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 Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia and chronic bowel and bladder incontinence received perineal care during which a CNA cleaned urine and feces while wearing a single pair of gloves, then, without changing those contaminated gloves or performing hand hygiene, handled and applied a clean brief to the resident. The CNA later acknowledged she should have changed gloves, and the DON confirmed that facility policy and expectations require removal of soiled gloves, hand hygiene, and donning of clean gloves during personal/perineal care as part of the infection control program.
A resident with dementia, diabetes, and pre-existing protein-calorie malnutrition experienced an 11.47% weight loss over approximately three months while on a regular diet and requiring only setup assistance for eating. Although a weight-loss assessment identified significant weight loss and listed interventions such as a red cup program and high-calorie supplements, these were not entered as MD orders, the resident was not placed on the red cup list, and supplements were not ordered until mid-way through the second month. The RD’s admission recommendation for house supplements three times daily was not converted into active orders, the RD did not receive accurate weight-loss reporting, and the NP was not notified of the significant weight change. Observations showed poor meal intake and lack of consistent offering of alternatives or supplements, while staff interviews revealed unawareness of the resident’s weight loss and confusion over who monitored the red cup program. These failures to follow the facility’s weight policy, to monitor and communicate significant weight changes, and to implement ordered or recommended nutritional interventions resulted in the resident’s continued weight decline.
Multiple incidents occurred where residents with severe cognitive impairment and behavioral issues engaged in physical altercations, resulting in injuries such as head lacerations and skin tears. Despite being identified as needing 1:1 supervision, residents were not provided with dedicated staff, and existing CNAs were expected to cover both general care and 1:1 monitoring. Staff interviews and records confirmed that required supervision was not maintained, directly leading to resident-to-resident abuse and injuries.
Multiple incidents occurred where residents with severe cognitive impairment and behavioral issues engaged in physical altercations, resulting in injuries such as head lacerations and skin tears. Despite care plans and facility protocols requiring 1:1 monitoring, staffing records and staff interviews confirmed that no additional staff were assigned for this purpose, and existing CNAs were expected to rotate 1:1 monitoring duties while supervising the entire unit. This lack of adequate supervision led to repeated resident-to-resident altercations and injuries.
Multiple incidents occurred where residents with severe cognitive impairment and behavioral risks did not receive required 1:1 monitoring due to insufficient staffing. Existing CNAs were expected to supervise large numbers of residents and provide 1:1 monitoring simultaneously, leading to unsupervised periods and resulting in altercations and injuries. Staff interviews and records confirmed that no additional staff were assigned for 1:1 monitoring, and the facility lacked a formal staffing policy.
The DON worked as a charge nurse on multiple occasions when the facility census was 60 or more, contrary to regulatory requirements. The DON reported covering night shifts due to a staff vacancy and was unaware of the regulation prohibiting this practice. No policy for RN/DON coverage was provided when requested.
The facility did not update or revise care plans for three residents with severe cognitive impairment after multiple documented incidents of aggression and wandering, despite repeated behavioral episodes that required staff intervention and hospital transfers. Care plans had not been revised to include new interventions following these events, contrary to facility policy and standard practice.
Staff at the facility were observed using personal cell phones in the presence of residents, violating their rights to dignity and respect. Residents reported feeling disrespected and ignored, with staff using phones while providing care and passing medications. Despite facility policies prohibiting such behavior, the issue persisted, indicating a failure to enforce these rules effectively.
A facility failed to restrict access to its medication room, allowing unauthorized personnel, such as a Medical Records staff member and Central Supply staff, to enter and be alone in the room. This breach of protocol, observed during a survey, involved the use of a code to unlock the room, which contained various medications and medical supplies. The facility's policy mandates that only authorized personnel should have access to the medication supply.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to Enhanced Barrier Precautions (EBP) for residents requiring such measures. CNAs did not use PPE during incontinent care and transfers for residents on EBP, and there was a lack of accessible PPE in resident rooms. Staff interviews revealed a breakdown in communication and understanding of EBP requirements, contributing to the risk of cross-contamination and infection spread.
