Health inspection·April 23, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 and staff interview, the facility failed to ensure a thorough assessment of a pressure ulcer was completed upon discovery. This affected one (#25) of three residents reviewed for wounds. The facility census was 82. Residents Affected - Few Findings include: Review of the medical record for Resident #25 revealed an admission date of 06/27/24 with diagnoses of dysphagia, oropharyngeal phase, chronic obstructive pulmonary disease, chronic venous hypertension (idiopathic) with ulcer of the bilateral lower extremity, peripheral vascular disease, and acquired absence of the left leg below the knee. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact and required supervision assistance with eating, partial assistance with oral hygiene, and was dependent on staff assistance with toileting hygiene, bathing, dressing, personal hygiene, and bed mobility. Review of Resident #25's physician order dated 02/03/25 revealed an order to reduce pressure to the right heel and left stump, float heel/stump off of the bed at all times. Review of Resident #25's progress note dated 02/11/25 at 3:30 P.M. revealed wound care provided for right heel area. Review of the physician order dated 02/11/25, with a discontinue date of 02/19/25, revealed an order for a treatment to the left (right) heel to cleanse area with wound cleanser, pat dry, cover in betadine, and apply boarder gauze. Review of Resident #25's skin observation tool dated 02/12/25 revealed no new skin concerns. Review of Resident #25's subsequent skin observation tool documents dated 02/19/25 revealed no new skin concerns, and on 02/22/25 revealed below the knee amputation with treatment currently in place and moisture associated skin damage with treatment and no new areas. Review of Resident #25's wound observation tool dated 02/24/25 revealed the physician was notified on 02/24/25 of a pressure wound to the right heel with no staging noted and measured 2.5 centimeters (cm) long by 5.0 cm wide by 0.0 cm deep with treatment noted as betadine. Interview on 04/23/25 at 9:49 A.M. with Licensed Practical Nurse (LPN) #501 confirmed on 02/11/25 Page 1 of 5 365819 365819 04/23/2025 Siena Woods Care Center 6125 N Main Street Dayton, OH 45415

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few when the wound on the right heel for Resident #25 was found, an assessment of the wound was not documented in the medical record to include measurements and a description of the wound bed. LPN #501 also confirmed the wound bed was 100 percent black necrotic tissue and dry with no drainage. LPN #501 stated it was the expectation when a new wound was found that a change in condition or skin assessment be completed with the measurements and description of the wound be completed. LPN #501 confirmed a change of condition nor skin assessment on the new pressure area to the right heel was not completed for Resident #25. The facility unable to provide a policy for documentation requirements for a new pressure wound. This deficiency represents non-compliance investigated under Complaint Number OH00164982 and Complaint Number OH00164075. 365819 Page 2 of 5 365819 04/23/2025 Siena Woods Care Center 6125 N Main Street Dayton, OH 45415

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure medications were secured in a safe manner. This affected one (#33) of three residents reviewed for medications. The facility census was 82. Findings include: Review of the medical record for Resident #33 revealed an admission date of 04/26/16 with diagnoses of chronic obstructive pulmonary disease, schizoaffective disorder, anemia, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had severe cognitive impairment. Resident #33 was independent with oral hygiene, toileting hygiene, dressing, bed mobility, and ambulation. Resident #33 required set-up assistance with eating, bathing, and personal hygiene, and required supervision assistance with transfers. Review of the care plan dated 08/11/22 revealed Resident #33 had impaired cognitive function/dementia or impaired thought processes related to dementia and schizoaffective disorder. Interventions were added on 08/31/24 to administer medications as ordered and observe for side effects and effectiveness. Review of the physician order dated 12/27/19 revealed Resident #33 had an order for the pain medication gabapentin 100 milligram (mg) tablet three times a day by mouth for pain. Review of the physician order dated 02/21/25 revealed Resident #33 had an order for the anti-anxiety medication buspirone 7.5 mg tablet by mouth three times a day for anxiety. Observation on 04/21/25 at 2:33 P.M. in Resident #33's room revealed a medication cup sitting on the bedside table with two pills in it. Interview at the time of the observation with Resident #33 stated she would take the medications. Interview on 04/21/25 at 2:34 P.M. with Licensed Practical Nurse (LPN) #374 confirmed Resident #33 was not approved to self-administer her medications. Interview on 04/21/25 at 2:35 P.M. with LPN #506 confirmed the medications sitting on Resident #33's bedside table were a gabapentin 100 mg tablet and a buspirone 7.5 mg tablet. LPN #506 also confirmed she left the medications on Resident #33's bedside table when she left the room and confirmed Resident #33 was not to administer her own medications. Review of the general guidelines for medication administration policy, dated 06/17/21, revealed medications will be administered by legally-authorized and trained persons in accordance to applicable State, Local, and Federal laws and consistent with accepted standards of practice. The staff should identify the resident, administer medication and remain with resident while medication is swallowed. Never leave medication in a resident's room without orders to do so. 365819 Page 3 of 5 365819 04/23/2025 Siena Woods Care Center 6125 N Main Street Dayton, OH 45415

F 0761 This deficiency represents non-compliance investigated under Master Complaint Number OH00165066 and Complaint Number OH00164982. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365819 Page 4 of 5 365819 04/23/2025 Siena Woods Care Center 6125 N Main Street Dayton, OH 45415

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure residents received food in a form to meet individual needs. This affected one (#101) of three residents reviewed for dietary status. The facility census was 82. Findings include: Review of Resident #101's medical record revealed an admission date of 02/13/25 with diagnoses of acute respiratory failure with hypoxia, aphasia, morbid (severe) obesity due to excess calories, and type II diabetes mellitus without complications. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was assessed with severe cognitive impairment. Resident #101 was dependent on staff assistance for all activities of daily living (ADLs). Resident had a percutaneous endoscopic gastrostomy (PEG) feeding tube and was not on a mechanically altered or therapeutic diet. Review of Resident #101's admission orders dated 02/13/25 revealed no dietary order was noted. Review of Resident #101's physician order dated 02/13/25 revealed an order for a regular diet, regular texture, and thin liquids consistency. Review of Resident #101's progress note dated 02/14/25 at 12:34 P.M. revealed a change in condition was reported with staff reporting the resident had a coughing episode. The physician was contacted with new orders for a chest x-ray and Resident #101 was to remain nil per os (NPO; meaning nothing by mouth). Review of Resident #101's physician order dated 02/14/25 revealed on order for NPO diet, NPO texture, NPO consistency, the resident has a feeding tube. Interview on 04/22/25 at 11:33 A.M. with Registered Nurse (RN) #327 confirmed Resident #101 was started on a regular diet, regular texture, thin liquid diet on admission on [DATE]. RN #327 also confirmed the diet order was not on the admission orders, and the regular diet, regular texture, thin liquids diet was started without verifying with the physician whether Resident #101 should be NPO. RN #327 stated Resident #101 was being fed by staff when the resident was coughing and confirmed the resident should have had nothing by mouth. The facility was unable to provide a policy for verifying dietary orders. This deficiency represents non-compliance investigated under Complaint Number OH00164982. 365819 Page 5 of 5