Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Sienna Extended Care & Rehab during CMS and state inspections, most recent first.
The facility did not ensure that the most recent state survey results were readily accessible to residents, family members, or legal representatives, as required by policy and resident rights. Despite posted notices indicating availability, the survey results could not be located by staff or administration, and the binder intended for these documents was empty. Residents reported never seeing the survey results and described barriers when requesting access.
The facility maintained resident trust account balances that exceeded the coverage amount of its surety bond, with account balances surpassing $40,000 while the bond covered only $25,000. The DON identified 11 residents with funds in the account. The administrator acknowledged the discrepancy and attributed it to an increased number of residents, stating that the facility relied on FDIC insurance for additional protection.
Residents repeatedly voiced grievances about dietary services, including food shortages, meal delays, and reduced portions, and reported feeling that their complaints led to retaliation, such as further reductions in food variety and quantity. Despite ongoing complaints documented in resident council meetings, issues remained unresolved, and staff were unclear on procedures for addressing allegations of retaliation.
Two residents had inaccurate MDS assessments: one resident's quarterly assessment failed to indicate ongoing hospice care, and another's annual assessment did not reflect regular dialysis treatments, despite supporting documentation and staff confirmation.
Staff failed to adhere to infection prevention protocols by not wearing required gowns and gloves during care of a resident on enhanced barrier precautions, and by improperly handling soiled linen and neglecting hand hygiene between resident care activities. These lapses occurred despite clear facility policies and the presence of infection control signage and supplies.
A resident with severe cognitive impairment experienced unauthorized charges to their debit card, with funds deposited into a CNA's cash app account. The facility did not conduct interviews with other residents or staff after being notified of the misappropriation, and the only related inservice had occurred prior to the incident. The CNA was terminated after the allegation was reported, and the incident was reported to authorities.
The facility did not ensure timely reporting of suspected abuse and misappropriation of property, failing to notify APS and the state agency as required. In two cases involving missing money and a missing phone, residents and their families reported the incidents, and police were involved, but there was no documentation of required notifications to APS or timely state reporting. Staff interviews revealed a lack of awareness of reporting requirements.
Three residents with non-pressure skin conditions did not receive weekly skin assessments as ordered by their physicians. In each case, required documentation was missing for extended periods, and staff interviews revealed confusion about responsibility for completing assessments. Observations included a resident with an untreated open wound and another with persistent dry, flaky skin, with no recent assessments or treatment orders documented.
A resident with COPD did not receive oxygen therapy as ordered, with the concentrator set at 2 liters per minute instead of the prescribed 5 liters. Nursing staff failed to verify the flow rate during checks, despite facility policy requiring adherence to physician orders.
The facility allowed the maintenance supervisor, who is not authorized to administer medications, to access medication storage rooms containing residents' medications without the presence of licensed nursing staff. Staff interviews confirmed that maintenance, nurses, and medication aides all had access, contrary to facility policy that restricts access to only qualified personnel.
The facility did not ensure that the dietary manager obtained certification as a certified dietary manager within the required timeframe. The DM, employed since 2011, had not completed the necessary certification or alternative qualifications, and this was confirmed by both the DM and the administrator. Most residents received meals from the cafeteria overseen by the uncertified DM.
The facility did not provide required dementia management training to staff caring for residents with dementia. An LPN who had been at the facility for a year reported not receiving such training, and there was no documentation of dementia care in-services for staff during the relevant period. Two residents with severe cognitive impairment and behavioral issues were among those affected, and the facility had no mandatory requirement for staff dementia training.
A facility failed to ensure medications were administered as ordered for a resident with sepsis and cellulitis. The MAR showed missed doses of ceftriaxone sodium and normal saline flushes. The DON and LPNs confirmed that blanks on the MAR indicated the medication was not given.
