Siena Woods Care Center

In the surveyor’s words

From the most serious findings on record at Siena Woods Care Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 11, 2024

  Based on medical record review, observations, staff and physician interviews, policy review, and review of the National Pressure Injury Advisory Panel (NPIAP), the facility failed to ensure interventions were implemented to prevent the development of pressure ulcers for a resident identified at high risk for skin breakdown. The resulted in Actual Harm when Resident #26, who was cognitively impaired, at risk for pressure ulcer development and dependent on staff for turning and repositioning developed an unstageable deep tissue injury to the right heel on 10/02/23 which worsened to a Stage IV pressure ulcer and developed a Stage III pressure ulcer to the sacrum on 12/14/23 due to inadequate and ineffective pressure ulcer prevention/interventions being in place. […]

• No harm, potential for more than minimal, widespreadF880Oct 7, 2021

  Based on observation, record review, interview and Centers for Disease Control (CDC) guidance, the facility failed to utilize personal protective equipment (PPE) to prevent the spread of COVID. This had the potential to affect all residents at the facility. The facility census was 73. Findings include: 1. During observation on 10/03/21 at 8:30 P.M., Licensed Practical Nurse (LPN) #30 was seated in a chair in the resident hallway of the facility without wearing a face mask or eye protection. During interview at the time of the observation LPN #30 confirmed she was not wearing PPE and stated the expectation was to wear PPE while inside the facility. 2. […]

• No harm, potential for more than minimal, patternF812Feb 18, 2026

  Based on observations, policy review, interviews and records reviews, the facility failed to label and date foods stored in resident designated refrigerators and failed to ensure temperatures were obtained daily for the resident designated refrigerators. This had the potential to affect all residents on Unit 400, except Resident #14 who received no food by mouth, and all residents on the Rehabilitation Unit and the Secured Care Unit. The facility total census was 91. Findings include:Observations on 02/09/26 at 10:30 P.M. revealed the refrigerator designated for residents on the Secured Care Unit had a lunch bag unlabeled and undated. There were six opened containers of nutritional supplements dated 12/18/25. […]

• No harm, potential for more than minimal, patternF883Jan 8, 2025

  Based on medical record review, staff interviews and review of the Influenza Vaccine Report, the facility failed to offer the annual influenza vaccines to residents. This affected three (#47, #14 and #39) out of three residents reviewed for influenza vaccines and had the potential to affected 80 out of 82 residents residing in the facility, the facility identified two (#16 and #79) residents who were not eligible for the influenza vaccine. The facility census was 82. Findings include: 1. Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF755Oct 24, 2024

  Based on medical record review, staff interviews and policy review, the facility failed to ensure medications were administered as physician ordered. This affected four (#47, #66, #80, and #91) out of four residents reviewed for medication administration. Facility census was 93. Findings include: 1. Review of the medical record for Resident #47 revealed an admitted [DATE] with diagnoses of seizures, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and chronic kidney disease, stage 3 unspecified. Review of the Medicare 5-Day Minimum Data Set (MDS) dated [DATE] revealed Resident #47 with severe cognitive impairment. Resident #47 required partial assistance with eating and oral hygiene. […]