Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interviews and policy review, the facility failed to ensure medications were
administered as physician ordered. This affected four (#47, #66, #80, and #91) out of four residents
reviewed for medication administration. Facility census was 93.
Findings include:
1. Review of the medical record for Resident #47 revealed an admission date of 12/23/22 with diagnoses of
seizures, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and
chronic kidney disease, stage 3 unspecified.
Review of the Medicare 5-Day Minimum Data Set (MDS) dated [DATE] revealed Resident #47 with severe
cognitive impairment. Resident #47 required partial assistance with eating and oral hygiene. Resident # 47
required substantial assistance with toileting hygiene, bathing, dressing, bed mobility, and wheelchair
mobility.
Review of the September 2024 Medication Administration Record (MAR): Levothyroxine Sodium Oral
Capsule 25 micrograms (MCG)-give 25 mcg by mouth one time a day, not initialed as completed on
09/20/24; Lexapro Oral Tablet 20 milligrams (MG)-give 1 tablet by mouth one time a day for depression, not
initialed as completed on 09/20/24; Lipitor Oral Tablet 40 MG-give 40 mg by mouth one time a day, not
initialed as completed on 09/20/24; MiraLax Oral Packet 17 grams (GM)-give 1 packet by mouth one time a
day for constipation, not initialed as completed on 09/20/24; Carvedilol Oral Tablet 3.125 MG-give 1 tablet
by mouth every 12 hours, not initialed as completed on 09/20/24 morning dose; Gabapentin Oral Capsule
300 MG-give 300 mg by mouth two times a day for nerve pain, not initialed as completed on 09/20/24
morning dose; Lacosamide Oral Tablet 100 MG-give 100 mg by mouth two times a day, not initialed as
completed on 09/20/24 morning dose; Levetricetam Oral Tablet 750 MG-give 1 tablet by mouth two times a
day, not initialed as completed on 09/20/24 morning dose.
2. Review of the medical record for Resident #66 revealed an admission date of 05/04/24 with diagnoses of
moderate protein-calorie malnutrition, pressure-induced deep tissue damage of right heel, pressure ulcer of
right buttock, stage 4.
Review of the significant change MDS completed on 09/06/24 revealed Resident #66 had moderate
cognitive impairment. Resident #66 required supervision assistance with eating, oral hygiene, and personal
hygiene, and was dependent on staff assistance for toileting hygiene, bathing, dressing, bed mobility,
transfers, and wheelchair mobility.
(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 3
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
10/24/2024
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of the Resident #66's September 2024 MAR revealed: Atorvastatin Calcium Oral Tablet 10 MG-give
1 tablet by mouth at bedtime for treatment of high cholesterol, not initialed as complete on 09/22/24 at 9:00
P.M.;
Cetirizine HCl Oral Tablet 5 MG-give 1 tablet by mouth at bedtime for seasonal allergies, not initialed as
complete on 09/22/24 at 9:00 P.M.; Levothyroxine Sodium Oral Tablet 150 MCG-give 1 tablet by mouth one
time a day for treatment of thyroid disease, not initialed as complete on 09/23/24 at 6:00 A.M.; Mirtazapine
Oral Tablet 15 MG-give 15 mg by mouth at bedtime for depression/appetite, not initialed as complete on
09/22/24 at 6:00 A.M.; Apixaban Oral Tablet 5 MG-give 1 tablet by mouth two times a day for A-Fib, not
initialed as complete on 09/22/24 at 9:00 P.M.; Coreg Oral Tablet 6.25 MG-give 1 tablet by mouth two times
a day for hypertension, not initialed as complete on 09/22/24 at 9:00 P.M.; Gabapentin Oral Capsule 100
MG-give 1 capsule by mouth two times a day for diabetic neuropathy, not initialed as complete on 09/22/24
9:00 P.M.; and Nifedipine ER Oral Tablet Extended Release 24 Hour 30 MG-give 1 tablet by mouth two
times a day for Hypertension, not initialed as complete on 09/22/24 9:00 P.M.
3. Review of the medical record for Resident #80 revealed an admission date of 07/20/22 with diagnoses of
pressure ulcer of left buttock, stage 2, pressure ulcer of sacral region, stage 4, hypertensive heart and
chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or
unspecified chronic kidney disease.
