Sienna Extended Care & Rehab

In the surveyor’s words

From the most serious findings on record at Sienna Extended Care & Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF602Jan 10, 2023

  On 01/06/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure policy was followed regarding allegations of misappropriation of pain medication signed out and not documented as given. On 01/03/23, LPN #1 signed out four narcotic pills for Resident #36, these were not documented as administered on the MAR. Upon interview, Resident #36 stated they did not receive any pain medications on 01/03/23. On 01/04/23, LPN #1 was observed signing out two doses of a narcotic pain medication when the count sheet for Resident #36 count was determined to be inaccurate during shift change. Resident #36 was not in the building at this time. […]

• Actual harm, isolatedF686Jan 10, 2023

  Based on record review, observation and interview, the facility failed to ensure: a. Thorough skin assessment was conducted on readmission, b. Weekly skin monitoring and/or weekly wound assessments were conducted, c. The physician was notified timely of the new or worsening wound; and d. Adequate wound care/treatment was initiated timely for one (#11) of three sampled residents reviewed for pressure ulcers. This resulted in actual harm to Resident #11 who developed a pressure injury which worsened to an avoidable pressure injury with slough visible. The DON identified 71 residents who were at risk for skin breakdown. […]

• No harm, potential for more than minimal, widespreadF577Apr 21, 2025

  Based on observation, record review, and interview, the facility failed to post the most recent state survey results of the facility in a place readily accessible to residents, family members, and legal representatives of the residents. The administrator identified 68 residents resided in the facility. Findings: On 04/17/25 at 9:17 a.m., a framed form that showed Copies of all [NAME] surveys and results are available to view on the table at the north end of our main entrance was observed on the wall directly outside of the dining room. […]

• No harm, potential for more than minimal, patternF570Apr 21, 2025

  Based on record review and interview, the facility failed to ensure the total amount of resident funds in the facility trust account did not exceed the amount covered under the facility surety bond. The DON identified 11 residents in the facility trust account resided in the facility. Findings: An undated facility form titled, Personal Funds Authorization, read in part, The facility maintains one trust fund account for both private and Medicare resident/patients .The facility has purchased a surety bond, or otherwise provided assurance satisfactory to the Secretary of the Department of Health and Human Services, to assure the security of all personal deposited with the facility. The facility trust account showed the following balances: a. […]

• No harm, potential for more than minimal, patternF585Apr 21, 2025

  Based on record review and interview, the facility failed to ensure residents had the right to voice grievances to the facility without fear of discrimination or reprisal and failed to promptly resolve grievances the residents had in the resident council group. The administrator identified 68 residents resided in the facility. Findings: An undated facility form, Resident's/Patient's Rights, read in part, You have the right to voice problems that you are concerned about regarding your treatment .Anyone who denies any of these rights is punishable by fine and/or imprisonment .If you are denied your rights, you may also be allowed punitive damages .There can be no retaliation of any type by the facility staff because of a complaint presented to the staff. […]