Health inspection·November 30, 2023

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete services would discontinue on 10/25/23. The NOMNC form did not specify which services would be discontinued. The form stated, the effective date coverage of your current skilled nursing facility will end: 10/25/23. During interview on 11/30/23 at 11:10 A.M., Social Services Director (SSD) #165 confirmed that the NOMNC form for Resident #235 did not specify which type of skilled services would be ending and only indicated the ending date of services. Event ID: Facility ID: 366331 If continuation sheet Page 2 of 14 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 366331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Skilled Nursing & Rehabilitation 250 Cadiz Road Wintersville, OH 43953 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #26's medical record revealed an admission date of 07/09/21 with diagnoses that included diabetes mellitus, congestive heart failure and chronic obstructive pulmonary disease. Review of Resident #26's Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 10/03/23 revealed the resident had an intact and independent cognition level. Further review of the medical record revealed on 10/26/23, 10/04/23, 07/10/23, 06/13/23 and 03/29/23 Resident #26 was admitted to the hospital. There was no evidence of ombudsman notification found advising the ombudsman of hospital admission. On 11/30/23 at 12:20 P.M. interview with Licensed Social Worker (LSW) #165 revealed she does not notify the Ombudsman when residents were admitted to the hospital. On 11/30/23 at 1:00 P.M. interview with the Director of Nursing verified the facility has not notified the Ombudsman of hospital admissions for Resident #26. 2. Review of the medical record for Resident #57 revealed an admission date of 04/07/23 with diagnoses including atrial fibrillation, protein-calorie malnutrition, dysphagia, amnesia, myeloid leukemia, history of transient ischemic attack, dementia, and Alzheimer's disease. Review of Resident #57's admission history revealed he was discharged to the hospital on [DATE]. Review of the progress note dated 10/15/23 at 1:22 P.M. revealed Resident #57 had a decline in condition, had labored respirations, elevated blood urea nitrogen (BUN) level, was non-reactive to touch, had decreased oxygen saturation levels on room air, and the physician ordered for Resident #57 to be sent to the emergency room for evaluation due to kidney failure. Review of transfer notice, dated 10/15/23, revealed Resident #57 was transferred to the hospital because his welfare and needs could not be met by the facility. There was no indication the resident or representative had received the notice in writing. Interview on 11/29/23 at 2:31 P.M. with Licensed Social Worker#165 revealed she verbally went over the transfer/discharge notices with the resident/resident representative, and she had not been sending the ombudsman a list of residents who had been discharged . She was unaware she was supposed to send a written copy of the transfer/discharge notice to the resident/resident representative or a list of discharge residents to the ombudsman as required. Interview on 11/29/23 at 3:47 P.M. with the Director of Nursing and Administrator confirmed written transfer/discharge notices had not been sent and the ombudsman had not been notified of facility discharges since LSW #165 started her position at the facility on 05/02/23. Review of undated facility policy Admission, Discharge, and Transfer revealed transfers occurred only after the facility provided the resident with a written notice which included the reason and location. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366331 If continuation sheet Page 3 of 14 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 366331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Skilled Nursing & Rehabilitation 250 Cadiz Road Wintersville, OH 43953 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 0623 Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview and facility policy review, the facility failed to send a written transfer/discharge notice for Resident #57 and #76 reviewed for hospitalization and failed to notify the ombudsman of discharge for Resident #26, #57 and #76. This affected three residents (#26, #57, and #76) of three residents reviewed for transfer/discharges. The facility census was 81. Residents Affected - Few Findings include: 1. Review of medical record review for Resident #76 revealed when the resident was sent to the hospital on [DATE] the reason for the transfer/discharge was reviewed with the Emergency Contact Number One for the resident and when the resident was sent to the hospital on [DATE] the reason was reviewed with Resident #76. There was no indication that a written transfer/discharge notice had been sent to the resident/resident representative for the 10/18/23 and 10/26/23 hospitalizations as required. Interview on 11/29/23 at 2:31 P.M. with Licensed Social Worker#165 revealed she verbally went over the transfer/discharge notices with the resident/resident representative, and she had not been sending the ombudsman a list of residents who had been discharged . She was unaware she was supposed to send a written copy of the transfer/discharge notice to the resident/resident representative or a list of discharge residents to the ombudsman as required. Interview on 11/29/23 at 3:47 P.M. with the Director of Nursing and Administrator confirmed written transfer/discharge notices had not been sent and the ombudsman had not been notified of facility discharges since LSW #165 started her position at the facility on 05/02/23. Review of undated facility policy Admission, Discharge, and Transfer revealed transfers occurred only after the facility provided the resident with a written notice which included the reason and location. