Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Villa Siena during CMS and state inspections, most recent first.
Bed rail use lacked required assessment and documentation for multiple residents. Surveyors observed residents with upper, lower, bilateral half, and four side rails attached to their beds, and staff confirmed some residents used the rails or could pull them up as needed. Records showed no documented FDA entrapment-zone inspections, no entrapment risk assessments for all residents with rails, no documented alternatives attempted for many residents, missing MD orders for most residents, and absent care plans and assessment forms related to bed rail use.
Failure to monitor use of restraint devices: Two residents had devices used for safety, including a personal alarm, bed alarm, and lap buddy for one resident with Parkinson’s disease and psychotic disorder, and a personal alarm for another resident with dementia. Staff observed both residents seated in wheelchairs with alarms in place, and the DON and RN stated the devices were used to prevent falls or impulsive movement. The DON confirmed there was no documented monitoring for safety, comfort, skin integrity, or continued need for the devices.
A resident with Alzheimer’s disease, GAD, and dementia received PRN lorazepam 9 times before showers or hospice shower visits even though the order was for anxiety and the chart did not show documented behavioral interventions before administration. RN and DON interviews confirmed the doses were sometimes given at hospice request and that pre-shower use was not part of the order. The record also showed the PRN lorazepam order was transcribed for 120 days even though the physician order and consent reflected 90 days.
Inaccurate MDS Coding of Bed Rails as Restraints: The facility incorrectly coded bed or side rail use as physical restraints for multiple residents in the MDS, even though Bed Rail assessments and direct observations showed the rails were used as enablers for repositioning, mobility, and transfers. The MDS nurse confirmed that several residents with varying BIMS scores used upper rails only, and that the rails did not hinder movement or should not have been coded as restraints.
Failure to develop required resident care plans: one resident with dementia did not receive a timely activity assessment or baseline activity care plan, one resident with bipolar disorder and dementia lacked care plans for TD and dementia, one resident with epilepsy had no restraint care plan despite full padded side rails being treated as restraints, and one resident with dementia had no care plan for a personal alarm. The DON and other staff confirmed the missing care plans and late assessment during record review and interviews.
Quarterly updates were missed for two residents' care documentation. One resident with Alzheimer's disease had an activity care plan and hospice care plan that were not updated quarterly, and another resident with Alzheimer's disease had an activity assessment and activity care plan that were not updated quarterly. The SW, RN C, MDS nurse, and DON all verified the missing updates, and the facility policy required IDT review and care plan revision at least quarterly with the MDS assessment.
The facility failed to provide care according to orders, resident preferences, and goals for two residents with Wander Guard devices. One resident had dementia, hypertension, and cataracts, and another had Alzheimer’s disease, dementia, hypertensive heart disease, CKD, HF, and ESRD. The DON confirmed there were no physician orders or monitoring for the devices, the facility had no policy for Wander Guard use, and an LVN stated the monitoring was not documented.
Unsafe food storage and damaged cutting boards were observed in the kitchen when three avocados were wrinkled, soft, and dented, and nine cutting boards had deep cut marks and brown discoloration. The NSD confirmed the findings and stated the avocados would not be served and the boards would be thrown out. The facility policy required fruit quality checks, and the FDA Food Code addresses resurfacing cutting boards that can no longer be effectively cleaned and sanitized.
Failure to Complete Annual CNA Performance Evaluations: The facility did not complete the annual performance evaluations for two CNAs. Record review showed each CNA had a prior evaluation on file, but no updated annual evaluation was present. HR confirmed one evaluation was missing and said the DON was responsible, with a backlog. The DON confirmed she was behind on staff performance evaluations and later provided copies of the evaluations, confirming they were not updated.
Daily Nurse Staffing Information Not Updated: The facility failed to keep the daily nurse staffing post current, leaving an outdated posting at the nurse station and later replacing it with a posting that had the wrong date. RN C confirmed weekend staff missed posting the staffing information and that it should always reflect the current date, and the DON confirmed the posting was not updated over the weekend and was posted with the wrong date when staff attempted to update it.