Review of the quarterly MDS dated [DATE] revealed Resident #80 was cognitively intact. Resident #80
required supervision assistance with eating and oral hygiene, required partial assistance with personal
hygiene, and was dependent on staff assistance with toileting hygiene, bathing, dressing, bed mobility, and
transfers.
Review of the September 2024 MAR revealed: Latanoprost PF Ophthalmic Solution 0.005 %-instill 1 drop in
both eyes at bedtime for glaucoma, not initialed as complete on 09/25/24 at 6:00 P.M.; Mirtazapine Oral
Tablet 7.5 MG-give 7.5 mg by mouth at bedtime for depression, not initialed as complete on 09/25/24 at
6:00 P.M.; Rosuvastatin Calcium Oral Tablet 20 MG-give 20 mg by mouth at bedtime for hyperlipidemia, not
initialed as complete on 09/25/24 at 6:00 P.M.; Vitamin D3 Oral Tablet-give 125 mcg by mouth in the
evening for supplement, not initialed as complete on 09/25/24 at 6:00 P.M.; Zoloft Oral Tablet 100 MG-give
100 mg by mouth at bedtime for depression, not initialed as complete on 09/25/24 at 6:00 P.M.;
Levetricetam Oral Tablet 500 M-give 500 mg by mouth two times a day for seizures, not initialed as
complete on 09/25/24 at 6:00 P.M.; Metformin Oral Tablet 500 MG-give two tablet by mouth two times a day
for diabetes mellitus type 2, not initialed as complete on 09/27/24 at 9:00 P.M.; Metformin Oral Tablet 500
MG-give 500 mg by mouth two times a day for diabetes mellitus, not initialed as complete on 09/25/24 at
6:00 P.M.
4. Review of the medical record for Resident #91 revealed an admission date of 11/03/23 with diagnoses of
pressure ulcer of sacral region, stage 4, depression, unspecified dementia, severe, without behavioral
disturbance, psychotic disturbance, mood disturbance, and anxiety.
Review of the Quarterly MDS dated [DATE] revealed Resident #91 with severe cognitive impairment.
Resident requires partial assistance with eating, requires substantial assistance with oral care and personal
hygiene, and was dependent on staff assistance with toileting hygiene, bathing, dressing, bed mobility, and
transfers.
Review of the September 2024 MAR revealed: Norco Oral Tablet 5-325 MG
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365819
If continuation sheet
Page 2 of 3
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
10/24/2024
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
(Hydrocodone-Acetaminophen)-give 1 tablet by mouth one time a day for stage 4 sacrum not initialed as
complete on 09/27/24 at 5:00 P.M.; Clobazam Oral Tablet 10 MG-give 1 tablet by mouth two times a day for
Seizures not initialed as complete on 09/27/24 at 10:00 P.M.; Clobazam Oral Tablet 10 MG-give 1 tablet via
g-tube two times a day for Seizures not initialed as complete on 09/24/24 at 10:00 P.M.; Lacosamide Oral
Tablet 200 MG-give 200 mg by mouth two times a day for Seizures, not initialed as complete on 09/27/24 at
10:00 P.M.; Lacosamide Oral Tablet 200 MG-give 200 mg via G-Tube two times a day for Seizures, not
initialed as complete on 09/24/24 at 10:00 P.M.; Pregabalin Oral Capsule 150 MG-give 1 capsule by mouth
two times a day for seizures / nerve pain, not initialed as complete on 09/27/24 at 10:00 P.M.; and
Pregabalin Oral Capsule 150 MG-give 1 capsule via G-Tube two times a day for seizures/nerve pain, not
initialed as complete on 09/24/24 at 10:00 P.M.
Interview on 10/24/24 at 7:57 A.M. with Licensed Practical Nurse (LPN) #325 confirmed Resident #47, #66,
#80, and #91 did not have orders completed as listed on their MAR's.
Review of the medication administration policy dated 06/21/17 revealed it is the policy of the facility that
medications will be administered by legally authorized and trained persons in accordance with applicable
State, Local and Federal laws and consistent with acceptable standards of practice.
This deficiency represents non-compliance investigated under Complaint Number OH00158320.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365819
If continuation sheet
Page 3 of 3
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
FAQ · About this visit
Common questions about this visit
What happened during the October 24, 2024 survey of SIENA WOODS CARE CENTER?
This was a inspection survey of SIENA WOODS CARE CENTER on October 24, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SIENA WOODS CARE CENTER on October 24, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.