A facility failed to label a Mid-line IV dressing with the date and initials, as required by policy, for a resident with chronic kidney disease and other conditions. The resident's dressing was intact but lacked labeling, which is necessary for monitoring changes and preventing infections. The DON confirmed the expectation for labeling to reduce infection risks.
A resident's shower log was inaccurately documented, showing multiple refusals of showers despite interviews indicating the resident never refused. Staff admitted to a possible documentation error, which could lead to inadequate care. The facility's policy requires accurate documentation, which was not followed in this instance.
A facility failed to accurately receive and store controlled medications for a resident, leading to the diversion of Alprazolam tablets. The resident, with multiple diagnoses including dementia and anxiety, was on hospice care. The medications were delivered by a hospice nurse without proper documentation or signature, and the DON was the last to have contact with them. Facility policies for securing and documenting controlled substances were not followed.
A resident's Tramadol was not secured in a double-locked area as required, leading to an investigation. The medication was delivered by a hospice nurse without obtaining a signature, and the DON, who was the last to see the medications, did not recall the specifics due to fatigue. The facility's policies for handling controlled substances were not followed, resulting in a breakdown in procedure adherence.
The facility failed to implement its QAPI plan, resulting in deficiencies in addressing adverse events for four residents. A resident repeatedly exhibited aggressive behaviors towards another, but the facility did not complete incident/accident reports, hindering behavior tracking. Additionally, two other residents demonstrated physical behaviors without proper documentation. Interviews revealed inconsistent tracking due to incomplete reports, impacting the facility's quality assurance processes.
The facility failed to follow professional standards for food service safety, resulting in improper food storage, cross-contamination risks, and inadequate use of hair restraints. Observations showed food stored beyond recommended periods, items on the floor, and improper thawing practices. Staff interviews confirmed these practices, and the facility's policies were not adhered to, posing potential risks to residents.
The facility failed to maintain essential kitchen equipment, including the oven, garbage disposal, and milk refrigerator, in safe operating condition. Observations revealed issues such as a rusted hinge and detached gasket on the refrigerator, a non-functional garbage disposal, and an oven that did not reach the required temperature. Staff acknowledged these problems, but no work orders were provided, and the Administrator was unaware of the issues.
A facility failed to update a care plan for a resident with a history of crawling behavior, leading to knee abrasions. Despite awareness of the behavior, the care plan lacked specific interventions, and video surveillance confirmed the resident's crawling and subsequent injuries. The resident was placed in a low bed with a floor mat, but no additional measures were taken to prevent injury.
A resident with a history of crawling behavior was not provided with adequate supervision or assistive devices, leading to injuries. Despite being aware of the behavior, the facility did not revise the care plan to include interventions. The resident sustained abrasions and reopened wounds on her knees, as documented in progress notes and observed in video surveillance. Staff interviews confirmed awareness of the behavior but not of specific incidents or injuries.
Failure to Change Contaminated Gloves During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain proper infection prevention and control practices during incontinent care for one resident. The resident, an older adult with dementia and constipation, was care planned and assessed as always incontinent of bowel and bladder, with instructions to check frequently, assist with toileting, and provide pericare after each incontinent episode. During an observation, a CNA donned clean gloves, opened the resident’s brief, and used wet wipes to clean the resident’s scrotum and penis. The CNA then turned the resident to his side and continued perineal care, wiping the rectal area and removing bowel movement from the resident’s bottom while still wearing the same pair of gloves. After completing the cleaning, the CNA removed the soiled brief and, without changing the contaminated gloves, took a clean brief and fastened it on the resident, then assisted him back onto his back, completing the care. In a subsequent interview, the CNA acknowledged she should have changed her gloves before handling the clean brief and stated she had been nervous during the care. The DON stated that facility expectations were for CNAs to remove gloves once contaminated, perform hand hygiene, and then don new gloves, and acknowledged that failure to change gloves could result in spread of fecal matter and germs. Facility policies on personal/perineal care and infection control required glove removal when visibly soiled, hand hygiene before and after glove use, and maintenance of an infection control program to prevent the development and transmission of disease and infection.
