Health inspection·November 14, 2019

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview; the facility failed to ensure advanced directives being stored in the hard chart and electronic health record (EHR) were consistent. This affected three (#26, #40, and #49) of 25 residents reviewed for consistency of advanced directives. The census was 92. Findings include: 1. Review of the medical record for Resident #26 revealed the resident was admitted to the facility on [DATE]. Review of the hard chart for Resident #26 revealed a do not resuscitate (DNR) form dated 06/17/17, which identified the residents code status was DNR comfort care (CC) arrest (A). Review of the EHR for Resident #26 revealed the resident's code status was DNR. 2. Review of the medical record of Resident #40 revealed the resident was admitted to the facility on [DATE]. Review of the hard chart for Resident #40 revealed a DNR form dated 12/06/17,which identified the residents code status was DNR CC A. Review of the EHR for Resident #40 revealed the residents code status was DNR. 3. Review of the medical record for Resident #49 revealed the resident was admitted to the facility on [DATE]. Review of the hard chart for Resident #49 revealed a DNR form dated 09/12/17, which identified the residents code status was DNR CC. Review of the EHR for Resident #49 revealed the residents code status was DNR CC A. Interview on 11/13/19 at 1:26 P.M. with the DON verified the advances directives stored in the hard chart and EHR of the above residents were not consistent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365819 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siena Woods Care Center 6125 N Main Street Dayton, OH 45415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately to reflect the resident's current status. This affected four (Residents #3, #53, #58 and #71) of 22 resident MDS reviews completed. The facility census was 92. Residents Affected - Few Findings include: 1. Record review for Resident #71 revealed an admission date of 10/09/19. Review of the admission MDS assessment, dated 10/16/19, documented the resident was receiving an anticoagulant medication. Her oral assessment stated she had obvious or likely cavities or broken natural teeth. Review of the Medication Administration Record (MAR) and physician orders for October 2019 revealed the resident was receiving an anti-platelet medication, Plavix, not an anti-coagulant. On 11/12/19 at 11:08 A.M. interview with Resident #71 verified she did not have any teeth and had a full set of dentures observed on her bedside table. 2. Record review for Resident #53 revealed an admission date of 10/24/19. Review of the admission MDS assessment dated [DATE], documented the resident was receiving an anti-coagulant medication. Review of the Medication Administration Record (MAR) and physician orders for October 2019 revealed the resident was receiving an anti-platelet medication, Plavix, not an anti-coagulant. 3. Review of medical record for Resident #58 revealed an admission date of 02/25/19. Review of the quarterly MDS assessment, dated 10/04/19, documented the resident was receiving an anti-coagulant medication Review of the Medication Administration Record (MAR) and physician orders for October 2019 revealed the resident was receiving an anti-platelet medication, Plavix, not an anti-coagulant On 11/13/19 at 1:50 P.M. interview with MDS Nurse #81 verified the above assessments were incorrectly coded as using an anticoagulant medication. She also verified Resident #71 dental status was coded inaccurately and should have been code as no natural teeth or tooth fragments. 4. Review of Resident #3's medical record revealed an admission date of 01/31/19. Review of progress notes dated 08/28/19 at 4:55 A.M. revealed Resident #3 returned from a hospital admission with no indwelling urinary catheter in place. Review of physician orders revealed the catheter was discontinued on 08/28/19. Review of a quarterly MDS, dated [DATE], revealed Resident #3's was assessed as having a indwelling urinary catheter. Interview with Registered Nurse (RN) #82 on 11/14/19 at 2:27 P.M. revealed that the assessment was coded incorrectly and the resident did not have a catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365819 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siena Woods Care Center 6125 N Main Street Dayton, OH 45415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based record review and staff interview, the facility failed to ensure a Preadmission Screen and Resident Review (PASARR) was accurate upon admission to the facility. This affected one (Resident #71) of three residents reviewed for PASARR assessments. The facility census was 92. Residents Affected - Few Findings include: Review of the medical record for Resident #71 revealed an admission date of 10/09/19 with diagnoses including major depression, anxiety and bipolar disorder. Review of PASARR dated 09/19/19 documented the resident had a diagnosis of dementia and no current diagnoses of mental health disorders or psychiatric services received in the past two years. Review of admission Minimum Data Set (MDS) assessment, dated 10/16/19, documented the resident did not have any indications of serious mental illness. She was cognitively intact and had no active diagnosis of dementia. On 11/12/19 at 11:08 A.M. interview with Resident #71 revealed she does not have a diagnosis of dementia and she received psychiatric service prior to admission to the facility by a physiatrist and a therapist. On 11/13/19 at 2:00 P.M. interview with admission Coordinator #129 revealed Resident #71 does not have a diagnosis of dementia and verified her PASARR screening