Sienna Skilled Nursing & Rehabilitation
Inspection Findings
F-Tag F0686
F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
08/28/25 09/04/25, 09/11/25, 09/18/25 or 09/25/25 he did not complete the weekly pressure ulcer assessment form; however, he was still learning and documented the area on the non-pressure form as MASD instead of pressure. Interim DON #140 confirmed there was no documented evidence the resident's physician had accessed the pressure ulcer, and the wound nurse did not assess the pressure ulcer until 09/26/25 due to the resident was in dialysis on the day the wound nurse visits the facility. LPN #108 and DON confirmed there was no evidence a treatment was implemented to the sacrum from 08/21/25 until 09/03/25. DON #140 reported she felt the non-pressure assessments were comprehensive even though the assessment did not document the stage of the pressure nor was it comprehensive to include all details regarding the description of the wound (wound bed appearance, edge of wound, type of drainage, etc.).
Interview on 09/29/25 at 3:35 P.M., LPN #120 confirmed the admission and five-day MDS dated [DATE REDACTED] was inaccurate and did not reflect the resident's pressure ulcer on the sacrum on admission [DATE REDACTED]. LPN #120 reported she would modify the MDS assessment. Review of the facility's undated policy and procedure titled Skin Measurement/Skin Grid revealed the facility would maintain an active record or any pressure ulcer/wound that was discovered upon admission or that developed during the course of the residents' stay. This is to monitor the progress of healing of the pressure ulcer and determine the need for alternative treatment methods. The wound would be measured and assessed for the wound characteristics.
The physician and responsible party would be notified of the new skin development and an order for treatment would be obtained. The initial and every seven days assessment/measurements are documented
on the electronic form. Review of the facility's undated policy and procedure titled Staging of Pressure Ulcers revealed the facility would assess each resident's skin condition and measure the skin area as indicated in the regulatory guidelines and National Pressure Injury Advisory Panel (NPIAP) guidelines.
Review of the facility's undated policy and procedure titled Pressure Ulcer Prevention and Risk Identification revealed if a new skin area was identified on the assessment or during any other type of care or service, the licensed nurse would initiate a skin grid/measurement flow record. The skin grid would be updated every seven days until the area was resolved. The physician and responsible party would be notified by the licensed nurse promptly of the newly identified skin area and treatment would be initiated according to the physician order. A care plan would be developed and updated routinely with identified skin risk and/or actual wound development. Intervention would be implemented as indicated by the physician and as determined by the Interdisciplinary team. Review of the NPIAP wound documentation guidelines dated 02/2027 revealed when charting a description of a pressure ulcer the following components should be part of your weekly assessment: location, stage, dimensions, undermining/tunneling, wound base descriptions, drainage, wound edges, odor, pain, and progress. This deficiency represents non-compliance investigated under Complaint Number 2608722.
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SIENNA SKILLED NURSING & REHABILITATION in WINTERSVILLE, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WINTERSVILLE, OH, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SIENNA SKILLED NURSING & REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.