Siena Gardens Rehabilitation & Transitional Care

In the surveyor’s words

From the most serious findings on record at Siena Gardens Rehabilitation & Transitional Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Mar 17, 2021

  Based on medical record review, hospital record review, interviews with facility staff, and review of the medication incident investigation, the facility failed to ensure residents were free from significant medication errors when one resident (#43) had not received the ordered anticoagulant medication for twenty-two days. This resulted in Immediate Jeopardy and serious life-threatening harm for Resident #43 when the resident had not received physician ordered anticoagulant medication, began complaining of right leg pain, chest pain and then subsequently required admission to the hospital with an acute right leg [MEDICAL CONDITION] (blood clot), and a [MEDICAL CONDITION] embolism (blood clot in the lung). This affected one resident (#43) of three reviewed for anticoagulant medication. […]

• No harm, potential for more than minimal, isolatedF609Sep 16, 2025

  Based on staff interview, medical record review, and review of facility policy, the facility failed to report an allegation of verbal abuse to the state survey agency (SSA). This affected one (#66) of two residents reviewed for abuse. The facility census was 93. Findings include:Review of Resident #66's medical record revealed an admission date of 12/13/24. Diagnoses included chronic peripheral venous insufficiency, cerebral infarction (stroke), and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/25/25, revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition.Review of the plan of care, initiated 12/27/24, revealed Resident #66 experienced an alteration in mood or behavior as… […]

• No harm, potential for more than minimal, isolatedF730Oct 6, 2022

  Based on facility personnel record review and staff interview the facility failed to ensure annual performance reviews were completed. This affected three of four State tested Nursing Assistants (STNAs) reviewed (STNAs #324, #325 and #397). The facility census was 94. Findings included: Review of STNA #324's personnel file revealed a date of hire on 08/23/21. Further review of the STNA's personnel file revealed no evidence of an annual performance review. Review of STNA #325's personnel file revealed a date of hire on 09/03/19. Further review of the STNA's personnel file revealed no evidence of an annual performance review. Review of STNA #397's personnel file revealed a date of hire on 10/04/21. […]

• No harm, potential for more than minimal, isolatedF770Oct 6, 2022

  Based on medical record review, staff interview and review of facility policy, the facility failed to ensure physician ordered laboratory (lab) tests were completed as ordered. This affected one Resident (#75) of five residents reviewed for unnecessary medications. The facility census was 94. Findings include: Review of the medical record of Resident #75 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 had intact cognition. Review of the plan of care dated 03/01/22 revealed Resident #75 was at risk for [CONDITION(S)] (low blood sugar) and/or [CONDITION(S)] (elevated blood sugar) episodes related to insulin dependent diabetes mellitus (IDDM). […]

• No harm, potential for more than minimal, isolatedF761Mar 17, 2021

  Based on medical record review, interview, review of the pharmacy delivery receipt, and policy review the facility failed to ensure medications were properly checked in, secured, and available for administration after they were delivered. This affected one resident (#43) of three reviewed for medication storage. The facility census was 80. Findings include: Review of the medical record revealed Resident #43 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #43 was discharged to the hospital on [DATE] and was readmitted from the hospital on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had severe cognitive deficits and received anticoagulant therapy. […]