A list of the most recent deficiencies for Siena Woods Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-11 | 2024-02-05 | N |
| Provide appropriate foot care. | Health | 2024-01-11 | 2024-02-05 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2024-01-08 | 2024-02-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-08 | 2024-02-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-08 | 2024-02-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-08 | 2024-02-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-13 | 2022-08-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-15 | 2022-01-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-21 | 2021-11-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-07 | 2021-11-08 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-08-16 | 2021-11-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-21 | 2021-10-04 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-11-14 | 2019-12-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-14 | 2019-12-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-11-14 | 2019-12-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-14 | 2019-12-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-14 | 2019-12-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-11-14 | 2019-12-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-14 | 2019-12-30 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-11-14 | 2019-12-30 | N |
| Provide or obtain dental services for each resident. | Health | 2019-11-14 | 2019-12-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-14 | 2019-12-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-11-14 | 2019-12-30 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-11-14 | 2019-12-19 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-10-18 | 2018-11-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-18 | 2018-11-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-10-18 | 2018-11-19 | N |
| Provide activities to meet all resident's needs. | Health | 2018-10-18 | 2018-11-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-18 | 2018-11-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-18 | 2018-11-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-18 | 2018-11-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-10-18 | 2018-11-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-18 | 2018-11-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-18 | 2018-11-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-10-18 | 2018-11-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-10-18 | 2018-11-19 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-10-18 | 2018-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-18 | 2018-11-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-18 | 2018-11-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-10-17 | 2018-11-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-17 | 2018-11-19 | N |