An expired emergency kit and an expired topical medication were found in the med room during survey observation. An LVN confirmed that two lorazepam vials in the refrigerated E-kit had expired and that a tube of Capzasin Quick Relief Gel for a resident was also past its expiration date and still in active stock. Facility policy required regular E-kit expiration checks and immediate removal of outdated meds.
The facility failed to follow their policies for influenza and pneumococcal vaccinations, not offering these vaccinations in accordance with CDC recommendations to 22 of 29 residents. The facility did not track or document the vaccination status for several residents, and eligible residents were not offered the vaccines as required.
The facility failed to accurately assess and complete the MDS for 20 of 29 residents, leading to discrepancies in documenting pressure ulcers, medication administration, and pneumococcal vaccination status. This compromised the ability to develop and implement resident-centered care plans and interventions.
The facility failed to ensure an RN was on duty for 8 consecutive hours on multiple days in October, November, and December of 2023. The DON confirmed the absence of an RN on the specified dates and acknowledged that no waiver was in place for the reduced RN hours.
The facility failed to maintain safe and sanitary food service operations. The ice machine drain pipe lacked the required air gap, a Dietary Aide served food without a hair net, and the resident's refrigerator temperature was not recorded twice daily as required. These issues could potentially expose residents to harmful contaminants.
The facility failed to obtain informed consents for the use of various alarms, considered restraints, for 13 residents. These included personal safety alarms, floor mat alarms, and wander/elopement alarms. The DSD and DON confirmed that the facility did not obtain consents because they did not consider these alarms as restraints, despite documenting them under Section P Restraints in the MDS assessments. The facility also lacked a policy on the use of these restraints.
A resident with severe cognitive impairment and a history of falls did not have a care plan developed to address fall prevention, despite multiple falls and a physician's order for a bed/wheelchair alarm. This was confirmed by the MDS Coordinator and was against the facility's policies and procedures.
The facility failed to provide appropriate respiratory care for a resident with heart failure and other conditions. The resident's nasal cannula and humidifier were outdated, and the humidifier was empty. Licensed nurses did not document oxygen administration, and the physician's order lacked an indication for use. These issues were confirmed by staff and violated the facility's policies.
The facility failed to obtain physician admission orders for two residents, leading to unauthenticated and potentially inaccurate treatment orders. The Infection Preventionist confirmed the absence of these orders and stated that licensed nurses should have obtained them. The facility's policy mandates that no resident shall be admitted without a physician's order.
A facility failed to ensure a PRN psychotropic medication order for a resident was limited to 14 days, resulting in the medication being administered beyond the allowed period. The DON confirmed the oversight, which did not comply with the facility's policy requiring re-evaluation by a physician after 14 days.
The facility failed to ensure proper medication storage, leading to the presence of expired medications in the medication cart for three residents. An inspection revealed expired Latanoprost, Furosemide, and Oxycodone HCL solutions, which should have been removed according to the facility's policy.
The facility failed to properly store and label food brought from outside by family members for a resident. Multiple observations revealed that seven small plastic containers in the resident's refrigerator were not labeled with a date. The FSD confirmed that all food should be labeled with the resident's name and date, and the DON stated that the licensed nurse should have checked and labeled the food. The facility's policy requires all food brought in to be checked and labeled, and food without a manufacturer's date must be discarded after three days.
The facility failed to follow proper infection prevention practices in two instances. Staff did not clean the glucometer machine according to the manufacturer's guidelines, and an LVN did not perform hand hygiene or change gloves appropriately during a wound treatment procedure. Both actions were against the facility's policies and procedures.
