General Information: SIENNA NURSING AND REHABILITATION LP
Nursing home name SIENNA NURSING AND REHABILITATION LP
Address2510 W EIGHTH
ODESSA, TX 79763
Phone number (432) 333-4511
Located within a hospital No
Type of ownership For profit - Partnership
Owner operates multiple homesYes
Accept Medicare or Medicaid Medicare and Medicaid
Continue Care Retirement CommunityNo
Resident and family councils Both
Certified number of beds 138
Total number of residents 93
Perc of occupied beds 67
Sprinkler status Yes
Number of Facility Reported Incidents0
Number of Substantiated Complaints1
Number of Fines0
Total Amount of Fines$0
Total Number of Penalties0
Total Number of Penalties0
Ratings Summary: SIENNA NURSING AND REHABILITATION LP
Overall rating 1
1
Nursing Home Staffing 1
1
Registered Nurses only 1
1
Health Inspections 2
2
Quality Measures 2
2
Nursing Home Staffing Info: SIENNA NURSING AND REHABILITATION LP
National AverageTexas AverageSIENNA NURSING AND REHABILITATION LP
Overall staff rating NA NA 1
1
Registered Nurses only rating NANA 1
1
Total Number of Residents NA NA 93
Total Number of Nurse Staff Hours per Resident per Day 4.11 hours 3.79 hours 3.17 hours
Total Number of Licensed Nurse Staff Hours per Resident per Day 1.64 hours 1.49 hours 0.93 hours
Registered Nurses Hours per Residents per Day 0.81 hours 0.57 hours 0.29 hours
Licensed Practical or Vacation Nurses Hours per Resident per Day 0.83 hours 0.92 hours 0.64 hours
Certified Nursing Assistants Hours per Residents per Day 2.47 hours 2.3 hours 2.24 hours
Physical Therapy Staffing Hours per Resident Per Day 0.1 hours 0.08 hours 0.04 hours
Health Survey: SIENNA NURSING AND REHABILITATION LP
Heath Survey Summary on 2013-12-23
Total Number of Health Deficiencies 11
Scope and Severity of most Severe Health Deficiency Widespread /Minimal harm or potential for actual harm
Heath Survey Summary on 2012-10-26
Total Number of Health Deficiencies 7
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Heath Survey Summary on 2011-10-28
Total Number of Health Deficiencies 3
Scope and Severity of most Severe Health Deficiency Widespread /Minimal harm or potential for actual harm
Health Survey Details: SIENNA NURSING AND REHABILITATION LP
Inspection Results: 12/23/2013
Corrected Deficiency Scope and Severity
02/07/2014 Keep residents' personal and medical records private and confidential. Pattern/Minimal harm or potential for actual harm
02/07/2014 Provide housekeeping and maintenance services. Pattern/Potential for minimal harm
02/07/2014 Ensure services provided by the nursing facility meet professional standards of quality. Isolated/Minimal harm or potential for actual harm
02/07/2014 Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Pattern/Minimal harm or potential for actual harm
02/07/2014 Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern/Minimal harm or potential for actual harm
02/07/2014 Make sure that special or therapeutic diets are ordered by the attending doctor. Pattern/Minimal harm or potential for actual harm
02/07/2014 Have a program that investigates, controls and keeps infection from spreading. Pattern/Minimal harm or potential for actual harm
02/07/2014 Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Pattern/Minimal harm or potential for actual harm
02/07/2014 Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Widespread /Minimal harm or potential for actual harm
02/07/2014 Keep accurate, complete and organized clinical records on each resident that meet professional standards. Widespread/Potential for minimal harm
02/07/2014 Train all employees on what to do in an emergency, and carry out unannounced staff drills. Widespread/Potential for minimal harm
Inspection Results: 10/26/2012
Corrected Deficiency Scope and Severity
11/30/2012 Keep residents' personal and medical records private and confidential. Pattern/Minimal harm or potential for actual harm
11/30/2012 Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern/Minimal harm or potential for actual harm
11/30/2012 Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern/Minimal harm or potential for actual harm
11/30/2012 Store, cook, and serve food in a safe and clean way. Pattern/Minimal harm or potential for actual harm
11/30/2012 Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Pattern/Minimal harm or potential for actual harm
11/30/2012 Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Pattern/Minimal harm or potential for actual harm
11/30/2012 Have a program that investigates, controls and keeps infection from spreading. Pattern/Minimal harm or potential for actual harm
Inspection Results: 10/28/2011
Corrected Deficiency Scope and Severity
11/23/2011 Have a program that investigates, controls and keeps infection from spreading. Pattern/Minimal harm or potential for actual harm
11/23/2011 Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Pattern/Minimal harm or potential for actual harm
11/23/2011 Train all employees on what to do in an emergency, and carry out unannounced staff drills. Widespread /Minimal harm or potential for actual harm