assessment was inaccurate. She also revealed they only received a level of care determination with the previous PASARR assessment from the hospital and verified she did not review the PASARR to ensure accuracy upon admission. The assessment would need to be completed again to ensure the resident was given appropriate services if needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365819 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siena Woods Care Center 6125 N Main Street Dayton, OH 45415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview and policy review, the facility failed to ensure laboratory tests were completed as ordered per the physician. This affected one (Resident #34) of one resident reviewed for dialysis. The facility census was 92. Residents Affected - Few Findings include: Review of medical record for Resident #34 revealed an admission date of 08/03/19 with diagnoses including sepsis, cerebral infarction, aphasia, dysphasia, muscle weakness, abnormal posture, anemia in chronic kidney disease, diabetes type two, need for assistance with personal care, vascular dementia, hypertension, hyperlipidemia, pressure ulcer of the sacral region, end stage renal disease (ESRD), dependence on renal dialysis. Review of physician order dated 08/04/19 documented an order for dialysis treatments every Tuesday, Thursday and Saturday. Review of comprehensive care plan documented Resident #34 has an alteration in kidney function related to ESRD. The goal was to keep lab values within therapeutic range with intervention of the resident's specific dialysis schedule of a chair time of 7:30 A.M. on every Tuesday Thursday and Saturday. Review of laboratory report dated Saturday, 11/02/19 revealed a laboratory blood test was not completed as the phlebotomist unable to obtain an adequate blood sample. The laboratory was to send another phlebotomist out to draw the blood again. Review of the physcian orders revealed no order for the laboratory test. Review of the nursing notes revealed no information related to the resident missing dialysis, that the physician was notified of the missed dialysis, that any staff followed up with the laboratory regarding the need to redraw the resident's blood, no documentation of missed transportation to dialysis and no notes regarding staff monitoring or assessing the resident due to the missed dialysis treatment. Review of laboratory report dated Monday, 11/04/19 documented a basic metabolic panel (BMP) and a complete blood count had been completed. The resident's potassium level was 6 milliequivalents per liter (mEq/l) with the normal range being between 3.5 - 5.3 mEq/l. Review of nursing note dated 11/04/19 at 1:33 P.M. documented Resident #34 was sent to the emergency room per dialysis [dialysis clinic] for elevated potassium and to dialyze. Review of the hospital assessment and plan dated 11/04/19 documented Resident #34 would return to the long term care facility in one or two days. She presented to the hospital with elevated potassium most likely secondary to missing dialysis and the resident would be having dialysis shortly per nephrology. Review of nursing notes dated 11/05/19 at 10:32 P.M. documented resident #34 returned from the hospital via stretcher. During interview on 11/14/19 at 1:20 A.M., Licensed Practical Nurse (LPN) #131 revealed she work first shift and took care of Resident #34 on 11/02/19. She verified Resident #34 did not go to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365819 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siena Woods Care Center 6125 N Main Street Dayton, OH 45415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dialysis as ordered due to transportation issues. She stated she notified the physician and she received laboratory orders for a stat (immediate) basic metabolic panel and to monitor the resident. She stated no physician orders for the laboratory work or monitoring was documented because she wasn't able to get into the facility's electronic charting system. She stated the laboratory order was placed directly into the laboratory system resulting in them coming to draw laboratory work. She stated the resident's blood was drawn, but she wasn't sure what the report said and she passed it on to the next shift. During interview on 11/14/19 at 3:04 P.M., LPN #13 revealed he worked the night shift on 11/02/19. He said he monitored Resident #34 but it was not documented. He said the laboratory results came back as needing a redraw and he notified the laboratory, but they never came on his shift. He did not follow up and reported it to day shift on Sunday, 11/03/19. During interview on 11/14/19 at 3:08 P.M., Regional Nurse #132 stated Resident #45 did not go to dialysis as scheduled on 11/02/19 due to a transportation issue. She said there was no documentation of the laboratory orders or monitoring of the resident on 11/02/19 and 11/03/19. She confirmed the resident was sent to the emergency room on Monday 11/04/19 to be dialyzed due to her high potassium level. Review of the facility policy titled General education/policy dialysis, undated, documented hemodialysis is a treatment that removes waste products and the excess fluids that accumulate in the blood as a result of kidney failure. Treatments typically occur three times a week and help remove excess fluid, balance electrolytes and acid-base. