Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Siena Skilled Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively intact resident with a history of substance abuse and childhood abuse was subjected to repeated sexual touching by another cognitively intact resident diagnosed with schizoaffective disorder and stimulant dependence. Over more than one occasion, the perpetrating resident grabbed the victim’s breast, waist, and buttock without consent, behavior that was witnessed by another resident, a nurse, and later confirmed by the DON. Progress notes documented the victim’s report of unwanted touching and feeling disrespected, as well as a subsequent incident where a nurse again observed the perpetrator brushing the victim’s buttock, demonstrating that the facility failed to prevent repeated sexual abuse despite a policy guaranteeing residents freedom from abuse.
A resident with multiple medical conditions and moderate cognitive impairment sustained a head injury when a CNA and a family member repositioned her in bed, causing her head to strike the headboard. An RN assessed the scalp and found no visible injury, but documented the event only on paper, not in the clinical record, and did not notify the physician or initiate monitoring as required by facility policy for accidents/incidents and changes in condition. Several days later, the resident developed severe headache and dizziness and was sent to the ED, at which time other staff learned of the prior head injury that had never been entered into the medical record.
A resident in need of pain management did not receive safe and appropriate pain control, as the facility did not adequately address the resident's pain according to their requirements.
The facility did not provide pharmaceutical services to meet the needs of each resident and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Surveyors found that medications were not properly labeled or stored, including loose unidentified pills in a med cart, opened inhalers without date labels, and expired lubricating jelly in a crash cart. Staff and the DON confirmed these findings were not in line with facility policy and could impact safety and infection control.
A resident with multiple health conditions and impaired cognition, who required assistance with personal care, was observed on several occasions to have long, jagged fingernails despite expressing a desire for them to be trimmed. Staff and documentation confirmed the need for nail care, but the required assistance was not provided in accordance with facility policy.
A resident with mental and psychological issues was not accurately assessed for behavior problems in the MDS, despite documented incidents of physical aggression and auditory hallucinations. The MDS Coordinators and DON confirmed the inaccuracies, highlighting the importance of accurate assessments for effective care planning.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. A resident with diabetes and atrial fibrillation lacked care plans for insulin and anticoagulation medications. Another resident using oxygen therapy had no care plan, and a third resident on antipsychotic medication also lacked a care plan. These oversights were confirmed by nursing staff and the Director of Nursing.
A resident with chronic obstructive pulmonary disease and other conditions was found using oxygen therapy without a physician's order or care plan in place. The facility's policies require a physician's order and a comprehensive care plan for such treatments, which were not followed in this case.
A resident with severe cognitive impairment and mood issues was prescribed Haloperidol without proper monitoring of behavior or side effects, and without a care plan. Facility staff confirmed the lack of adherence to the facility's policy on psychotropic medication use, which requires monitoring for efficacy and adverse consequences.
A resident with severe cognitive impairment and multiple health issues was found to have an inaccessible call light, placed inside a bucket on a bedside cabinet, making it unreachable. The resident was unaware of its location, and staff confirmed the call light should have been within reach. Facility policy and CMS guidelines require accessible call systems for residents.
Failure to Protect Resident From Repeated Sexual Abuse by Peer
Penalty
Summary
The facility failed to protect a resident from sexual abuse when another resident grabbed her breast, waist, and buttock without permission on multiple occasions. Resident 1, who had a history of substance abuse and a personal history of unspecified childhood abuse, was cognitively intact with a BIMS score of 15/15. On 2/27/26, Resident 3 reported to staff, via a SOC 341 form, that he saw Resident 2 grabbing Resident 1’s buttock and breasts and that Resident 1 did not like it. Resident 1 later stated that a tall Black male resident had touched her breast, waist, and buttock three times, that she did not like it, and that she felt disrespected by the inappropriate touching. Resident 2, who had schizoaffective disorder and stimulant dependence and was also cognitively intact with a BIMS score of 15/15, admitted during interview that he used his right hand to grab the chest, waist, and buttock of a female resident and that the incident occurred again the next day until staff intervened. Resident 3, who had schizoaffective disorder and depression and was cognitively intact, confirmed witnessing Resident 2 grabbing Resident 1’s breast and buttock three to four times and physically demonstrated the grabbing motion during interview. Licensed Nurse 1 and the Director of Nursing both confirmed that Resident 3 had seen Resident 2 touching Resident 1’s breast and buttock inappropriately. Progress notes documented that on 3/2/26 Resident 1 reported a male resident had touched her waist, pulled her close, and touched her breasts and buttocks, and that she wanted staff to tell Resident 2 not to bother her anymore. Additional progress notes dated 2/28/26 indicated a nurse again witnessed Resident 2 using his right hand to brush Resident 1’s left buttock. Resident 2’s progress notes on 3/2/26 showed that the interdisciplinary team discussed his ongoing behaviors of initiating physical contact with peers without invitation. Despite the facility’s written policy stating residents have the right to be free from abuse, including sexual abuse, these documented incidents show that Resident 1 experienced sexual abuse by Resident 2 on more than one occasion before effective protection was in place.