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366331 If continuation sheet Page 4 of 14 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 366331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Skilled Nursing & Rehabilitation 250 Cadiz Road Wintersville, OH 43953 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #57 revealed an admission date of 04/07/23 with diagnoses including atrial fibrillation, protein-calorie malnutrition, dysphagia, amnesia, myeloid leukemia, history of transient ischemic attack, dementia, and Alzheimer's disease. Review of Resident #57's admission history revealed he was discharged to the hospital on [DATE]. Review of the progress note dated 10/15/23 at 1:22 P.M. revealed Resident #57 had a decline in condition, had labored respirations, elevated blood urea nitrogen (BUN) level, was non-reactive to touch, had decreased oxygen saturation levels on room air, and the physician ordered for Resident #57 to be sent to the emergency room for evaluation due to kidney failure. There was no evidence that the resident or representative had received a bed hold notice and policy in writing. Interview on 11/29/23 at 2:51 P.M. with Business Office Manager #176 revealed she only sent bed hold notices to the residents sent to the hospital who were under Medicaid payor source. Since Resident #76 was under a managed care payor source, she had not sent bed hold notices for when Resident #76 was sent out to the hospital on [DATE] and 10/26/23. Interview on 11/30/23 at 8:34 A.M. with the Administrator confirmed bed hold notices were only being sent to residents with Medicaid payor source and was unaware all residents were to receive a bed hold notice when being sent to the hospital. Review of the undated facility policy Admission, Discharge, and Transfer revealed the facility would provide at the time of the transfer to the hospital written information to the resident and their responsible party concerning the duration the bed-hold standard under the state plan and alternative payor plans. Based on record review, staff interview, and facility policy review, the facility failed to ensure written bed hold notices were provided for Resident #57 and Resident #76 at the time of transfer. This affected two residents (#57 and #76) of three residents reviewed for hospitalizations. The facility census was 81. Findings include: 1. Review of medical record for Resident #76 revealed the resident was sent to the hospital on [DATE] and again on 10/26/23. Review of the facility documentation for the bed hold notices revealed there was no bed hold notification sent to Resident #76 or the Resident Representative when the resident was sent to the hospital on [DATE] and 10/26/23. Interview on 11/29/23 at 2:51 P.M. with Business Office Manager #176 revealed she only sent bed hold notices to the residents sent to the hospital who were under Medicaid payor source. Since Resident #76 was under a managed care payor source, she had not sent bed hold notices for when Resident #76 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366331 If continuation sheet Page 5 of 14 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 366331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Skilled Nursing & Rehabilitation 250 Cadiz Road Wintersville, OH 43953 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 0625 was sent out to the hospital on [DATE] and 10/26/23. Level of Harm - Minimal harm or potential for actual harm Interview on 11/30/23 at 8:34 A.M. with the Administrator confirmed bed hold notices were only being sent to residents with Medicaid payor source and was unaware all residents were to receive a bed hold notice when being sent to the hospital. Residents Affected - Few Review of the undated facility policy Admission, Discharge, and Transfer revealed the facility would provide at the time of the transfer to the hospital written information to the resident and their responsible party concerning the duration the bed-hold standard under the state plan and alternative payor plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366331 If continuation sheet Page 6 of 14 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 366331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Skilled Nursing & Rehabilitation 250 Cadiz Road Wintersville, OH 43953 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASARR) documents were accurate to reflect resident current conditions and diagnoses. This affected three residents (#52, #54, and #66) of four residents reviewed for PASARR documents. The census was 81. Findings Include: 1. Medical record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including heart failure, emphysema, protein calorie malnutrition, psychotic disorder with hallucinations, depressive disorder, and anxiety disorder. Review of Resident #52's PASARR document, dated 10/29/21, revealed under Section E, there were no diagnoses listed. During interview on 11/30/23 at 8:42 A.M., Social Services Director (SSD) #165 confirmed the resident's PASARR document did not indicate any mood disorders and should have been updated with the diagnoses of psychotic disorder with hallucinations, depressive disorder, and anxiety disorder. 