Failure to Implement and Coordinate Nutritional Interventions for Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident maintained acceptable parameters of nutritional status, as evidenced by an 11.47% weight loss over 80 days without timely and fully implemented interventions. The resident was an elderly female admitted with diagnoses including protein-calorie malnutrition, diabetes mellitus, dementia, and anxiety disorder. Her admission MDS showed severe cognitive impairment (BIMS score of 2), a regular diet, and no documented weight loss or physician-ordered weight-loss program. Her care plan, revised in early December, identified her as at risk for malnutrition with interventions such as determining food preferences, monitoring and documenting intake, monitoring weight per facility protocol, serving the ordered diet, and notifying the physician of negative findings. Weight records showed an active decline from early December through mid-February, with the resident’s weight decreasing from 191.8 pounds to 169.8 pounds. A nutrition assessment by the RD in mid-December documented a weight of 185.6 pounds, a regular diet and texture, and food intake ranging from 25–100%. A weight watchers’ assessment in mid-January identified a 14.4‑pound weight loss and listed interventions of a red glass and a 2‑calorie supplement with each med pass. However, the resident did not appear on the facility’s red cup program list, and there were no corresponding physician orders in January for supplements or the red glass program. In February, no supplement order was present until mid-month, when Boost twice daily was ordered; there was still no physician order for the red glass program. Observations and interviews further demonstrated that the identified interventions were not consistently implemented or communicated. During lunch observations on consecutive days in February, the resident took only a few bites of food, repeatedly left the table, and on one day accepted a supplement, while on another day no alternative or supplement was observed being offered. The Dietary Manager stated she was responsible for the red glass program notifications but was unaware of the resident’s weight loss and confirmed the resident was not on the snack list. The new DON reported she had only recently become aware of the weight loss, implemented a supplement order mid-February, and believed the resident should have had weekly weights, supplements, and placement on the red glass program. The ADON acknowledged completing a weight watcher assessment in mid-January and intending to initiate the red glass program and 2‑calorie supplements with each med pass but admitted she forgot to enter these as physician orders. The RD stated she had recommended house supplements three times daily on admission and that these should have been entered as physician orders, but the resident did not appear on the January weight loss report. The NP reported she was unaware of the extent of the weight loss and had not been notified. These actions and inactions occurred despite a facility policy requiring review of significant weight changes, documentation on weight watcher forms with interventions, physician and family notification, initiation of an acute care plan for weight loss, and RD assessment and recommendations for significant weight loss. The facility’s own policy defined significant weight loss thresholds and required that such changes be recorded on a weight watchers’ form with interventions and follow-up, that the physician and family be notified, and that an acute care plan for weight loss be initiated. It also required referral of all significant weight changes to the Regional Dietitian for assessment and review of interventions. In this case, although a weight watchers’ assessment was completed and interventions were listed, they were not converted into active physician orders, the resident was not placed on the red glass program list, and the RD did not receive accurate weight loss reporting in January. Staff interviews showed inconsistent awareness of the resident’s weight loss and program status, and the NP was not informed of the significant weight change. These documented failures to follow policy and to implement and coordinate ordered or recommended nutritional interventions contributed directly to the resident’s continued weight decline. Throughout this period, meal intake documentation for January and February continued to show 25–100% consumption, while direct observations showed poor intake and difficulty remaining at the table. CNAs and nursing staff reported offering alternatives and snacks generally, but the assigned CNA confirmed the resident was not on the red cup program, which was supposed to trigger extra attention to intake. The DON, ADON, RD, and NP each described gaps in communication and follow-through regarding weight monitoring, program placement, and supplement orders. Collectively, these documented lapses in monitoring, communication, and implementation of nutritional interventions led to the resident’s significant, ongoing weight loss and constituted the cited deficiency in maintaining acceptable nutritional status.
