Health inspection·September 26, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and policy review, the facility failed to initiate treatment for a pressure ulcer in a timely manner. This affected one (#08) of three residents reviewed for wound care and treatment. The facility census was 81. Residents Affected - Few Findings include: Review of the medical record for Resident #08 revealed an admission date of 05/04/24 with medical diagnoses of moderate protein calorie malnutrition, diabetes mellitus with neuropathy, hypertension, anxiety, and chronic kidney disease. Review of the medical record for Resident #08 revealed a significant change Minimum Data Set (MDS) assessment, dated 09/06/24, which indicated Resident #08 had moderate cognitive impairment and was dependent upon staff for toilet hygiene, bathing, bed mobility, and transfers. The MDS assessment indicated Resident #08 had a stage four pressure ulcer (full-thickness skin and tissue loss) that was not present upon admission. Review of a wound observation assessment, dated 05/30/24, revealed Resident #08 had an unstageable pressure ulcer (obscured full-thickness skin and tissue loss) to the right buttock which measured 8.0 centimeters (cm) long by 5.0 cm wide by 0.1 cm deep. The assessment revealed a low air loss mattress was in place and the current treatment was to apply calcium alginate. Review of a wound nurse practitioner (NP) note, dated 05/31/24, revealed Resident #08 had an unstageable pressure ulcer to the right buttock due to necrosis (dead tissue). The wound measured 8.0 cm long by 5.0 cm wide by 0.1 cm deep, and a treatment was ordered to apply calcium alginate and cover with gauze and bordered dressing daily. Review of Resident #08's medical record revealed a physician order dated 06/04/24 to cleanse the right buttock wound with wound cleanser, pat dry, apply calcium alginate, and cover with bordered gauze daily. Review of the medical record revealed no documentation to support Resident #08's right buttock pressure ulcer treatment was started until 06/04/24. Further review of a wound NP note, dated 09/26/24, revealed Resident #08 had a stage four pressure ulcer to the right buttock and indicated the wound had improved as evidenced by decreased surface area and decreased undermining. Interview on 09/26/24 at 4:17 P.M. with Director of Nursing (DON) confirmed the medical record for Resident #08 had no documentation to support treatment to the right buttock pressure ulcer was started until 06/04/24. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365819 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 09/26/2024 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)