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365819 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siena Woods Care Center 6125 N Main Street Dayton, OH 45415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure the physcian addressed pharmacy recommendations. This affected one Resident (#3) of five residents reviewed for unnecessary medications. The census was 92. Findings include: Record review revealed Resident #3 was admitted on [DATE]. Review Resident #3's electronic medical record review revealed pharmacy reviews were completed on 08/20/19, 09/16/19, and 10/02/19. The reviews contained no documentation of what the pharmacist was recommending, just that a review was done. Transition Nurse Specialist (TNS) #130 presented copies of pharmacy recommendations dated 08/20/19, 09/16/19, and 10/02/19 on 11/14/19 at 3:50 P.M. that had been sent form the consultant pharmacy. Review of these pharmacy recommendations revealed on 08/20/19 pharmacy had recommended aspirin be discontinued due to an allergy. On 09/16/19 pharmacy recommended Prozac (anti-depressant) be addressed for an improper diagnosis of insomnia. On 10/0219 pharmacy recommended Lactobacillus (probiotic) be given a stop date. None of the pharmacy recommendations were signed by physician. Transition Nurse Specialist (TNS) #130 confirmed during an interview on 11/14/19 at 4:00 P.M. that the pharmacy recommendations dated 08/20/19, 09/16/19, and 10/02/19 had not been addressed or signed by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365819 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siena Woods Care Center 6125 N Main Street Dayton, OH 45415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to monitor a resident's weights as ordered by the physician. This affected one (Resident #24) of five residents reviewed for unnecessary medications. The facility census was 92. Residents Affected - Few Findings include: Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses of hypertension and stage three chronic kidney disease. Review of a care plan, dated 10/23/18, revealed the resident had impaired cardiovascular status related to the diagnosis of hypertension. The goal was for the resident to be free of symptoms and not have a decline in function related to cardiac condition. Interventions included: daily weights as ordered, notify physician of a two-pound weight gain in one day or five-pound weight gain in three days. Observe and report signs of hypertension such as headaches, flushing, fatigue, blurred vision, shortness of breath. Review of the resident's annual Minimum Data Set (MDS) assessment, dated 08/09/19, revealed the resident had moderate cognitive impairment. Review of physician orders for Resident #24 revealed an order, dated 03/31/19, to obtain daily weights. Call the physician if two-pound weight gain in one day or five-pound weight gain in three days. Review of the Treatment Administration Record (TAR) revealed on 11/10/19 the resident's weight was documented 156.4 pounds. On 11/12/19, the resident's weight was documented as 161.2 pounds, indicating the resident had a 4.8-pound weight gain in two days. Medical record review revealed no evidence the physician was notified of the resident's weight gain. An interview on 11/13/19 at 2:26 P.M. with the Director of Nursing (DON) verified the physician was not notified of Resident #24's, 4.8-pound weight gain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365819 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siena Woods Care Center 6125 N Main Street Dayton, OH 45415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review, staff interview, and review of Medscape (online medical resource), the facility failed to ensure an appropriate diagnosis for use of an anti-psychotic medication. This affected one (Resident #58) of five residents reviewed for unnecessary medications. The census was 92. Findings include: Review of Resident #58's medical record revealed an admission date of 02/25/19. Diagnoses included major depressive disorder, dementia without behavioral disturbance , Alzheimer's disease, generalized anxiety disorder, and cognitive communication deficit. Review of physician orders revealed an order dated 02/25/19 for Zyprexa, anti-psychotic medication, five milligrams (mg) by mouth daily. The diagnoses listed for the use of the medication was depression. Noted with the order was a request for a supporting diagnosis for use of the medication or recommendation for discontinuation of the medication. Review of medication administration records from 02/15/19 through 11/13/19 revealed Resident #58 had received Zyprexa daily since admission. During an interview on 11/13/19 at 3:29 P.M. the Director of Nursing (DON) confirmed that Resident #58 did not have an appropriate diagnosis for use of Zyprexa and had received the medication since admission. Review of Medscape revealed that Zyprexa was recommended for use to treat bipolar depression and schizophrenia. Zyprexa was not approved for dementia-related psychosis in geriatric patients because of the increased risk of cardiovascular or infection-related mortality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365819 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siena Woods Care Center 6125 N Main Street Dayton, OH 45415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure that after an inadequate blood sample was obtained for a laboratory test, a second blood draw was completed timely. This affected one (Resident #34) of one resident reviewed for dialysis. The facility census was 92. Residents Affected - Few Findings include: Review of medical record for Resident #34 revealed an admission date of 08/03/19 with diagnoses including sepsis, cerebral infarction, aphasia, dysphasia, muscle weakness, abnormal posture, anemia in chronic kidney disease, diabetes type two, need for assistance with personal care, vascular dementia, hypertension, hyperlipidemia, pressure ulcer of the sacral region, end stage renal disease (ESRD), dependence on renal dialysis. Review of