Failure to Provide Sufficient Staffing and 1:1 Monitoring Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse and neglect, specifically by not providing sufficient staffing and failing to implement required 1:1 monitoring for residents with known behavioral risks. Multiple incidents occurred in both male and female secured locked units, where residents with severe cognitive impairment and behavioral diagnoses engaged in physical altercations resulting in injuries such as head lacerations, skin tears, and hospitalizations. In several cases, residents who were supposed to be under 1:1 supervision were not provided with a dedicated staff member, as required by the facility's own in-service training and policy. On multiple occasions, staff assignments did not include additional personnel for 1:1 monitoring, despite residents being identified as needing such supervision due to aggressive or violent behaviors. For example, one male resident with a history of explosive disorder and severe cognitive impairment physically assaulted another resident, causing a head injury that required emergency room treatment and staples. Another incident involved a resident slapping and injuring a peer while supposed to be under 1:1 monitoring, but no extra staff was assigned, and the monitoring was performed by staff already responsible for the entire unit. Similar failures occurred in the female secured unit, where a resident with traumatic brain injury and dementia physically assaulted two other residents, causing skin tears and facial injuries, again without the required 1:1 supervision being provided. Interviews with staff and review of staffing schedules confirmed that the facility routinely failed to assign additional staff for 1:1 monitoring, instead expecting existing CNAs to rotate or cover both general care and 1:1 supervision, even during night shifts when staffing was further reduced. Staff reported being unable to maintain arm's-length supervision as required, and monitoring sheets were often signed by staff who were simultaneously responsible for multiple units or entire halls. These actions and inactions directly led to resident-to-resident altercations and injuries, as documented in progress notes, investigation reports, and staff interviews.
Failure to Provide Adequate Supervision and 1:1 Monitoring Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents, specifically in relation to resident-to-resident altercations on two secured units. Multiple incidents occurred where residents with known behavioral issues and severe cognitive impairment engaged in physical altercations, resulting in injuries such as head lacerations, skin tears, and hospitalizations. In several cases, residents who were supposed to be on 1:1 monitoring did not have a designated staff member assigned to them, as required by the facility's own in-service training and staffing protocols. Instead, existing staff were expected to rotate or cover 1:1 monitoring in addition to their regular duties, leading to lapses in supervision. On the male secured locked unit, one resident with a history of explosive disorder and severe cognitive impairment physically assaulted another resident who had wandered into his room, causing a head injury that required emergency room treatment and staples. The same resident later assaulted a different resident, resulting in a fall and a skin tear. Despite care plans indicating the need for 1:1 supervision, staffing records and interviews confirmed that no additional staff were assigned for this purpose, and the two CNAs on duty were responsible for supervising all residents on the unit as well as providing 1:1 monitoring. Staff interviews corroborated that it was common practice for no extra staff to be provided for 1:1 monitoring, even when required. Similar deficiencies were observed on the female secured unit, where a resident with traumatic brain injury and severe cognitive impairment physically assaulted two other residents, causing skin tears and facial injuries. Again, although 1:1 monitoring was indicated after the first incident, staffing records showed that only one CNA was present for the entire unit, and no additional staff were assigned for 1:1 monitoring. Staff interviews revealed that it was rare for a third CNA to be sent for 1:1 monitoring, and that CNAs often had to rotate the responsibility among themselves while still supervising the rest of the unit. The lack of adequate supervision and failure to follow established protocols for 1:1 monitoring directly contributed to repeated resident-to-resident altercations and injuries.