Bed Rail Use Lacked Required Assessment and Documentation
Penalty
Summary
The facility failed to ensure proper use of side rails and bed rails for 30 of 30 residents with bed rails installed. Surveyors found no documentation that the facility completed an accurate routine bed inspection using the FDA entrapment zones for the beds and side rails, and the Plant Operations Manager confirmed he had stopped checking the bed measurements after being told the state regulation had changed. He stated he only measured the spaces between the mattress and the side rails, and between the mattress and the headboard and footboard, but could not demonstrate the other FDA-recommended zones during observation. Surveyors observed multiple residents with upper, lower, bilateral half, or four side rails attached to their beds, including residents who were in bed, seated in wheelchairs, sleeping, or not present in the room. The Minimum Data Set Nurse confirmed that several residents used the rails or could pull them up as needed. Record review showed that 30 of 30 residents did not have documentation of an entrapment risk assessment completed before bed rail use, and the DON and POM confirmed that no entrapment risk assessment had been completed for all 30 residents. The facility also failed to document alternatives attempted before bed rail use for 15 of 15 residents who used them. Record review and staff interviews confirmed that the assessments for those residents did not show that alternatives such as roll guards, foam bumpers, lowering the bed, or concave mattresses had been offered or tried. In addition, 13 of 15 residents did not have a physician's order for bed rail use, 15 of 15 residents did not have a person-centered care plan related to bed rail use, 12 of 30 residents had no side/bed rail assessment form completed, and 2 residents did not have updated bed rail assessments. The facility's policy stated that bed frames, mattresses, and bed rails must be checked for compatibility and that gaps must remain within FDA safety dimensions, but the records reviewed did not show completion of the required assessments and documentation.
Failure to Monitor Use of Restraint Devices
Penalty
Summary
The facility failed to ensure monitoring for safety, comfort, skin integrity, and continued need for physical restraints for two residents who had devices used to limit movement. One resident was admitted with Parkinson’s disease with dyskinesia, psychotic disorder with hallucinations, and major depressive disorder, and had physician orders for a personal alarm, bed alarm, and lap buddy for safety. During observations, the resident was seen sitting in a wheelchair near the nurse’s station with a personal alarm attached to her back and a lap buddy placed in front of the wheelchair. The DON stated the lap buddy and personal alarm were used to prevent falls and to prevent sudden and abrupt movement. A second resident was admitted with unspecified dementia, essential hypertension, and cataract, and had a physician’s order for a personal alarm for fall alert. During observation, the resident was sitting in a wheelchair near the nurse’s station with a personal alarm attached to her back. RN C stated the alarm was used because the resident was impulsive and got out of the chair. The DON confirmed there was no documented monitoring for safety, comfort, skin integrity, and continued need for the personal alarm, lap buddy, or bed alarm for either resident. The facility policy stated restraint use should be the least restrictive alternative for the least amount of time necessary and that ongoing re-evaluation and monitoring for safety, comfort, skin integrity, and continued need should be documented.
Unnecessary PRN Lorazepam Use and Order Duration Error
Penalty
Summary
Resident 29, who was admitted with Alzheimer’s disease, generalized anxiety disorder, and dementia, had a PRN lorazepam order for anxiety related to constantly looking for his wife and repeatedly asking to go home. During observations on 7/21/25, 7/22/25, and 7/23/25, the resident was calm, quiet, pleasant, patient, and without observed anxiety or distress. However, the record showed that lorazepam 0.5 mg was administered 9 times between 3/27/25 and 7/17/25 before showers or hospice shower visits, including documentation such as “given before scheduled shower,” “premedication before scheduled shower,” and “premedicate for hospice shower.” During interview, RN C stated she gave one dose of lorazepam before a shower at hospice request and acknowledged that premedication before a shower was not part of the physician’s order. The DON reviewed the 9 administrations and confirmed she could not find documented evidence that behavioral or non-pharmacological interventions were attempted and failed before the medication was given. The DON later stated some behavioral interventions were documented at the end of shift and were not necessarily tied to the time of medication administration, especially before hospice showers. The record also showed a discrepancy in the duration of the PRN lorazepam order. The physician’s order dated 4/25/25 and the informed consent form both reflected lorazepam 0.5 mg every 6 hours as needed for 90 days, but the active order was transcribed as 120 days. The DON reviewed the record and confirmed the latest lorazepam order was for 90 days, not 120 days. The facility policy stated psychotropic medication management includes duration of use and that non-pharmacological approaches are used unless contraindicated.
