SIENA WOODS CARE CENTER

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has plan of correction, corrected March 31, 2026

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Nutrition and Dietary Deficiencies — Deficient, Provider has plan of correction, corrected March 31, 2026

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has plan of correction, corrected March 31, 2026

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected May 12, 2025

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has plan of correction, corrected March 31, 2026

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 12, 2025

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has plan of correction, corrected March 31, 2026

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has plan of correction, corrected March 31, 2026

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 12, 2025

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2024

Provide appropriate foot care.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 5, 2024

Provide timely, quality laboratory services/tests to meet the needs of residents.

Administration Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2019

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected January 20, 2025

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected November 6, 2024

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2019

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 6, 2024

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2019

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2019

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2019

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 6, 2024

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 6, 2024

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2019

Provide or obtain dental services for each resident.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2019

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2019

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2019

Ensure residents have reasonable access to and privacy in their use of communication methods.

Resident Rights Deficiencies — Deficient, Provider has plan of correction, corrected December 19, 2019

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2019

Provide timely, quality laboratory services/tests to meet the needs of residents.

Administration Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2018

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2018

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2018

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2018

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2018

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2018

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2018

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2018

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2018

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2018

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2018

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2018

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2018

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2018

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 19, 2018