Failure to Provide Sufficient Staffing and 1:1 Monitoring in Secure Units
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, particularly in the secure male and female units, resulting in multiple resident-to-resident altercations and injuries. On several occasions, residents who required 1:1 monitoring due to behavioral risks did not have a designated staff member assigned to them, as required by the facility's own in-service training and stated procedures. Instead, existing CNAs were expected to rotate or attempt to monitor these residents in addition to their regular duties, despite being responsible for large numbers of residents with known behavioral issues. This lack of dedicated staffing led to incidents where residents were left unsupervised, resulting in physical altercations, falls, and injuries such as skin tears and lacerations. Specific incidents included a male resident with severe cognitive impairment and a history of physical aggression who was placed on 1:1 monitoring after an altercation, but no additional staff was assigned. This resident subsequently assaulted another resident, causing a fall and injury, while unsupervised in the dining room. Similarly, in the female secure unit, a resident with a traumatic brain injury and severe cognitive impairment was involved in multiple altercations, including grabbing and slapping other residents, while supposed to be on 1:1 monitoring. Staffing records and interviews confirmed that no extra staff were provided for 1:1 monitoring during these times, and CNAs reported being unable to maintain required supervision due to being the only staff on the unit or having to cover both secure units simultaneously. Interviews with staff, including CNAs and nurses, revealed that it was common practice for the facility to operate with fewer staff than required, especially during night shifts, and to rely on existing staff to provide 1:1 monitoring without relief. The Director of Nursing and Assistant Director of Nursing acknowledged that additional staff should be assigned for 1:1 monitoring but were unaware of instances where this did not occur. The facility did not have a formal staffing policy, and documentation showed that 1:1 monitoring sheets were often signed by staff already assigned to the unit, rather than by a dedicated monitor. These failures were confirmed through observation, record review, and staff interviews.
DON Served as Charge Nurse During High Census
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse when the average daily occupancy was 60 or more residents, as required by regulation. Review of the daily staffing schedule showed that the DON worked as a charge nurse on nine separate days during the review period. During an interview, the DON confirmed she had been working night shifts as the charge nurse due to a recent staff resignation and stated that no one else had been designated to perform her DON duties during these times. The DON also indicated she was unaware of the regulation prohibiting her from working the floor in this capacity. Additionally, when requested, the facility was unable to provide a policy for RN/DON coverage. The job description for the DON emphasized the need for knowledge of nursing home regulations and accountability for compliance, but also included a provision to augment floor staffing if needed. There were no details provided about specific residents or their conditions related to this deficiency.
Failure to Update Care Plans After Behavioral Incidents and Assessments
Penalty
Summary
The facility failed to review and revise comprehensive care plans by the interdisciplinary team after each assessment for three residents. Specifically, the care plans were not updated to reflect new or ongoing behavioral issues, such as aggressive and physical behaviors towards other residents and wandering, despite documented incidents in the residents' progress notes. The care plans for these residents had not been updated with new interventions since their last revisions, even though there were multiple documented episodes of aggression and wandering that required staff intervention and, in some cases, resulted in hospital transfers. One male resident with severe cognitive impairment and a history of explosive disorder exhibited repeated aggressive behaviors, including hitting and shoving other residents, which led to another resident being sent to the emergency room. Despite these incidents, his care plan had not been updated with new interventions since the previous year. Another female resident with traumatic brain injury and dementia also demonstrated physical aggression, such as grabbing and slapping other residents, but her care plan interventions had not been revised since the previous year, even after multiple aggressive episodes were documented. A third male resident, also with severe cognitive impairment and a history of explosive disorder, was involved in a resident-to-resident altercation after wandering into another resident's room, resulting in a fall and injury. His care plan, which addressed wandering, had not been updated with new interventions since his admission, despite these incidents. The Director of Nursing confirmed that care plans should be updated after such events but was unable to explain why this had not occurred. Facility policy requires care plans to be reviewed and revised after each assessment and in response to changes in the resident's condition or interventions.
Staff Cell Phone Use Violates Resident Dignity
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect, as evidenced by staff members using personal cell phones in the presence of residents. This behavior was observed during a confidential group interview with 11 residents, who reported feeling disrespected and ignored. The residents expressed concerns that staff were frequently on their phones, even while providing care, passing medications, and ignoring call lights. This led to feelings of discomfort and the perception that staff did not care about them. The issue was reported multiple times in Resident Council Meetings, with residents noting that staff conversations were often personal and inappropriate. The facility's policy prohibits the use of personal communication devices during work hours, except during breaks, and explicitly forbids the use of cell phones in residents' presence. Despite this policy, the Activity Director was observed using a cell phone in the main dining room, and residents reported that staff were on their phones while providing care. Interviews with the ADON, DON, and RN Consultant revealed that they were unaware of the extent of the issue, although they acknowledged the policy and the potential for privacy violations. The facility had conducted in-services on phone use, but the problem persisted, indicating a failure to enforce the policy effectively.