Inaccurate MDS Coding of Bed Rails as Restraints
Penalty
Summary
The facility failed to accurately reflect resident status in the MDS for 11 of 15 residents who used side or bed rails. For Residents 26, 19, 6, 17, 18, 29, 22, 4, 14, 15, and 7, the MDS assessments coded the use of side or bed rails as physical restraints, even though the Bed Rail assessments identified the rails as enablers used to promote independence. The report states that this inaccurate coding affected residents with varying cognitive status, including residents with BIMS scores ranging from 5 to 15, and one resident with short-term and long-term memory problems. During observations, surveyors and the MDS nurse found that the residents had upper bed rails in place, but the rails were being used for repositioning, mobility, or transfers rather than as restraints. For example, Resident 19 had two upper bed rails and the MDS nurse stated the rails did not hinder movement and could help with transfers out of bed. Resident 26 used the two upper rails at night to reposition himself. Resident 17 stated he used the left rail to reposition in bed and transfer out of bed, and Resident 14’s rails helped him reposition and transfer. Similar findings were documented for Residents 18, 29, 22, 4, 15, and 7, with the MDS nurse confirming that the rails were used only as enablers or for mobility and should not have been coded as restraints. The report also notes that the MDS nurse reviewed the Bed Rail assessments and the quarterly or annual MDS assessments during interviews and confirmed that the restraint coding was inaccurate for each of the listed residents. The CMS LTCF RAI Manual excerpt included in the report states that physical restraints are devices attached or adjacent to the body that the individual cannot easily remove and that restrict freedom of movement or access to one’s body. The deficiency was based on the facility’s failure to code the residents’ bed rail use consistently with the documented assessments and observed use.
Failure to Develop Required Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans and failed to complete timely initial assessments and baseline care plans for four sampled residents. For one resident admitted with unspecified dementia and mood disturbance, the initial recreational activity assessment was not completed within 14 days of admission, and no baseline activity care plan was initiated. The social worker verified both the late assessment and the absence of a baseline activity care plan, and the DON acknowledged that the assessment should have been completed within the required timeframe and that a baseline care plan should have been in place. For another resident admitted with bipolar disorder and receiving fluphenazine and benztropine, the clinical record showed treatment for tardive dyskinesia, including benztropine ordered for TD. The record did not contain a comprehensive care plan addressing TD, including signs and symptoms to monitor, treatment approaches, goals, or interventions. The DON stated the resident had tongue rolling and later confirmed that a care plan for TD was not found and should have been developed. The same resident also had diagnoses of unspecified dementia with anxiety and a history of dementia with paranoia, but the record did not contain a person-centered dementia care plan. The resident’s MDS assessments coded non-Alzheimer’s dementia, and the MDS nurse and DON both confirmed that a dementia care plan should have been developed. The facility also failed to develop care plans for the use of restraints and a personal alarm. One resident with generalized epilepsy and unspecified intellectual disabilities had a physician’s order for full padded side rails, and the DON stated that all side rails were raised and considered restraints; however, no restraint care plan was developed. Another resident with unspecified dementia, hypertension, and cataracts had a physician’s order for a personal alarm for fall alert, and the DON confirmed that no care plan had been developed for the alarm. The facility’s policies referenced timely assessments and comprehensive person-centered care planning, but the records for these residents did not reflect those care plans.
Quarterly care plan and assessment updates were not completed for two residents
Penalty
Summary
The facility failed to ensure that care plans and assessments were reviewed and updated quarterly for two residents. Resident 2, who was admitted with a primary diagnosis of unspecified Alzheimer's disease and was confused and unable to answer questions during observation, had an activity care plan last updated on 3/25/25 with no later update. Her hospice care plan was also last updated on 3/25/25 and was not updated regularly or quarterly. During record review and staff interviews, the social worker, RN C, and the MDS nurse each verified that both plans should have been updated quarterly, and the DON acknowledged the lack of quarterly updates. Resident 22, who was admitted with a primary diagnosis of unspecified Alzheimer's disease and was observed eating lunch in the dining area while alert, calm, and verbally responsive, also had an activity assessment and activity care plan that were not updated quarterly. During concurrent review, the social worker verified that both documents were not updated regularly or quarterly. The DON acknowledged that Resident 22's activity assessment and activity care plan should have been updated quarterly. The facility policy stated that the interdisciplinary team reviews and updates the care plan at least quarterly in conjunction with the required quarterly MDS assessment.
