Sienna Nursing and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF600Jun 24, 2025

  Based on observation, interview, and record review the facility failed to protect the resident's right to be free from abuse and neglect for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 18 residents reviewed for abuse and neglect. 1. The facility failed to prevent Resident #1 from abusing Resident #3 on Hall 400 (male secured locked unit) that led to an emergency room visit resulting in head laceration requiring 3 staples for Resident #3 on 05/25/2025. 2. […]

• Immediate jeopardy, patternF689Jun 24, 2025

  Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 18 residents reviewed for resident-to-resident altercations. 1. The facility failed to prevent supervision of Resident #1 from abusing Resident #3 on Hall 400 (male secured locked unit) that led to an emergency room visit resulting in head laceration requiring 3 staples for Resident #3 on 05/25/2025. 2. […]

• Immediate jeopardy, patternF725Jun 24, 2025

  Based on observation, interviews, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 5 (Resident #1, Resident #2, Resident #4, Resident #5, and Resident #6) of 18 residents reviewed for sufficient staffing related resident-to-resident altercations and 1:1 monitoring. 1. […]

• Immediate jeopardy, isolatedF689Oct 10, 2022

  Based on observation, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #44) of four residents reviewed for accidents and supervision. The facility failed to provide adequate supervision to Resident #44 who resided in the secure unit. As a result, he eloped from the facility and was located approximately 20 minutes later after he had crossed a 5-lane street. Resident #44, who was diagnosed with dementia, had attempted on 2 other occasions to elope from the secure unit through a resident room window. […]

• Immediate jeopardy, isolatedF600Jul 28, 2022

  Based on observation, interview, and record review the facility failed to ensure the right to be free from abuse for 1 (Resident #1) of 4 residents reviewed for abuse. The facility failed to follow their policy and procedure for the locked unit that provided monitoring and supervision of residents to prevent elopement, and accounting of all residents on all units, which would have alerted staff of a missing resident. On 07/19/22 at 1:45p.m., Resident #1 who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . While the Charge nurse was doing rounds at 3:15 p.m. a resident alerted the Charge nurse that she saw Resident #1 laying on the ground outside in the courtyard. The resident was found unconscious and rushed by ambulance to local hospital. […]