Health inspection·January 11, 2024

F 0686 ulcer. Level of Harm - Actual harm Review of the care plan dated 10/23/23 revealed to place moon boots on the resident. Residents Affected - Few Review of wound physician's notes dated 12/14/23 revealed Resident #26 had a new area to his sacrum that was in-house acquired that measured 5.0 cm by 6.0 cm by 0.3 cm with a surface area of 30.00 cm that was a Stage III. There was moderate serous exudate with 100% granulation. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was rarely or never understood. The assessment revealed the resident had impairment to his lower extremities and was dependent on staff for bed mobility, transfers, eating and toileting. The resident was assessed to be always incontinent for bowel and bladder. Review of wound physician's notes dated 01/11/24 revealed the right heel wound was a Stage IV that measured 5.0 cm by 3.6 cm by 0.4 cm with a surface area of 18 cm. There was moderate serous exudate. There was 10% thick adherent necrotic tissue, 20% slough, 20 % granulation and 50% bone. Further review of notes revealed the Stage III sacrum was measured 2.5 cm by 4.0 cm times 0.4 cm with a surface area of 10.00. There was moderate serous exudate, 40% slough, and 60% granulation tissue. Further review of Resident #26's medical record revealed an order on the January 2024 Treatment Administration Record (TAR) dated 10/02/23 to float heels while in bed and an entry dated 10/23/23 for heel protectors to bilateral heels every shift two times a day. The record review revealed there was no documented evidence the turning and repositioning was being provided. Observations on 01/08/24 at 10:05 A.M. revealed Resident #26 was sitting up in the common area in a Broda chair leaning to the right side without moon boots on and no pillows on either side of the resident for positioning. At 11:08 A.M. Resident #26 continued in the Broda chair leaning to the right side without moon boots on and no pillows for positioning and was in the same position. At 1:06 P.M., Resident #26 continued in the Broda chair leaning to the right side without moon boots on and had not been repositioned. At 1:47 P.M., Resident #26 was still lying in the Broda chair leaning to the right side and had not been repositioned. Interview with State Tested Nursing Aide (STNA) #199 on 01/08/24 at 1:54 P.M. confirmed Resident #26 had been up before 7:00 A.M., before she came to work, and he had not been repositioned in the chair. STNA #199 confirmed she left Resident #26 sit in the Broda chair for seven hours without being turned and repositioned. Observations were made on 01/09/24 at 10:16 A.M. revealed Resident #26 was lying in bed on his back and didn't have any moon boots on his heels and his right heel was lying on his mattress where his pressure ulcer was. There were no pillows in the bed to help reposition Resident #26. At 11:19 A.M., Resident #26 was lying in bed in the same position with no foot boots and no turns observed. Resident #26 had his right heel lying on the bed on his pressure ulcer. At 1:55 P.M. before Resident #26's dressing change the resident continued to lie on his back and didn't have any boots on his heels and his right heel was lying on the bed where his pressure ulcer was. Interview with STNA #199 on 01/09/24 at 2:02 P.M. revealed she took care of Resident #26 yesterday and today. STNA #199 stated she did not turn him or place heel boots on Resident #26 either day because she didn't have time. During the interview STNA #199 looked for Resident #26's moon boots but they were not in the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365819 If continuation sheet Page 2 of 5 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 01/11/2024 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 0686 Level of Harm - Actual harm Residents Affected - Few Observation of dressing change on 01/09/24 at 2:05 P.M. revealed the dressing for Resident #26's right heel and the sacrum were not dated. Observations revealed Resident #26's right heel looked necrotic with beefy red tissue, and there was a scant amount of serous exudate. When Licensed Practical Nurse (LPN) #104 measured the wound and placed the Q-tip into the wound she stated she felt bone and didn't push anymore into the wound. LPN #104 measured the wound to be 6.0 cm by 5.0 cm by 0.3 cm. Interview with the Licensed Practical Nurse (LPN) #104 on 01/09/24 at 2:30 P.M. confirmed she didn't turn or place boots on Resident #26 today. LPN #104 confirmed the bandages were not dated when they were changed on Resident #26's right heel or the sacrum. LPN #104 confirmed there were no boots in Resident #26's room. LPN #104 stated when she measured Resident #26's wound she felt bone. Observations on 01/10/24 at 8:08 A.M., 10:01 A.M. and at 11:56 A.M. revealed Resident #26 was lying on his back in the bed. Interview with the Director of Nursing (DON) on 01/10/24 at 1:00 P.M. confirmed