Lack of Orders, Monitoring, and Policy for Wander Guard Use
Penalty
Summary
The facility failed to provide care in accordance with standards of practice for two residents when there was no physician's order, monitoring, or policy for the use of Wander Guard. Resident 28 was admitted with diagnoses including unspecified dementia, essential hypertension, and cataract. During interview, RN C confirmed that Resident 28 had a Wander Guard, and the DON later confirmed there was no physician order and no monitoring for its use. Resident 29 was admitted with diagnoses including Alzheimer's disease, dementia, hypertensive heart disease, chronic kidney disease with heart failure, and end stage renal disease. During a concurrent interview and record review, the DON confirmed that Resident 29 had a Wander Guard, but there was no physician order and no monitoring for its use. The DON also stated the facility did not have a policy for the use of Wander Guard, and LVN D stated that the facility did not document monitoring for its use.
Unsafe Food Storage and Damaged Cutting Boards
Penalty
Summary
The facility failed to ensure safe food storage practices and sanitary conditions in the kitchen when three of 13 avocados were observed to be wrinkled, soft, and dented, and nine of 13 cutting boards had deep cut marks and brown discoloration on their surfaces. During a concurrent observation and interview, the Nutrition Service Director confirmed the condition of the avocados and stated they would not be served and would be thrown out. The facility's policy for refrigerated storage indicated that fruit should be checked for quality, and the FDA Food Code states that cutting boards with scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete the CNA Annual Performance Evaluation for two of five sampled employees, CNA E and CNA F. During record review on 7/25/2025, CNA E’s file contained an Annual Performance Evaluation for 4/16/2023 to 4/16/2024, but no evaluation for 4/16/2024 to 4/16/2025. CNA F’s file also contained an Annual Performance Evaluation for 4/16/2023 to 4/16/2024, but no evaluation for 4/16/2024 to 4/16/2025. During interview, HR confirmed CNA F’s Annual Performance Evaluation had not been completed and stated the DON was responsible for completing the evaluations, but there was a backlog. The DON later confirmed she was responsible for the staff performance evaluations and stated she was behind with them. On 7/28/2025, the DON provided copies of CNA E and CNA F’s Annual Performance Evaluations for 4/16/2024 to 4/16/2025 and confirmed that both evaluations were not updated. The facility’s Employee Handbook stated that performance reviews occur annually.
Daily Nurse Staffing Information Not Updated
Penalty
Summary
The facility failed to update the daily nurse staffing information posts for 7/19/2025, 7/20/2025, and 7/21/2025. During an observation beside the nurse station on 7/21/2025 at 10:15 a.m., a glass-covered board displayed the daily nurse staffing information dated 7/18/2025. During another observation on 7/21/2025 at 3:21 p.m., the posting beside the nurse station had been changed to a new one dated 7/22/2025. During a concurrent interview and photo review on 7/22/2025 at 2:38 p.m., RN C confirmed the first picture was dated 7/18/2025 and the second picture was dated 7/22/2025. RN C stated the daily nurse staffing information should have been updated during the weekend and should be updated by night shift nurses, and confirmed weekend staff missed posting the 7/19/2025, 7/20/2025, and 7/21/2025 information. During an interview with the DON on 7/25/2025 at 2:15 p.m., the DON confirmed the staffing information was not updated over the weekend and that the evening shift tried to update it on 7/21/2025 but posted it with the wrong date. Review of the facility policy titled, Posting Direct Care Daily Staffing Numbers, indicated staffing data is to be posted on a daily basis and include the current date.
Expired Emergency Kit and Medication Found in Stock
Penalty
Summary
Drugs and biologicals were not maintained in accordance with accepted storage and labeling practices when an expired emergency kit and an expired medication remained in active stock. During observation of the medication room with an LVN, an emergency kit in the medication refrigerator was found to contain three refrigerated medications, including two lorazepam vials listed on the outside contents sheet with an expiration date of 3/2025. On inspection of the kit contents, one lorazepam vial was found expired in 3/2025 and another in 4/2025, and the LVN acknowledged the kit should have been replaced. During the same visit, a tube of Capzasin Quick Relief Gel for Resident 18 was found with an expiration date of 5/2025, and the LVN acknowledged the expired medication should have been removed from active stock. Facility policy stated emergency kits are checked regularly for expiration dating and outdated medications are immediately removed from stock.
