to affect resident's care, health, and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily staffing information posted was complete. This failure had the potential to result in nurse staffing misinformation about resident's care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an account of controlled drug was maintained and reconciled for one of three randomly selected residents (Resident 5). This failure had the potential for misuse or diversion of controlled medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly label and store medications and biologicals when: 1. The medication cart drawer had some sticky, brown substance at the bottom and on the sides; 2. A box of Loperamide Hydrochloride (a medication for loose stools) 2 mg (milligram - a unit of measurement) tablets for Resident 26 was expired and stored in the medication cart; 3. A bottle of Fluticasone Propionate (a nasal spray for relief of nasal congestion, itchy and runny nose) for Resident 1 was not labeled. These failures had the potential for residents to receive unsafe and reduced potency of medications.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit staffing information based on payroll data on a quarterly schedule to the Centers for Medicare & Medicaid Services (CMS) in 2022. The deficient practice prevented the provision of complete and accurate direct care staffing information to the public.