Deficiency Records for Sienna Hills Nursing and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Sienna Hills Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-18 | 2023-10-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-30 | 2023-09-07 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-12-01 | 2022-12-16 | N |
| Provide activities to meet all resident's needs. | Health | 2022-12-01 | 2022-12-16 | 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 | 2022-12-01 | 2022-12-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-01 | 2022-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-01 | 2022-12-16 | N |
| Dispose of garbage and refuse properly. | Health | 2022-12-01 | 2022-12-16 | N |
| Keep all essential equipment working safely. | Health | 2022-12-01 | 2022-12-16 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-12-02 | 2022-12-16 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-12-02 | 2022-12-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-02 | 2022-12-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-02 | 2022-12-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-02 | 2022-12-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-02 | 2022-12-16 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2020-03-05 | 2020-07-31 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-03-05 | 2020-04-17 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2020-03-05 | 2020-04-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-05 | 2020-04-17 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-03-05 | 2020-04-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-03-05 | 2020-04-17 | 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 | 2020-03-05 | 2020-04-17 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2020-03-05 | 2020-04-17 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2020-03-05 | 2020-04-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-05 | 2020-04-17 | 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 | 2020-03-05 | 2020-04-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-05 | 2020-04-17 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-03-05 | 2020-04-17 | N |
| Have a properly installed and maintained dumbwaiter or escalator. | Fire Safety | 2020-03-05 | 2020-04-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-05 | 2020-04-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-03-05 | 2020-04-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-03-05 | 2020-04-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-03-05 | 2020-04-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-03-05 | 2020-04-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-24 | 2019-02-15 | N |
| Provide appropriate foot care. | Health | 2019-01-24 | 2019-02-15 | 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 | 2019-01-24 | 2019-02-15 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-01-24 | 2019-02-15 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-01-24 | 2019-02-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-24 | 2019-02-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-01-24 | 2019-02-15 | N |
| Use approved construction type or materials. | Fire Safety | 2019-01-24 | 2019-02-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-01-24 | 2019-02-15 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-01-24 | 2019-02-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-24 | 2019-02-15 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-01-24 | 2019-02-15 | N |