Fire Safety Survey: SIENNA NURSING AND REHABILITATION LP
Fire Safety Survey Summary on 2013-12-19
Total Number of Fire SafetyDeficiencies 7
Scope and Severity of most Severe Health Deficiency Widespread /Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2012-10-23
Total Number of Fire SafetyDeficiencies 4
Scope and Severity of most Severe Health Deficiency Isolated/Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2011-11-02
Total Number of Fire SafetyDeficiencies 4
Scope and Severity of most Severe Health Deficiency Widespread /Minimal harm or potential for actual harm
Fire Safety Survey: SIENNA NURSING AND REHABILITATION LP
Fire Safety Survey Results: 12/19/2013
Corrected Deficiency Severity
02/06/2014 Walls that prevent smoke from passing through and would resist fire for at least one hour. Widespread /Minimal harm or potential for actual harm
02/06/2014 Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. Widespread /Minimal harm or potential for actual harm
02/06/2014 Exits that are accessible at all times. Pattern/Minimal harm or potential for actual harm
02/06/2014 Proper backup exit lighting. Widespread /Minimal harm or potential for actual harm
02/06/2014 An approved installation, maintenance and testing program for fire alarm systems. Pattern/Minimal harm or potential for actual harm
02/06/2014 Properly maintained smoke detectors. Pattern/Minimal harm or potential for actual harm
02/06/2014 Weekly inspections and monthly testing of generators. Widespread /Minimal harm or potential for actual harm
Fire Safety Survey Results: 10/23/2012
Corrected Deficiency Severity
11/30/2012 Proper backup exit lighting. Isolated/Minimal harm or potential for actual harm
11/30/2012 Automatic sprinkler systems that have been maintained in working order. Widespread/Potential for minimal harm
11/30/2012 Properly protected cooking facilities. Widespread/Potential for minimal harm
11/30/2012 Properly installed electrical wiring and equipment. Widespread/Potential for minimal harm
Fire Safety Survey Results: 11/02/2011
Corrected Deficiency Severity
11/23/2011 Walls that prevent smoke from passing through and would resist fire for at least one hour. Pattern/Minimal harm or potential for actual harm
11/23/2011 Exits that are accessible at all times. Isolated/Minimal harm or potential for actual harm
11/23/2011 Automatic sprinkler systems that have been maintained in working order. Pattern/Minimal harm or potential for actual harm
11/23/2011 Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Widespread /Minimal harm or potential for actual harm

Resident Complaints: SIENNA NURSING AND REHABILITATION LP
Date Complaint Substantiated: 10/14/2013
CorrectedCategoryDeficiencySeverity
11/15/2013Keep accurate, complete and organized clinical records on each resident that meet professional standards. F
11/15/2013Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. E
Date Complaint Substantiated: 09/24/2013
CorrectedCategoryDeficiencySeverity
10/31/2013Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. E

Quality Measures: SIENNA NURSING AND REHABILITATION LP
Quality Measures National Average Texas Average SIENNA NURSING AND REHABILITATION LP
Overall quality rating NA NA 2
2
Long-Stay Residents
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased 15.4% 19.2% 26.3%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain 8.3% 9.1% 18.2%
Percent of High Risk Long Stay Residents With Pressure Ulcers 6.1% 6.8% 4.7%
Percent of Long Stay Residents Who Lose Too Much Weight 7.2% 6.0% 5.0%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder 43.9% 43.2% 48.0%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder 3.2% 3.2% 5.7%
Percent of Long Stay Residents With a Urinary Tract Infection 6.2% 7.2% 14.4%
Percent of Long Stay Residents Who Have Depressive Symptoms 6.3% 8.1% 16.9%
Percent of Long Stay Residents Who Were Physically Restrained 1.4% 1.2% 5.3%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury 3.2% 3.5% 1.4%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine 92.7% 90.4% 87.5%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 94.3% 89.7% 95.8%
Percent of Long Stay Residents Who Received an Antipsychotic Medication 20.7% 27.1% 17.9%
Short-Stay Residents
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain 19.2% 18.8% 31.6%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened 1.2% 1.2% 0.0%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine 83.4% 74.3% 73.1%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 82.4% 73.2% 72.8%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication 2.6% 3.6% 0.0%

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