Failure to Follow Vaccination Policies
Penalty
Summary
The facility failed to follow their policies for influenza and pneumococcal vaccinations, as they did not offer these vaccinations in accordance with the current CDC recommendations to 22 of 29 residents. Specifically, the facility did not track or document the pneumococcal vaccination status for Residents 2, 6, 7, 9, 12, 15, 27, and 181. The Director of Nursing (DON) confirmed the lack of documentation and acknowledged that the facility should have tracked these records. Additionally, the Infection Preventionist (IP) confirmed that the facility did not offer the vaccines to eligible residents per CDC recommendations, and the facility's policy was not followed in this regard. For Residents 3, 5, 10, 11, 13, 14, 16, 18, 20, 21, 23, 24, and 25, the medical records indicated that they were eligible for pneumococcal vaccines but were not offered the vaccines as per the CDC's recommendations. The DON and IP both confirmed that these residents were eligible and should have been offered the vaccines to be up to date with the CDC guidelines. The facility's policy required assessments and administration of pneumococcal vaccines within specific timeframes, which were not adhered to. Furthermore, the facility failed to document the influenza vaccination status for Residents 12 and 181. The IP could not locate any documentation for Resident 181's influenza vaccination status and acknowledged that the facility should have tracked this record. For Resident 12, although the resident refused the influenza vaccine, there was no documentation indicating the refusal. The facility's policy required documentation of vaccine refusals, which was not followed in this case.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately assess and complete the Minimum Data Set (MDS) for 20 of 29 residents, which compromised the ability to develop and implement resident-centered care plans and interventions. For instance, Resident 29's MDS inaccurately indicated the presence of a stage 2 pressure ulcer upon admission, which was confirmed to be incorrect by the Minimum Data Set Coordinator (MDSC). Similarly, Resident 24's MDS failed to accurately reflect the administration of antipsychotic medications, despite physician orders indicating their use. This discrepancy was acknowledged by the Director of Staff Development (DSD) during an interview and record review. Additionally, the MDS for multiple residents inaccurately reported their pneumococcal vaccination status. Residents 2, 6, 7, 9, and 15, among others, were documented as having up-to-date pneumococcal vaccinations, but the facility's immunization records did not support this. The Director of Nursing (DON) confirmed that these residents were eligible for the vaccine but had not received it, leading to inaccuracies in their MDS documentation. The DSD also confirmed that the MDS for these residents was not accurate. The Long-Term Care Facility Resident Assessment Instrument (RAI) manual requires that assessments accurately reflect the resident's status, which was not adhered to in these cases.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was on duty for 8 consecutive hours on multiple days in October, November, and December of 2023. Specifically, no RN was scheduled or on duty on 10/7/23, 10/21/23, 10/28/23, 11/4/23, 11/11/23, 11/24/23, 12/2/23, and 12/9/23. This was confirmed by the Director of Nursing (DON) during an interview on 4/18/24, where she acknowledged the absence of an RN on the specified dates and admitted that the facility did not have any waiver in place for the reduced RN nursing hours. The facility was aware of the requirement for a registered nurse to provide resident care for 8 hours a day, 7 days a week, but failed to meet this standard on the mentioned dates.
Deficiencies in Food Service Operations and Temperature Monitoring
Penalty
Summary
The facility failed to ensure safe and sanitary food service operations were carried out according to standards of practice. Specifically, the ice machine drain pipe in the Skilled Nursing Facility (SNF) kitchen was observed to be touching the bottom of the floor drainage sink, lacking the required two-inch air gap. This was confirmed by the Food Service Director (FSD) during an observation and interview. Additionally, a Dietary Aide (DA) was observed serving food without wearing a hair net, which was against the facility's policy and procedure for sanitation and infection control. The DA acknowledged the oversight during the interview. Furthermore, the temperature of the resident's refrigerator in the activity room was not recorded two times each day as required by the facility's policy. The FSD confirmed that the temperature log showed weekly recordings instead of the mandated twice-daily checks. The facility's policy indicated that refrigerator temperatures should be recorded twice daily to ensure they remain at or below 41 degrees Fahrenheit. These failures could potentially expose 29 residents to harmful contaminants that could cause foodborne illness.
