Deficiency Records for Siena Skilled Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Siena Skilled Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-21 | 2023-12-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-21 | 2023-12-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-23 | 2023-01-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-13 | 2022-11-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-13 | 2022-11-10 | 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 | 2022-10-13 | 2022-11-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-13 | 2022-11-10 | N |
| Use approved construction type or materials. | Fire Safety | 2022-10-17 | 2022-11-01 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-10-17 | 2022-11-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-17 | 2022-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-29 | 2022-10-27 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-10-10 | 2019-11-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-10 | 2019-11-26 | 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 | 2019-10-10 | 2019-11-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-10 | 2019-11-26 | 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 | 2019-10-10 | 2019-11-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-10 | 2019-11-26 | 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 | 2019-10-10 | 2019-11-26 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-10-10 | 2019-11-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-10 | 2019-11-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-10 | 2019-11-26 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-10-30 | 2019-11-12 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-10-30 | 2019-11-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-30 | 2019-11-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-30 | 2019-11-12 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-12-18 | 2019-01-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-12-18 | 2019-01-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-18 | 2019-01-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-18 | 2019-01-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-12-18 | 2019-01-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-12-18 | 2019-01-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-18 | 2019-01-08 | 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 | 2018-10-11 | 2018-11-09 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-10-11 | 2018-11-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-11 | 2018-11-09 | 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 | 2018-10-11 | 2018-11-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-11 | 2018-11-09 | N |
