Cycle 1
Health 2025-01-23 · Fire 2025-01-23
9 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Odessa, TX
Sienna Nursing and Rehabilitation
2-star overall rating with 1-star inspections with abuse icon flag with $366,050 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2510 W 8Th Street, Odessa, TX
(432) 333-4511
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
138
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
2002-09-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
149 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.49
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.45
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.10
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
0.95
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.60
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.08
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,888
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.64
Baseline 7.00% · Performance 6.75% · Measure score 3.64 · Achievement 3.64 · Improvement 0.75
Total nurse turnover
5.79
Baseline 40.00% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.27 hours · Performance 3.13 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.85% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 10.81% · Lower 95% interval 6.47% |
| Discharge to community | 40.65% |
50.57%
9.9 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 29.63% · Lower 95% interval 27.45% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 27 · Denominator 27 |
| Falls with major injury | 3.7% |
0.77%
2.9 pts worse
|
Numerator 1 · Denominator 27 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 18 · Denominator 24 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 16 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 3.7% |
2.29%
1.4 pts worse
|
Numerator 1 · Denominator 27 · Adjusted rate 2.98% |
| Healthcare-associated infections requiring hospitalization | 6.75% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 3.85% · Lower 95% interval 3.84% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 108 |
| Staff flu vaccination coverage | 58.39% |
42%
16.4 pts better
|
Numerator 94 · Denominator 161 |
| Discharge function score | 70.83% |
56.45%
14.4 pts better
|
Numerator 17 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.3%
1.8 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 5.5% · Q3 5.7% · Q4 4.3% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
2.7%
0.2 pts worse
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.2% · Q3 0.0% · Q4 6.6% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
3.3%
3.2 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 7.1% · Q3 7.7% · Q4 6.2% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.5% |
18.9%
4.4 pts better
|
19.6%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 12.9% · Q3 12.8% · Q4 19.5% · 4Q avg 14.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.0% |
10.8%
5.8 pts better
|
16.7%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 4.5% · Q3 4.6% · Q4 4.5% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.0% |
15.4%
10.4 pts better
|
16.3%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 4.2% · Q3 1.9% · Q4 10.1% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
16.1%
7.4 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 6.2% · Q3 4.0% · Q4 20.0% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.4% |
15.0%
0.4 pts worse
|
19.8%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 23.3% · Q3 10.1% · Q4 15.9% · 4Q avg 15.4% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
4.2%
3.1 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.6% · Q3 9.6% · Q4 8.5% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
89.7%
8.3 pts better
|
81.7%
16.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q3 96.9% · Q4 100.0% · 4Q avg 98.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
12.0%
4.6 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 8.3% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
25.9%
3.9 pts better
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 20.8% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-13 · Fire 2023-12-13
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-10-10 · Fire 2022-10-10
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-23
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-01-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-01-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-03
C · Minimal harm
2025-01-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-03
F · Potential for more than minimal harm
2023-12-13
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-01-18
E · Potential for more than minimal harm
2023-12-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-12-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-19
C · Minimal harm
2023-12-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-01-05
C · Minimal harm
2022-10-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-10-20
Inspection history
Recent health citations
K · Immediate jeopardy
2025-06-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-25
K · Immediate jeopardy
2025-06-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-25
K · Immediate jeopardy
2025-06-24
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-06-24
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-07-15
E · Potential for more than minimal harm
2025-06-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-25
E · Potential for more than minimal harm
2025-01-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-25
E · Potential for more than minimal harm
2025-01-23
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-01-25
E · Potential for more than minimal harm
2025-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-25
D · Potential for more than minimal harm
2025-01-23
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-01-25
D · Potential for more than minimal harm
2024-09-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-13
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-09-16
E · Potential for more than minimal harm
2024-06-21
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-07-19
F · Potential for more than minimal harm
2023-12-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-12-13
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-13
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-12-14
E · Potential for more than minimal harm
2023-12-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-14
D · Potential for more than minimal harm
2023-12-13
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-12-14
E · Potential for more than minimal harm
2023-08-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-07
E · Potential for more than minimal harm
2023-08-09
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-07
J · Immediate jeopardy
2022-10-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-19
E · Potential for more than minimal harm
2022-10-10
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-10-20
E · Potential for more than minimal harm
2022-10-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-20
E · Potential for more than minimal harm
2022-10-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-10-20
E · Potential for more than minimal harm
2022-10-10
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-10-20
Penalties and ownership
What sits behind the stars
$366,050
2025-06-24
Fine
Fine · fine $366,050
Fine
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Blake, Gary
Operational/Managerial Control · Individual
Blake, Malisa
Operational/Managerial Control · Individual
Huggins, Linda
Corporate Director · Individual
Odessa Iii Enterprises, LLC
Operational/Managerial Control · Organization
Thompson, Johnny
Corporate Officer · Individual
Willig, Zachary
Corporate Director · Individual
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