Failure to Obtain Informed Consents for Use of Restraints
Penalty
Summary
The facility failed to obtain informed consents for the use of various alarms, which are considered restraints, for 13 sampled residents. These alarms included personal safety alarms, floor mat alarms, and wander/elopement alarms. The lack of informed consent was confirmed through observations, interviews, and record reviews. For instance, Resident 2 was using a floor mat alarm without any documentation of informed consent from her or her responsible party. Similarly, Resident 5 was using a wander/elopement alarm without informed consent documentation. Additionally, multiple residents, including Residents 3, 5, 7, 8, 9, 15, 17, 18, 20, 24, 26, and 29, were using personal safety alarms on their beds or chairs without signed informed consents from them or their responsible parties. The Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed during interviews that the facility did not obtain informed consents for these alarms because they did not consider them as restraints. This was despite the fact that these alarms were documented under Section P Restraints in the Minimum Data Set (MDS) assessments for the residents. The facility also failed to provide a policy on the use of restraints, including personal safety alarms, floor mat alarms, and wander/elopement alarms. The failure to obtain informed consents for the use of these alarms had the potential to result in the continued use of restraints without the residents' or their responsible parties' knowledge or agreement. This could significantly impact the physical and psychosocial well-being of the residents and potentially lead to a deterioration in their overall health and quality of life. The facility's inaction in obtaining informed consents and its lack of a clear policy on the use of restraints were key factors leading to this deficiency.
Failure to Develop and Implement Fall Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who had multiple falls. The resident, who had severe cognitive impairment, dementia, congestive heart failure, and a history of traumatic fracture, fell on three separate occasions. Despite these incidents and a physician's order for a personal bed/wheelchair alarm, no care plan was created to address the falls. This was confirmed by the Minimum Data Set Coordinator during an interview and record review. The facility's policies and procedures require the development of a comprehensive care plan for each resident, including a fall prevention plan for those at risk or with a history of falls. However, the review of the resident's care plans showed no such plan was developed. The facility's failure to create and implement a fall care plan was acknowledged by the MDS Coordinator, who confirmed that interventions to address falls should have been included.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for a resident with heart failure, hypertensive heart disease, and cardiomyopathy. The resident's nasal cannula and humidifier were outdated, with the nasal cannula and humidifier bottle both dated 13 days prior to the observation. The humidifier bottle was also found to be empty. Licensed vocational nurse A confirmed the outdated equipment and stated that the oxygen tubing and humidifier bottle should be changed every seven days. The facility's policy indicated that the humidifier bottle should be dated and replaced as needed, but this was not followed. Additionally, the licensed nurses failed to document the administration of oxygen to the resident. Despite observations on multiple occasions showing the resident receiving oxygen at 2 liters per minute, the treatment administration records for March and April were blank for oxygen usage. Licensed vocational nurse C confirmed that the documentation was missing and stated that it should have been recorded. Furthermore, the physician's order for oxygen did not include an indication for its use. The director of nursing confirmed that the order lacked a rationale for oxygen administration, which is required to ensure the expected outcome is addressed. The facility's policy stated that oxygen therapy must be ordered by a physician when needed, but this was not properly documented in the resident's records.
