Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 2 | 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 August 2026) and official state health department websites.