Failure to Make State Survey Results Accessible to Residents
Penalty
Summary
The facility failed to make the most recent state survey results readily accessible to residents, family members, and legal representatives, as required. Although a framed notice was posted outside the dining room indicating that survey results were available on a table at the north end of the main entrance, the surveyor did not find any survey results on the indicated table. The facility's policy stated that the most recent survey results should be maintained in a 3-ring binder in an area frequented by most residents, such as the main lobby or activity room. However, when the activity director and administrator were asked about the location of the survey results, neither could locate them, and the binder produced by the administrator was empty. Interviews with the resident council revealed that they had never seen the state survey results and that staff questioned their reasons when they requested to view them. The activity director, responsible for the resident council, was also unaware of the survey results' location. The facility's own Resident's/Patient's Rights form stated that residents have the right to examine the last state survey, and denial of this right could result in penalties. Despite these policies and notices, the survey results were not accessible as required at the time of the survey.
Resident Trust Account Balances Exceeded Surety Bond Coverage
Penalty
Summary
The facility failed to ensure that the total amount of resident funds held in the facility trust account did not exceed the coverage provided by the facility's surety bond. Record review showed that the trust account balances at several points in time were significantly higher than the $25,000 surety bond, with balances reaching over $40,000. The Director of Nursing identified 11 residents with funds in the trust account. During interviews, the administrator acknowledged that the surety bond was intended to protect resident funds but stated that the facility relied on the bank's FDIC insurance for additional protection, considering the surety bond as redundant. The administrator also noted that an increase in the number of residents likely contributed to the higher account balances, and admitted that the facility should have monitored the account amounts more closely.
Failure to Protect Residents' Right to Voice Grievances Without Retaliation
Penalty
Summary
The facility failed to ensure that residents could voice grievances without fear of discrimination or reprisal and did not promptly resolve grievances raised by the resident council. Resident council meeting minutes over several months documented repeated complaints about dietary issues, including being out of requested food items, food not being served as ordered, meals being late, and dissatisfaction with the quality and temperature of meals. Despite meetings with the dietary manager and assurances that issues were resolved, the same complaints persisted in subsequent meetings, and documentation of how issues were resolved was often incomplete or missing. Residents reported that after voicing complaints, particularly about receiving greens daily, the facility reduced the variety and quantity of food items, such as cutting breakfast bacon portions. Residents expressed that this reduction felt retaliatory, stating that complaining led to negative consequences, including longer wait times for meals and incomplete orders. Interviews with the activity director confirmed that dining complaints were ongoing and that the process for addressing retaliation was unclear, as they were unaware of any established procedure for residents who felt retaliated against.
Inaccurate Coding of Resident Assessments
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for two residents. For one resident who began hospice services, the quarterly Minimum Data Set (MDS) assessment did not reflect their hospice status, despite documentation in the hospice contract and care plan indicating ongoing hospice care. The MDS coordinator confirmed that the assessment was coded incorrectly. For another resident requiring dialysis three times a week due to renal failure, the annual MDS assessment inaccurately indicated that the resident had not received dialysis in the facility during the assessment period, despite care plans and physician orders confirming regular dialysis treatments. The MDS coordinator acknowledged the inaccuracy in the assessment coding for this resident as well.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to follow evidence-based practices (EBP) for infection prevention and control during the care of a resident on enhanced barrier precautions. A certified nursing assistant (CNA) provided care to a resident with a PEG tube, who was on EBP, without donning a gown as required by facility policy. The CNA assisted the resident with toileting, changing clothing, and stripping bedding without wearing a gown, despite EBP signage and the availability of gowns and gloves at the room entrance. The CNA later acknowledged not following the EBP process, and the Director of Nursing confirmed that residents with PEG tubes require both gown and gloves for care activities under EBP. Additionally, the facility did not ensure proper handling of dirty linen and hand hygiene between resident care activities. A CNA was observed transporting unbagged soiled clothing through the hallway while wearing gloves, contrary to facility policy, and did not wash or sanitize hands between setting up meal trays for different residents. The CNA admitted to not knowing the hand hygiene policy and was observed performing multiple tasks for residents without appropriate hand hygiene. The administrator later clarified that dirty linen should be bagged, gloves should not be worn in the hallway, and hand hygiene is required between residents.
