Health inspection·January 8, 2025

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews and review of the Influenza Vaccine Report, the facility failed to offer the annual influenza vaccines to residents. This affected three (#47, #14 and #39) out of three residents reviewed for influenza vaccines and had the potential to affected 80 out of 82 residents residing in the facility, the facility identified two (#16 and #79) residents who were not eligible for the influenza vaccine. The facility census was 82. Residents Affected - Some Findings include: 1. Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic obstructive pulmonary disease, spondylosis without myelopathy or radiculopathy, lumbosacral region, and unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Further review of Resident #47's medical record revealed there was no documentation the resident was not offered or administered the influenza vaccine for the 2024-2025 influenza season. 2. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include pressure ulcer of sacral region, stage 3, malignant neoplasm of middle lobe, bronchus or lung, and type 2 diabetes mellitus with diabetic neuropathy. Further review of Resident #14's medical record revealed there was no documentation the resident was not offered or administered the influenza vaccine for the 2024-2025 influenza season. 3. Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebral atherosclerosis, pressure ulcer of sacral region, stage 4, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Further review of Resident #39's medical record revealed there was no documentation the resident was not offered or administered the influenza vaccine for the 2024-2025 influenza season. Interview on 01/08/25 at 11:46 A.M. with Assistant Director of Nursing (ADON) #3 confirmed the facility has not offered the residents the annual 2024-2025 influenza vaccine due to losing the infection control nurse approximately six weeks ago and reorganizing the position. Interview with ADON #3 also confirmed the floor nurses were given consent paperwork on 12/30/24 to review with the resident and get their consent for the vaccine. Interview with ADON #3 also confirmed on 01/03/25 pharmacy was notified of the need of 60 additional flu vaccines. ADON #3 confirmed there were some residents not (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 2 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 01/08/2025 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)