Siena Skilled Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Siena Skilled Nursing & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF658Aug 14, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF697Aug 14, 2025

  Based 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.Findings:1. […]

• No harm, potential for more than minimal, patternF755Aug 14, 2025

  Based 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… […]

• No harm, potential for more than minimal, patternF761Aug 14, 2025

  Based 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).These failures had the… […]

• No harm, potential for more than minimal, patternF656Sep 12, 2024

  Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three out of 21 sampled residents (Resident 24, Resident 23, and Resident 25) when: 1. Resident 24's care plan interventions did not accurately reflect Resident 24's physician's orders for insulin (controls the amount of sugar in the blood) and anticoagulation (used to prevent and treat blood clots in blood vessels and the heart) medication; 2. Resident 23's oxygen therapy care plan was not developed; and, 3. Resident 25's antipsychotic medication (a medication used to treat symptoms of losing touch with reality such as disrupted thoughts and perceptions) care plan was not developed. […]