2. Medical record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including pulmonary hypertension, hypertensive heart and chronic kidney disease, diabetes mellitus, post-traumatic stress disorder (PTSD) 07/08/22, and depressive episodes (07/08/22). Review of Resident #52 PASARR document, dated 03/23/22, revealed under Section E, there were no diagnoses listed. During interview on 11/30/23 at 8:42 A.M., Social Services Director (SSD) #165 confirmed the resident's PASARR document did not indicate any mood disorders and should have been updated with the diagnoses of PTSD and depressive episodes. 3. Medical record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity, protein-calorie malnutrition, history of falling, asthma, and non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity, delusional disorders, anxiety, and depressive disorder. Review of Resident #66's PASARR document, dated 10/03/23, revealed under Section E, there were no diagnoses listed. During interview on 11/30/23 at 8:42 A.M., Social Services Director (SSD) #165 confirmed the resident's PASARR document did not indicate any mood disorders and should have been updated with the diagnoses of delusional disorders, anxiety, and depressive disorder. During interview on 11/30/23 at 9:17 A.M., the Director of Nursing (DON) confirmed the SSD was responsible for checking PASARR's for accuracy and referring the resident for a level two PASARR if indicated. The DON further revealed the facility had identified the PASARR's had not been correctly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366331 If continuation sheet Page 7 of 14 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 366331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Skilled Nursing & Rehabilitation 250 Cadiz Road Wintersville, OH 43953 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 0644 Level of Harm - Minimal harm or potential for actual harm completed at the discharging hospital and the facility had reached out to the hospital. The DON stated she had in-serviced the SSD, the admission staff, and the Assistant Director of Nursing (ADON) regarding correctly completing PASARR's and had begun audits of all new admissions on 10/23/23. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366331 If continuation sheet Page 8 of 14 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 366331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Skilled Nursing & Rehabilitation 250 Cadiz Road Wintersville, OH 43953 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and interview, the facility failed to ensure residents were free from accident hazards and received adequate assistance to prevent accidents. This affected two residents (#29 and #58) of five residents reviewed for accidents. The facility census was 81. Findings include: 1. Review of the medical record for Resident #29 revealed an admission date of 02/09/21 with diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, diabetes mellitus, dementia, and osteoarthritis. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 was dependent for bed to chair and chair to bed transfers and required the use of a Hoyer lift (manual hydraulic lift). Review of the care plan dated 10/28/23 revealed Resident #29 was totally dependent for completion of activities of daily living (ADLs) and unable to participate in any aspect of transfers. The care plan further revealed he required the use of a Hoyer lift. Review of physician orders revealed an order dated 01/26/23 for a Hoyer lift for transfers. Observation on 11/29/23 at 03:55 P.M. revealed Resident #29 was in a sling hooked to a Hoyer lift and raised in the air just above his wheelchair. Only one staff member, State Tested Nursing Assistant (STNA) #175, was with him at the time. STNA #175 proceeded with the Hoyer transfer of Resident #29 from the wheelchair to the bed without assistance. Interview on 11/29/23 at 4:00 P.M. with STNA #175 confirmed she completed the transfer without the assistance of another staff member. STNA #175 further confirmed she was aware the facility required Hoyer transfers be a two-person transfer and she was aware she should not have completed the transfer without the presence of another staff member, which she added was sent to answer another call light at the time of the chair to bed transfer initiation. Interview on 11/29/23 at 04:03 P.M. with the Director of Nursing (DON) confirmed all Hoyer transfers were to be completed by two staff members. Review of facility undated policy titled Hoyer Lift revealed the facility would maintain safety when lifting and transferring residents with a mechanical lift. The procedure required that two staff members were present to perform the procedure. 