laboratory report dated Saturday, 11/02/19 revealed a laboratory blood test was not completed as the phlebotomist unable to obtain an adequate blood sample. The laboratory was to send another phlebotomist out to draw the blood again. Review of the physcian orders revealed no order for the laboratory test. Review of the nursing notes revealed no information that any staff followed up with the laboratory regarding the need to redraw the resident's blood. Review of laboratory report dated Monday, 11/04/19 documented a basic metabolic panel (BMP) and a complete blood count had been completed. The resident's potassium level was 6 milliequivalents per liter (mEq/l) with the normal range being between 3.5 - 5.3 mEq/l. During interview on 11/14/19 at 1:20 A.M., Licensed Practical Nurse (LPN) #131 revealed she work first shift and took care of Resident #34 on 11/02/19. She verified Resident #34 did not go to dialysis as ordered due to transportation issues. She stated she notified the physician and she received laboratory orders for a stat (immediate) basic metabolic panel and to monitor the resident. She stated no physician orders for the laboratory work or monitoring was documented because she wasn't able to get into the facility's electronic charting system. She stated the laboratory order was placed directly into the laboratory system resulting in them coming to draw laboratory work. She stated the resident's blood was drawn, but she wasn't sure what the report said and she passed it on to the next shift. During interview on 11/14/19 at 3:04 P.M., LPN #13 revealed he worked the night shift on 11/02/19. He said the laboratory results came back as needing a redraw and he notified the laboratory, but they never came on his shift. He did not follow up and reported it to day shift on Sunday, 11/03/19. During interview on 11/14/19 at 3:08 P.M., Regional Nurse #132 stated there was no documentation of the laboratory orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365819 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siena Woods Care Center 6125 N Main Street Dayton, OH 45415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and interview, the facility failed to provided dental services in a timely manner. This affected one (Resident #66) of three resident reviewed for dental services. The census was 92. Residents Affected - Few Findings include: Review of the medical record for Resident #66 revealed the resident was admitted to the facility on [DATE]. Review of a dental consult progress note dated 05/17/19 revealed the resident's lower teeth were all decayed. Documentation revealed the resident refused extraction at this time. Review of the care plan updated 05/20/19, revealed Resident #66 was at risk for dental problems related to natural teeth. Documentation revealed the resident complained of mouth pain, was seen by a dentist but refused to have decayed lower teeth extracted. Interventions include refer to dental services as needed. Review of a general progress note dated 09/17/19 at 1:01 P.M., documented by social services, revealed Resident #66 reported complaints of his teeth hurting. The resident was in agreement to consult with the dentist. Nursing was made aware of the resident's complaints of pain and the need to consult with dental services. Review of the medical record revealed no evidence a dentist had seen the resident for continued mouth pain. During interview on 11/12/19 at 10:16 A.M. Resident #66 stated his bottom teeth were decayed and sometimes caused pain. The resident notified staff of the need to have the bottom teeth extracted but was unsure when the request for the dental consult was made. The resident denied tooth pain during this interview. Observation revealed the resident's remaining lower teeth were black and brown in color at the gum line. During interview on 11/13/19 at 10:20 A.M. Social Service Supervisor (SS) #119 revealed Resident #66 was seen by a dentist in May 2019. At that time, the resident refused tooth extractions. Resident #66 later reported to SS #119 in September 2019 of his desire to have the lower teeth extracted due to pain. Nursing was notified of the resident's need for a dental consult. SS #119 had no knowledge if the dental consult was ever scheduled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365819 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Siena Woods Care Center 6125 N Main Street Dayton, OH 45415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview and policy review, the facility failed to monitor the water supply to ensure the water could not be contaminated with the Legionella bacterium. This had the potential to affect all 92 residents in the facility. Residents Affected - Many Findings include: Review of the Legionella documentation provided by the facility revealed it contained no documentation related to the Centers for Disease Control (CDC) toolkit, completion of a water risk assessment or completion of any water flow diagrams. Interview on 11/14/19 at 1:45 P.M. with Maintenance Supervisor #112 confirmed the facility does not have a water flow diagram, did not complete the CDC toolkit or complete a water risk assessment. Review of the facility policy titled Legionnaires' Disease: Detection, Response, Prevention Policy, undated, revealed the facility will utilize sound clinical and infection control practices to quickly identify and treat any potential Legionnaires' related illnesses. Sound engineering, preventive maintenance and housekeeping practices will be utilized to minimize the risk of exposing residents and team members to the Legionella bacteria. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365819 If continuation sheet Page 12 of 12