Failure to Prevent and Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to protect a resident from misappropriation of property by a staff member. A resident with severe cognitive impairment was found to have six unauthorized charges on their debit card, including four withdrawals deposited into a cash app account belonging to a CNA employed at the facility. The charges were discovered by the resident's family, who reported the incident to the facility and filed a police report. The resident's bank confirmed the cash app account was in the CNA's name, and the card was also used at a food establishment and a gas station. The facility's abuse, neglect, exploitation, and misappropriation prevention program required identification and investigation of all possible incidents of misappropriation. However, after being notified of the incident, the facility did not conduct interviews with other residents or staff regarding the misappropriation allegation. The DON stated that no additional residents were interviewed because they did not have similar bank cards, and no staff were interviewed in relation to the incident. The only documentation related to the investigation consisted of some statements, and the only inservice related to misappropriation was conducted prior to the incident. The CNA implicated in the misappropriation had not worked at the facility since before the incident was reported but remained on the PRN rotation until being terminated after the allegation surfaced. The facility was notified of the unauthorized charges after the resident had already been discharged. The administrator and DON confirmed that the incident was reported to the appropriate authorities, but no further internal investigation or interviews were conducted with other potentially affected individuals.
Failure to Timely Report Suspected Abuse and Misappropriation to Authorities
Penalty
Summary
The facility failed to ensure timely and proper reporting of suspected abuse, neglect, or misappropriation of resident property as required by policy and regulation. In two cases, allegations of misappropriation involving residents' personal property were not reported to Adult Protective Services (APS), and in one case, the initial report to the state agency was not made within the required two-hour timeframe. The facility's policy mandates immediate reporting of such suspicions to the administrator and appropriate authorities, including APS and the state licensing agency, but documentation and staff interviews revealed these steps were not consistently followed. One resident, with intact cognition and diagnoses including diabetes mellitus and angina pectoris, reported missing money on two separate occasions. The resident stated that the police were notified both times, and facility documentation confirmed that the administrator, family, and physician were also informed. However, there was no evidence that an initial incident report was filed with the state agency within two hours, nor was there documentation that APS had been notified. Staff interviews indicated a lack of awareness regarding the requirement to notify APS in cases of suspected abuse or misappropriation. In another instance, a resident's family reported a missing phone, which was last seen on the bedside table and later believed to have accidentally fallen into a waste basket. The police were involved, and the family, physician, and resident were notified. Despite this, there was no documentation of an initial facility-reported incident for this allegation, nor evidence that APS had been notified. The DON confirmed unawareness of the requirement to report such incidents to APS, contributing to the facility's failure to comply with mandated reporting protocols.
Failure to Complete Weekly Skin Assessments as Ordered
Penalty
Summary
The facility failed to complete weekly skin assessments as ordered for three residents with non-pressure skin conditions. For one resident with peripheral autonomic neuropathy and protein-calorie malnutrition, the last documented skin assessment was several months prior to the survey, despite a physician's order for weekly assessments. Nursing staff confirmed that no recent skin evaluations were present in the medical record. Another resident with chronic obstructive pulmonary disease and moderate cognitive impairment was observed to have moderate white, dry flakes on the face and head. Although there was a physician's order for weekly skin assessments, the last documented assessment was several weeks prior. Nursing staff were unaware of any treatment orders for the skin condition and could not confirm how long the issue had been present. The DON acknowledged that weekly assessments were not being completed as ordered and that responsibility for these assessments had shifted among staff without proper follow-through. A third resident was observed with an open wound on the right lower leg. Although there was a physician's order for weekly skin assessments and documentation of findings, there were no weekly assessments recorded for over two months. The DON and nursing staff identified a system error that resulted in the failure to generate and complete the required assessments after the departure of the wound care nurse. Review of shower sheets completed by CNAs did not document the resident's current wound, and staff interviews confirmed a lack of proper skin assessment documentation during the relevant period.