Failure to Document and Report Resident Head Injury as Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to document and respond appropriately to a resident’s change in condition following a head injury. The resident was admitted with diagnoses including a lumbar vertebral wedge compression fracture, giant cell arteritis, and major depressive disorder, and had moderate cognitive impairment per the MDS. On an evening shift, a CNA and the resident’s family member repositioned the resident in bed; during this maneuver, the resident’s head struck the headboard. The CNA’s written statement indicated she told the family member she would notify the nurse, and the family member initially declined but the CNA stated she would inform the nurse anyway. According to the nurse’s written statement, the family member reported that the resident’s head had hit the headboard when being pulled up in bed. The nurse assessed the resident’s scalp, found no drainage or openings, and confirmed twice with both the resident and family member that the resident was “okay.” However, the nurse documented the incident only on paper and not in the resident’s clinical record or progress notes. There was no documentation of this event as a change in condition, no physician notification, and no monitoring initiated at that time, despite the facility’s policy requiring notification and documentation for accidents or incidents involving a resident. Several days later, the resident developed a severe headache rated 10/10 and dizziness, which led to a change in condition note and transfer to the emergency department. At that time, the family member reported the earlier head injury, and staff, including another nurse and a physical therapist, were unaware of the prior incident because it had not been entered into the clinical record. Interviews with nursing staff, the DON, and the Administrator confirmed that the incident on the earlier date was not documented in the resident’s medical record, the physician was not notified, and the resident was not monitored following the head injury, contrary to the facility’s written policy on changes in a resident’s condition or status.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to ensure that the resident's pain was properly addressed according to their needs.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Improper Medication Labeling and Storage, Expired Supplies Found
Penalty
Summary
Surveyors observed that the facility failed to ensure medications and biologicals were properly labeled and stored according to facility policies and accepted professional standards. Specifically, three loose pills were found in a medication cart, which staff confirmed should not occur as the medications could not be identified and this posed infection control concerns. Additionally, two opened Trelegy Ellipta inhalers were found in medication carts without opened date labels, contrary to facility policy and manufacturer instructions that require inhalers to be discarded six weeks after opening. Staff interviews confirmed that the lack of labeling could affect medication efficacy and that opened inhalers should be dated to ensure timely disposal. Further, seven expired lubricating jellies were discovered in a crash cart, which staff acknowledged should not be present due to the risk of irritation or side effects if used during emergencies. The facility's policies require regular inspection and maintenance of crash carts to ensure supplies are current and safe for use. The Director of Nursing confirmed that expired items and improperly stored medications were not in compliance with facility procedures and posed safety concerns.
Failure to Provide Required Nail Care Assistance
Penalty
Summary
The facility failed to provide necessary assistance with nail care for one resident who was unable to perform this activity independently. The resident, who had diagnoses including bipolar disorder, heart failure, muscle weakness, and required assistance with personal care, was observed on multiple occasions to have long and jagged fingernails with sharp edges. The resident expressed a desire to have his fingernails trimmed short, specifically mentioning his interest in playing the guitar. Despite this, observations on consecutive days confirmed that the resident's fingernails remained untrimmed. Documentation on the resident's Shower Check Skin Observations sheets also indicated that nail clipping was needed, and these sheets were signed by both a CNA and a licensed nurse. Interviews with staff, including a CNA, the Director of Staff Development (DSD), and the Director of Nursing (DON), confirmed that nail care should be performed at least twice a week on shower days and as needed, and that the resident's current nail condition was not acceptable. The facility's policy required that residents unable to perform ADLs independently receive appropriate support and assistance with hygiene and grooming, including nail care. However, the necessary care was not provided, as evidenced by the resident's continued long and jagged fingernails despite documented need and staff awareness.