Unauthorized Access to Medication Room
Penalty
Summary
The facility failed to ensure that only authorized personnel had access to the medication room, which was reviewed for drug storage. During an observation, it was noted that a Medical Records staff member, who was unauthorized to be in the medication room unattended, had access to the room. The staff member unlocked the medication room using a code and was present in the room without any nursing staff. The room contained various medications, including over-the-counter and prescribed drugs, as well as insulin and other medical supplies. Interviews revealed that the Medical Records staff member often stocked the medication room with over-the-counter medications and was sometimes left alone in the room when the nurse stepped out. Additionally, the Central Supply staff member also had access to the medication room and had been in the room alone to stock it. The facility's policy indicated that only licensed nursing personnel, pharmacy personnel, or staff members authorized to administer medications should have access to the medication supply. This breach in protocol could potentially lead to drug diversion.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to Enhanced Barrier Precautions (EBP) for residents requiring such measures. Specifically, CNAs A, B, E, and D did not use personal protective equipment (PPE) during incontinent care for residents on EBP, such as Residents #17 and #60. CNA B, in particular, did not change her gloves after they became contaminated during care for Resident #17, and neither CNA A nor B wore gowns during the procedure. Additionally, CNAs C, D, E, and F did not use PPE during transfers for EBP residents, including Residents #49, #60, and #67. For instance, CNA C and CNA D assisted Resident #49 with a transfer without wearing gowns, despite the resident being on EBP due to a past diagnosis of an antibiotic-resistant infection. Similarly, CNA E and CNA D performed incontinent care and a transfer for Resident #60 without gowns, even though there was a sign indicating EBP was required. The facility's failure to ensure proper use of PPE and adherence to EBP protocols was further highlighted by the lack of accessible PPE in resident rooms and the staff's lack of awareness regarding which residents were on EBP. Interviews with staff, including the ADON, revealed a breakdown in communication and understanding of EBP requirements, contributing to the risk of cross-contamination and infection spread among residents.
Failure to Label IV Dressing
Penalty
Summary
The facility failed to ensure the proper administration of intravenous (IV) fluids for a resident, specifically by not adhering to professional standards regarding the labeling of a Mid-line intravenous line dressing. The resident, a female with chronic kidney disease, type 2 diabetes, and pressure ulcers, was admitted to the facility with a Mid-line IV for administering fluids and medications. The dressing on the resident's Mid-line IV was observed to be intact but lacked the required date and initials, which are essential for monitoring dressing changes and preventing infections. The resident was unable to recall when the Mid-line was inserted or when the dressing was last changed. The Director of Nursing (DON) confirmed that the facility's policy mandates that IV dressings be labeled with the date, time, and initials to track dressing changes and minimize infection risks. The facility's policy on dressing changes explicitly requires this labeling, yet the observation and record review revealed non-compliance with this standard. The absence of labeling on the dressing could potentially place residents at risk for infections, although no signs of infection were noted at the time of observation.
Inaccurate Documentation of Resident's Shower Log
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for a resident whose assessments were reviewed. Specifically, the shower log for the resident inaccurately documented that the resident refused showers on multiple occasions, despite interviews indicating that the resident never refused showers. The resident, a male with diagnoses including Dementia, Malnutrition, and obstructive pulmonary disease, was supposed to receive showers on specific days, but the log incorrectly noted refusals. Interviews with staff and another resident revealed that the resident consistently received showers and never refused them. A staff member admitted to possibly mis-clicking on the documentation, leading to the incorrect recording of shower refusals. The Assistant Director of Nursing confirmed that this was a documentation error, which could potentially lead to inadequate care due to inaccurate records. The facility's policy requires complete and accurate documentation for each resident, which was not adhered to in this case.