Failure to Administer Oxygen as Ordered for Resident with COPD
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of chronic obstructive pulmonary disease (COPD) did not receive oxygen therapy as ordered by the physician. The physician's order specified continuous oxygen via nasal cannula at 5 liters per minute, with titration to maintain oxygen saturation above 90%. However, observations revealed that the resident's oxygen concentrator was set to deliver only 2 liters per minute. Nursing staff confirmed the concentrator was set at 2 liters and acknowledged the order was for 5 liters, but did not verify the flow rate during their checks, only noting the resident's oxygen saturation was 93%. The facility's policy required staff to follow physician orders for oxygen administration, but this was not done in this instance.
Unrestricted Access to Medication Storage Rooms by Non-Qualified Staff
Penalty
Summary
The facility failed to ensure that access to medication storage rooms was limited only to qualified staff, as required by policy. During multiple observations, the maintenance supervisor was able to open medication storage rooms using their own key without the presence of licensed nursing personnel. On several occasions, the maintenance supervisor accessed these rooms alone or called for a nurse only after the room was already open. Both the medication storage room by the DON's office and the one on hall 500 contained numerous containers of residents' medications at the time of access. Interviews with staff confirmed that the maintenance supervisor, along with nurses and medication aides, had access to the medication storage rooms. The DON stated that the maintenance supervisor was allowed access due to the presence of a fire panel control in one of the rooms, but was supposed to be accompanied by nursing staff. Facility policy, however, specified that only licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications should have access to the medication supply. No controlled medications were reported to be stored in these rooms at the time.
Dietary Manager Lacked Required Certification
Penalty
Summary
The facility failed to ensure that the dietary manager (DM) completed the required certification as a certified dietary manager within three years of employment, as mandated by state regulations. The DM was hired on 11/22/2011 and, as of the time of the survey, had not obtained the certification. Documentation confirming completion of the certification was not available, and the DM confirmed during interview that although they had started the classes, they never completed them and did not possess any alternative qualifications accepted by regulation. The administrator acknowledged that the DM was expected to become certified within three years and believed the classes had been completed, but this was not substantiated by records or the DM's statements. At the time of the survey, the facility had 68 residents, with 66 receiving meals from the cafeteria managed by the uncertified DM.
Lack of Dementia Management Training for Staff
Penalty
Summary
The facility failed to provide dementia management education to staff members responsible for the care of residents with dementia. Specifically, one LPN who had been employed at the facility for a year reported not receiving any dementia management training during 2024 and 2025. Record review confirmed there was no documentation of staff in-service or training on dementia management for the period between April 2024 and April 2025. The Director of Nursing confirmed that no in-service training on dementia care had occurred during this time frame, and the administrator stated there was no mandatory requirement for all staff to participate in dementia management training. At the time of the deficiency, the facility had 18 residents diagnosed with dementia, including residents with severe cognitive impairment and behavioral issues such as yelling, throwing food, and disorganized thinking.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered for one resident reviewed for intravenous medications. The resident had diagnoses including sepsis and cellulitis of the left upper arm. A physician's order dated 09/19/23 required ceftriaxone sodium injection solution to be administered intravenously once a day for eight days starting 09/20/23. Another order dated 09/20/23 required a normal saline flush every shift. The September Medication Administration Record (MAR) showed blanks on 09/25 and 09/26/23 for the ceftriaxone sodium and four blanks out of 21 opportunities for the flush. The Director of Nursing (DON) and two Licensed Practical Nurses (LPNs) confirmed that blanks on the MAR indicated the medication was not given and if it was not documented, it was assumed not to have been administered.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 239 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Midwest City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Midwest City Post Acute & Rehab | 1.8 mi | ★★★★★ | 2 | 0 |
| Emerald Care Center Midwest | 1.9 mi | ★★★★★ | 0 | 0 |
| Cross Timbers Nursing And Rehabilitation | 2.8 mi | ★★★★★ | 0 | 0 |
| Mid-del Skilled Nursing And Therapy | 5 mi | ★★★★★ | 0 | 0 |
| Park Place Healthcare And Rehab | 6.1 mi | — | 29 | 1 |
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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.