Failure to Obtain Physician Admission Orders
Penalty
Summary
The facility failed to obtain physician admission orders for two residents, leading to unauthenticated and potentially inaccurate treatment orders. Resident 1 was admitted with chronic atrial fibrillation and heart failure, while Resident 17 was admitted with unspecified atrial fibrillation and sequelae of cerebral infarction. A review of their physician order summaries revealed no admission orders. During an interview and record review, the Infection Preventionist confirmed the absence of these orders and stated that licensed nurses should have obtained them. The facility's policy mandates that no resident shall be admitted without a physician's order.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure a physician's order for a PRN psychotropic medication was limited to 14 days for one resident. Specifically, Resident 27 had a physician's order for Lorazepam 0.5 mg PRN for anxiety/restlessness, dated 3/14/24, without a stop date. The medication was administered on 4/3/24, 4/4/24, and 4/5/24, which was beyond the 14-day limit. During an interview and record review, the Director of Nursing (DON) confirmed that the PRN order should have been limited to 14 days and re-evaluated by the physician, but this was not done for Resident 27. The facility's policy on psychotropic medication use, dated July 2022, also indicated that PRN orders for psychotropic medications should be limited to 14 days unless extended by the physician with documented rationale and duration. The DON acknowledged that the Lorazepam order for Resident 27 did not comply with the facility's policy and confirmed that the medication was administered beyond the 14-day limit. This oversight had the potential to result in the resident receiving the medication for an excessive length of time and experiencing adverse medication side effects. The deficiency was identified through a combination of interview and record review, highlighting a lapse in adherence to the facility's established protocols for managing PRN psychotropic medications.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure proper medication storage for three residents, leading to the presence of expired medications in the medication cart. During an inspection with LVN C, it was observed that a Latanoprost solution for Resident 6 was stored in the cart despite being expired. The medication container box indicated it was opened and had an expiration date that had passed. LVN C confirmed that the Latanoprost solution had expired and should have been removed from the cart. Additionally, two bottles of Furosemide for Resident 13 were found in the cart, both of which had expiration dates that had passed. LVN C again confirmed that these medications should have been removed from the cart. Further inspection revealed that a bottle of Oxycodone HCL solution for Resident 27 was also stored in the cart despite being expired. The medication container bottle indicated it was refilled and had an expiration date that had passed. LVN C confirmed that the Oxycodone HCL solution had expired and should have been removed from the cart. A review of the facility's policy and procedure on the storage of medications indicated that discontinued, outdated, or deteriorated drugs or biologicals should be returned to the dispensing pharmacy or destroyed, which was not adhered to in these instances.
Improper Storage and Labeling of Food Brought from Outside
Penalty
Summary
The facility failed to properly store and label food brought from outside by family members for Resident 24. During multiple observations on 4/17/2024, 4/18/2024, and 4/19/2024, it was noted that seven small plastic containers in an open big container in the resident's refrigerator were not labeled with a date. The Food Service Director (FSD) confirmed that all food in the refrigerator should be labeled with the resident's name and date. The Director of Nursing (DON) stated that the licensed nurse should have checked and labeled the food brought from an outside source. The facility's policy indicated that all food brought in should be checked by the charge nurse or the Director of Food and Nutrition Services and must be placed in a tightly sealed container with the resident's name and date on it. Food without a manufacturer's date must be discarded three days from the time it was brought in.
Infection Control Deficiencies in Glucometer Cleaning and Wound Treatment
Penalty
Summary
The facility failed to ensure proper infection prevention practices were followed in two specific instances. Firstly, for three residents, staff did not clean the glucometer machine according to the manufacturer's guidelines. During observations, Licensed Vocational Nurses (LVNs) used a Sani-Cloth wipe to clean the glucometer but did not allow it to remain wet for the required two minutes and air dry before placing it back in the medication cart. Both LVNs confirmed they were unaware of the need to let the glucometer air dry for two minutes as per the manufacturer's instructions. The facility's policy and procedure also indicated that staff should follow the manufacturer's guidelines for cleaning the glucometer, which was not adhered to in these instances. Secondly, during a wound treatment procedure for a resident, an LVN did not perform hand hygiene or change gloves appropriately. The LVN removed the previous dressing from the resident's wound without performing hand hygiene or changing gloves, then proceeded to cleanse the wound and apply a new dressing. The LVN confirmed that she should have performed hand hygiene and changed gloves after removing the previous dressing and between glove changes. The facility's policy and procedure on handwashing indicated that hands should be washed before putting on gloves, immediately after removing gloves, and after contact with wounds, secretions, mucous membranes, and other body fluids, which was not followed in this instance.
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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 Mountain View
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Camino Ridge Post-acute | 0.5 mi | ★★★★★ | 2 | 0 |
| Mountain View Healthcare Center | 0.7 mi | ★★★★★ | 3 | 0 |
| Los Altos Post-acute | 1.2 mi | ★★★★★ | 2 | 0 |
| The Terraces At Los Altos Health Facility | 2.1 mi | ★★★★★ | 0 | 0 |
| Sunnyvale Post-acute Center | 2.2 mi | ★★★★★ | 3 | 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.