Failure to Secure and Document Controlled Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of controlled medications for a resident. Specifically, the facility did not accurately receive and store 45 tablets of Alprazolam, an anti-anxiety medication, and 60 tablets of Tramadol, a pain medication, both classified as Schedule IV narcotics. This failure resulted in the diversion of the Alprazolam tablets. The resident involved was an elderly male with multiple diagnoses, including dementia with behavioral disturbance, hypertension, depression, anxiety, and a psychotic disorder with delusions. He was living in a secured unit and receiving hospice services. The resident's care plan included the use of anti-anxiety medications to manage his symptoms, and he had a prescription for Alprazolam to be administered twice daily and as needed. The deficiency was identified when a Licensed Vocational Nurse (LVN) discovered that the Alprazolam medication card was missing from the medication cart. The facility's investigation revealed that the medications were delivered by a hospice nurse, but there was no signature or confirmation of receipt. The Director of Nursing (DON) was reportedly the last person to have contact with the medications, but she did not recall handling them. The facility's policies required controlled substances to be stored under double lock and documented with a narcotic count sheet, which was not followed in this instance.
Medication Storage Deficiency in LTC Facility
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to medications, specifically for one of the four medication carts reviewed. This deficiency was highlighted by the case of a resident whose 60 tablets of Tramadol were not secured in a double-locked area, as required for controlled substances. The Tramadol was delivered by a hospice nurse and was later found missing, leading to an investigation by the facility. The investigation revealed that the Tramadol was delivered by a hospice nurse who did not obtain a signature upon delivery, and the medication was allegedly left in the medication room instead of being secured in the medication cart's locked drawer. The Director of Nursing (DON) was identified as the last person to have seen the medications, but due to working multiple shifts and being tired, the DON did not recall the specifics of the delivery or handling of the medications. The Assistant Director of Nursing (ADON) and other staff members expressed concerns about the lack of proper procedures followed during the delivery and storage of the medications. Interviews with various staff members, including the Administrator, ADON, and MDS Coordinator, indicated a breakdown in communication and procedure adherence. The hospice nurse admitted to not having the DON sign for the medications and mentioned the chaotic environment on the day of delivery. The facility's policies and procedures for handling controlled substances were not followed, as the Tramadol was not placed in the narcotic box with a count sheet, and the delivery process lacked proper documentation and accountability.
Failure to Implement QAPI Plan and Document Incidents
Penalty
Summary
The facility failed to implement its Quality Assessment and Performance Improvement (QAPI) plan, which led to deficiencies in addressing adverse events related to potential deficient practices for four residents. The facility did not identify a pattern of behaviors between two residents, where one resident repeatedly exhibited aggressive behaviors towards another over a six-month period. Despite multiple incidents, including hair-pulling and physical aggression, the facility did not complete incident/accident reports, which hindered the ability to track and trend these behaviors effectively. Additionally, the facility failed to complete incident/accident reports for two other residents who demonstrated physical behaviors. One resident exhibited aggressive behaviors such as attempting to hit others and making false accusations, while another resident engaged in behaviors that could lead to altercations, such as shaking other residents' wheelchairs. The lack of documentation and reporting of these incidents prevented the facility from identifying patterns and implementing appropriate interventions. Interviews with facility staff revealed a lack of consistent tracking and trending of behaviors due to incomplete incident/accident reports. The facility relied on morning meetings to discuss behaviors, but without proper documentation, it was challenging to identify patterns or trends. The facility's policy required incident/accident reports for behaviors affecting others, but this was not consistently followed, leading to deficiencies in the facility's quality assurance processes.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, leading to several deficiencies. Observations revealed that food was not stored properly, with items such as pudding, garbanzo beans, and black olives being kept beyond the recommended seven-day period. Additionally, pasteurized eggs, tea, and water were stored on the floor of the walk-in refrigerator, which is against food safety protocols. A tube of ground beef was found thawing without a pan, resulting in a puddle of blood on the floor, indicating improper thawing practices. The facility also failed to prevent cross-contamination during food preparation. Cook A was observed changing gloves multiple times without washing or sanitizing her hands after touching the trash can lid, which could lead to contamination. Furthermore, dietary aides were not using effective hair restraints, with one aide's beard partially uncovered and another aide's hair partially exposed. The pots and dishes were stored face up and uncovered, leaving them susceptible to airborne contamination. Interviews with the Dietary Manager (DM) and staff confirmed these practices, with the DM acknowledging the improper storage and handling of food items. The DM also admitted that the hairnets used were ineffective and that there was no explanation for the eggs being stored on the floor. The facility's policies and procedures, dated 2012, were reviewed and found to be in place to prevent such deficiencies, but they were not being followed, leading to potential risks of foodborne illness and cross-contamination for residents receiving meals from the kitchen.
