Sienna Hills Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Sienna Hills Nursing & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 30, 2023

  Based on observation, record review, hospital record review, self-reported incident review, policy review and interview the facility failed to prevent an incident of resident-to-resident sexual abuse/assault involving Resident #13. Actual harm occurred based on the reasonable person concept on 08/22/23 when Resident #13, who was severely cognitively impaired and was unable to provide evidence of consent was sexually assaulted by Resident #26 who was observed fondling the resident's breast and with possible vaginal bleeding (per hospital record review). This affected one (Resident #13) of three residents reviewed for abuse. The facility census was 25. Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF921Feb 6, 2025

  Based on observation and staff interview, the facility failed to ensure resident rooms and common areas were maintained in a clean and comfortable manner by repairing and painting walls properly. This had the potential to affect all 34 residents within the facility. Findings include: Observations throughout the survey from 02/03/25 to 02/06/25 revealed numerous resident rooms and common areas with evidence of repaired drywall which had not been properly painted. Observations with the facility administrator on 02/06/25 from 9:30 A.M. to 9:40 A.M. […]

• No harm, potential for more than minimal, widespreadF812Dec 1, 2022

  Based on observation, interview, facility record review and facility policy review the facility failed to ensure food was stored and prepared under sanitary conditions. This had the potential to affect all Residents living in the facility and receiving meals from the kitchen. The were no Residents identified by the facility as receiving nothing by mouth. The facility census was 34. Findings included: 1. Observation on 11/28/22 at 8:40 A.M. of meat in a plastic bag floating in water in the staff hand washing sink. The water was not running in the sink and the sink was plugged to make a pool of water. On 11/28/22 at 9:00 A.M. an interview with Dietary #213 verified the meat should not be thawed in a pool of water or in the staff hand washing sink. […]

• No harm, potential for more than minimal, widespreadF814Dec 1, 2022

  Based on observation, interview and facility policy review, the facility failed to ensure an outdoor dumpster lid was completely covering the opening to the dumpster to protect from pest infestation. This had the potential to affect all 34 Residents living in the facility. The facility census was 34. Findings included: Observation on 11/28/22 at 08:30 A.M. of the outdoor dumpster revealed one fourth of the lid was missing leaving the refuse open to air and pests. Observation on 11/29/22 at 12:30 P.M. of the outdoor dumpster revealed one fourth of the lid was missing leaving the refuse open to air and pests. […]

• No harm, potential for more than minimal, widespreadF908Dec 1, 2022

  Based on observation and interview the facility failed to ensure a kitchen oven was maintained in safe operating condition. This had the potential to affect all 34 Residents living in the facility. The facility census was 34. Findings included: Observation on 11/28/22 at 8:40 A.M. of the left kitchen oven revealed the door of the oven had a piece of wood wedged into the top of it. An interview at the time of the observation with Dietary #213 revealed the oven door did not close properly so the piece of wood was used to wedge the oven door closed. On 11/29/22 at 10:00 A.M. an interview with Dining Services Director (DSD) #204 revealed the spring in the left oven door was not working correctly and a company came to fix it but ended up making it worse and the door would not close all the way. […]