Resident #26 developed an unstageable pressure ulcer on the right heel which was first discovered on 10/02/23. The DON confirmed the wound physician assessed Resident #26's right heel on 10/19/23 a Stage IV. The DON confirmed Resident #26 developed a Stage III pressure ulcer on the sacrum on 12/14/23. The DON confirmed the Resident #26 didn't have interventions in place to prevent the wounds from developing for the resident. The DON confirmed the lack of pressure ulcer intervention could result in the development of skin breakdown for Resident #26. Interview with the Wound Physician (WP) #205 on 01/11/24 at 9:00 A.M. revealed his expectation for an intervention for a resident who was very high risk for a pressure ulcer would be for moon boots prior to the pressure ulcers. WP #205 stated Resident #26's right heel was down to the bone. After listening to the observations the surveyor had during the survey, he stated Resident #26 should not be up in a Broda chair for seven hours and should have the boots on his heels. Review of the policy entitled Preventions of Pressure Ulcers dated 01/01/23 revealed to reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. Choose frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. Provide support devices and assistance as needed. Review of the NPIAP dated 2020 revealed to turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. Choose a frequency for turning based on the support surface in use, the tolerance of skin for pressure and the individual's preferences. Ensure the heels are free from the bed. Reposition weak or immobile individuals in chairs hourly. Use heel offloading devices or polyurethane foam dressings on individuals at high-risk for heel ulcers. Further review of NPIAP revealed the definitions for the pressure ulcers were as followed: Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage IV Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365819 If continuation sheet Page 3 of 5 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 01/11/2024 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 0686 Level of Harm - Actual harm Residents Affected - Few with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuate) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuate) on the heel or ischemic limb should not be softened or removed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365819 If continuation sheet Page 4 of 5 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 01/11/2024 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observations, staff and family interviews, and review of facility policy, the facility failed to provide podiatry services to a resident. This affected one (#70) of three reviewed for activities of daily living (ADL's). The census was 79. Residents Affected - Few Findings include: Review of Resident #70's medical record revealed an admission dated of 07/29/22. Diagnoses listed included type two diabetes mellitus, stage three chronic kidney disease, anxiety disorder, major depressive disorder, psychotic disturbance, and macular degeneration. Review of a quarterly Minimum Data Set (MDS) assessment dated revealed staff has assessed Resident #70 as being severely cognitively impaired. Review of a plan of care dated revised 10/23/23 revealed Resident #70 needed assistance with ADL self-performance care due to confusion, dementia, and visual disturbance. Resident #70 was dependent for personal hygiene. Further review of Resident #70's medical record revealed a physician order dated 05/13/21 for may see podiatrist, dentist, audiologist, and ophthalmologist. Review of facility forms titled Attending Physician Request for Services/Consultation dated 02/10/23, 06/13/23, and 09/18/23 revealed Resident #70's physician requested podiatry consultations due to thickened, dystrophic, and/or painful nails with increased risk of infection. Further review of Resident #70's medical record revealed no documentation of podiatry services being provided. During an interview on 01/08/24 at 1:50 P.M. Resident #70 family member reported requesting podiatry services for Resident #70. Resident #70 has yet to be seen by a podiatrist at the facility. During an interview on 01/09/24 at 2:43 P.M. the Administrator confirmed Resident #70 should have had podiatry services at the facility. Observation of Resident #70's feet on 01/11/24 at 8:46 A.M. revealed some toenails on each foot that extended beyond the end of the toe. Toenails on the great toe of each foot were thick and extended beyond the end of the toe. Review of the facility's policy titled Foot Care dated revised October 2022 revealed residents will receive appropriated treatment in order to maintain mobility and foot health. Residents are assisted in making appointments and with transportation to and from specialists (podiatrist, endocrinologist, etc.) as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365819 If continuation sheet Page 5 of 5