Facility Fails to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, which included the oven, garbage disposal, and milk refrigerator. Observations revealed that the milk refrigerator had a rusted hinge and a detached, black gasket, which compromised its sealing ability. The garbage disposal was non-functional, and the oven failed to reach the required temperature during meal preparation. These issues were observed over several days, with staff acknowledging the problems but no immediate corrective actions were evident. Interviews with the Dietary Manager (DM) indicated that the garbage disposal had been non-functional for two weeks, and the refrigerator issues had persisted for over a year. The DM had informed the maintenance director about these issues, but no work orders were provided to substantiate these claims. The DM also mentioned that the oven's temperature gauge had been replaced, but it still failed to reach the correct temperature intermittently. The Administrator and Regional Compliance Officer were unaware of these issues, indicating a communication breakdown within the facility.
Failure to Revise Care Plan for Crawling Behavior
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident who exhibited crawling behavior, which was not addressed in her care plan. The resident, a female with multiple diagnoses including seizures, developmental disorder of speech and language, and schizophrenia, was admitted with a history of crawling behavior. Despite this, the care plan did not include interventions for this behavior, even though it was documented in progress notes multiple times over the course of a year. The resident was placed in a low bed with a floor mat due to poor safety awareness, but no specific interventions were in place to address the crawling behavior. The deficiency was highlighted when the resident sustained abrasions to her knees from crawling, which were documented in progress notes. Interviews with the resident's responsible party and facility staff revealed that the facility was aware of the behavior but had not implemented additional interventions to prevent injury. Video surveillance confirmed the resident's crawling behavior and subsequent injuries. The facility's failure to update the care plan to include interventions for the resident's crawling behavior placed her at risk of injury.
Failure to Prevent Injuries from Crawling Behavior
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for a resident with a known crawling behavior. The resident, a female with multiple diagnoses including seizures and schizophrenia, was admitted with a history of crawling behavior. Despite this, her comprehensive care plan did not include interventions for this behavior. The resident was placed in a low bed with a floor mat due to poor safety awareness, but no additional measures were implemented to address her crawling. The resident's progress notes documented her crawling behavior on multiple occasions, leading to abrasions and reopened wounds on her knees. Staff interviews revealed that the facility was aware of the behavior but not of specific incidents or injuries. Video surveillance showed the resident crawling and walking in the hallway, refusing staff assistance, and becoming aggressive. The facility's lack of intervention and supervision resulted in the resident sustaining injuries, highlighting a deficiency in ensuring a safe environment.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 52 citations issued within 25 miles in the last 12 months — 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Odessa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Odessa | 0.6 mi | ★★★★★ | 12 | 0 |
| Deerings Nursing And Rehabilitation, Lp | 0.7 mi | ★★★★★ | 1 | 0 |
| Buena Vida Nursing And Rehab Odessa | 4.5 mi | ★★★★★ | 6 | 0 |
| Madison Medical Resort | 5.5 mi | ★★★★★ | 0 | 0 |
| Parks Health Center | 8.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.