Inaccurate MDS Assessment of Resident's Behavior
Penalty
Summary
The facility failed to accurately assess a resident's behavior issues during the seven-day look-back period on the Minimum Data Set (MDS). The resident, admitted in October 2024 with mental and psychological diagnoses, was involved in a physical altercation with another resident, as noted in a Change in Condition Note dated 11/3/24. Despite this incident and the administration of Haloperidol for auditory hallucinations, the MDS dated 11/9/24 did not reflect these behaviors, indicating no physical behaviors or hallucinations during the look-back period. Interviews with the MDS Coordinators confirmed the inaccuracy of the MDS, as the resident's medical records showed evidence of auditory hallucinations and physical aggression. The Director of Nursing emphasized the importance of accurate MDS assessments for effective care planning. The facility's policy requires all personnel completing any part of the MDS to certify its accuracy, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in their care. Resident 24, who was admitted with multiple diagnoses including type 2 diabetes mellitus and atrial fibrillation, did not have care plans reflecting the physician's orders for insulin and anticoagulation medication. Despite having orders for Humalog, Levemir, and Eliquis, there were no corresponding care plans in the resident's medical record. This oversight was confirmed by both a Licensed Nurse and the Director of Nursing, who acknowledged the absence of care plans for these critical medications. Resident 23, diagnosed with chronic obstructive pulmonary disease, congestive heart failure, and dementia, was observed using oxygen therapy without a developed care plan. The resident's clinical records lacked documentation for the oxygen therapy, which was confirmed by a Licensed Nurse and the Director of Nursing. The absence of a care plan for oxygen therapy meant that staff did not have guidance on how to administer and manage the resident's oxygen needs effectively. Resident 25, with diagnoses including congestive heart failure and an anxiety disorder, was prescribed Haloperidol for delirium and agitation. However, there was no care plan for the antipsychotic medication in the resident's records. This was confirmed by a Licensed Nurse, the Director of Nursing, and a Consultant Pharmacist, all of whom stated that the medication should have been care planned. The facility's policy indicated that care plans should be comprehensive and include measurable objectives and timeframes, which were not met in these cases.
Oxygen Therapy Administered Without Physician's Order
Penalty
Summary
The facility failed to ensure proper delivery of respiratory care for a resident, identified as Resident 23, who was using oxygen therapy without a physician's order and without the therapy being included in the care plan. Resident 23, who was admitted in May 2024, had diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and dementia, with a moderately impaired cognition as indicated by a BIMS score of 8 out of 15. During an observation, Resident 23 was found using oxygen delivered via a nasal cannula with the concentrator set at 3.5 LPM, despite not having a physician's order for this treatment. Licensed Nurse 3 confirmed the absence of a physician's order and care plan for the oxygen therapy, acknowledging that oxygen therapy requires a physician's order and should be care planned. The Director of Nursing also stated that delivering oxygen without a physician's order is not acceptable as it is a treatment that could be unsafe for the resident. The facility's policy and procedures for oxygen administration and care planning were not followed, as they require verification of a physician's order and a comprehensive care plan for each resident.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident did not receive unnecessary antipsychotic medication. The resident, who was admitted in June 2023, had diagnoses including congestive heart failure, anxiety disorder, altered mental status, and required assistance with personal care. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and mood issues, with behavioral symptoms occurring 1 to 3 days a week. Despite these conditions, the resident was prescribed Haloperidol Lactate Concentrate, an antipsychotic medication, without proper monitoring of disruptive behavior or side effects, and without a developed care plan for the medication. Interviews with facility staff, including a Licensed Nurse, the Director of Nursing, and a Consultant Pharmacist, confirmed the lack of monitoring and care planning for the antipsychotic medication. The facility's policy on psychotropic medication use requires monitoring for efficacy and adverse consequences, which was not adhered to in this case. The absence of monitoring and care planning for the antipsychotic medication had the potential to result in unsafe administration and adverse effects for the resident.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to provide an accessible call system for a resident, identified as Resident 25, whose call light button was not within reach. Resident 25, admitted in June 2023, had diagnoses including congestive heart failure and an anxiety disorder, and required varying levels of assistance with personal care and mobility. The resident's cognitive assessment indicated severely impaired cognition, and mood assessment showed feelings of depression. During an observation, the call light was found inside a bucket on a bedside cabinet, approximately three feet away from the resident's bed, making it inaccessible. The resident was unaware of the call light's location and confirmed the inability to reach it. Licensed Nurse 3 confirmed the call light was not within reach and acknowledged that it should not have been placed in the bucket, as the resident needed access to it for assistance. The Director of Nursing stated that the expectation was for the call light to be within the resident's reach. The facility's policy, revised in 2017, required that residents confined to bed have access to a call light. The Centers for Medicare & Medicaid Services document also indicated that the call system must be accessible to residents while in bed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Auburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Auburn Oaks Care Center | 0.1 mi | ★★★★★ | 9 | 0 |
| Westview Healthcare Center | 0.8 mi | ★★★★★ | 12 | 0 |
| Auburn Ravine Healthcare Center | 3.1 mi | ★★★★★ | 19 | 0 |
| Rock Creek Care Center | 4.1 mi | ★★★★★ | 9 | 0 |
| Lincoln Meadows Care Center | 11.4 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.