A list of the most recent deficiencies for Sienna Extended Care and Rehab. 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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-21 | 2024-02-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-21 | 2024-01-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-21 | 2024-01-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-21 | 2024-01-22 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-10-13 | 2023-10-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-13 | 2023-10-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-13 | 2023-10-14 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-10 | 2023-02-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-10 | 2023-02-13 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-01-10 | 2023-02-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-10 | 2023-02-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-10 | 2023-02-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-10 | 2023-02-13 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-01-10 | 2023-02-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-10 | 2023-02-13 | Y |
| 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 | 2023-01-10 | 2023-02-13 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-01-10 | 2023-02-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-10 | 2023-02-13 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-26 | 2023-02-13 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-01-26 | 2023-02-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-25 | 2022-11-20 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-21 | 2021-12-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-21 | 2021-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-21 | 2021-12-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-21 | 2021-12-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-21 | 2021-12-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-20 | 2021-11-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-20 | 2021-11-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-10-20 | 2021-11-24 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-10-20 | 2021-11-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-20 | 2021-11-24 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-10-20 | 2021-11-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-20 | 2021-11-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-20 | 2021-11-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-20 | 2021-11-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-23 | 2021-09-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-23 | 2021-09-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-23 | 2021-09-24 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-23 | 2021-09-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-23 | 2021-09-24 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-08-23 | 2021-09-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-23 | 2021-09-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-14 | 2021-05-24 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-14 | 2021-05-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-14 | 2021-05-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-14 | 2021-05-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-14 | 2021-05-24 | Y |