2. Review of Resident #58's medical record revealed an admission date of 01/24/23 with diagnoses including cerebral infarction, COPD, depression, atrial fibrillation, and hemiplegia and hemiparesis of his non-dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had a mobility impairment on one side of his body, was unsteady when walking, and used a walker and a wheelchair for locomotion. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366331 If continuation sheet Page 9 of 14 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 366331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Skilled Nursing & Rehabilitation 250 Cadiz Road Wintersville, OH 43953 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 0689 Level of Harm - Minimal harm or potential for actual harm Review of the care plan dated 11/13/23 revealed Resident #58 was at risk for falls and non-compliant with use of safety measures, such as walking with the ordered appliance or using his wheelchair. Interventions included maintaining a clear pathway, placing items within reach, bed stabilizers, resident education, and encouraging the use of non-skid footwear. There was no care plan intervention for non-skid strips at the bedside. Residents Affected - Few Interview and observation on 11/27/23 at 10:15 A.M. indicated Resident #58 was concerned about the non-skid strips at the side of his bed, further stating it caused him to fall in the past when his slipper got caught on a small section that was lifted from the floor. Resident #58 then pointed out the non-skid strips, demonstrating one corner was no longer adhered to the floor and stated the other strip was partially missing because he trimmed it himself after it kept coming up. Observation at that time revealed the non-skid strips were laid vertically in relation to the bed over top of thinner white strips which were laid horizontally in relation to the resident's bed. Further observation revealed the corner of the strip closest to the head of the bed was creased in several spots with a small space lifted away from the floor. The second non-skid strip was one-third to one-half missing. Interviews on 11/30/23 at 10:40 A.M. with STNA #101 and STNA #172 confirmed Resident #58 had non-skid strips by his bed that were creased, coming up from the floor and one was partially missing. Interview on 11/30/23 at 10:43 A.M. with Maintenance Director #120 confirmed one black non-skid strip was partially removed and the other was loose and creased. He further confirmed the expectation that housekeeping staff cleaning the floors in the bedroom or STNAs providing care should report such concerns to maintenance, but none had been reported regarding the strips coming up from Resident #58's bedside. Maintenance Director also confirmed the black non-skid strips should not have been applied over top of the thinner white strips, and conjectured such placement could be the potential cause of the black non-skid strips not adhering properly to the floor. Interview on 11/30/23 at 11:10 A.M. with the DON regarding the non-skid strips in Resident #58's room confirmed there was no order or care plan intervention for Resident #58 to have non-skid strips at his bedside and they may have been there from a previous resident. The DON was uncertain how long ago the room change was made but stated it was not recent. Review of the facility undated policy titled Fall Management revealed the facility would provide an environment free of potential hazards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366331 If continuation sheet Page 10 of 14 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 366331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Skilled Nursing & Rehabilitation 250 Cadiz Road Wintersville, OH 43953 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, staff interview, and review of facility spreadsheets and recipes, the facility failed to ensure the recipe for puree chicken and dumplings was followed and the correct portion size of chicken and dumplings was served to those residents on a regular and puree diet. This had the potential to affect 60 residents who were on either a regular or puree consistency diet. The facility identified 21 residents as being on a mechanical soft diet, and there were no residents who didn't receive food from the kitchen. The facility census was 81. Findings include: Review of the facility recipe for pureed chicken and dumplings revealed for ten servings, the chicken and dumpling recipe should be prepared as directed; ten eight-ounce ladles of prepared chicken and dumplings should be added to the food processor and processed until fine in consistency. Two and one half teaspoons of low sodium chicken base should be gradually added to the mixture (All liquid may not be required). Observation and interview on 11/30/23 at 10:47 A.M. with Dietary [NAME] (DC) #160 revealed she was going to puree ten portions of the puree chicken and dumplings. DC #160 brought over a rectangular metal pan that contained ten chicken thighs, about two cups of peas and carrots, and approximately three fourth cup of cooked onion and celery with some liquid in the bottom of the container and proceed to puree the items to a mashed potato consistency. DC #160 confirmed at the time of observation she had not followed the puree recipe for chicken and dumplings. Review of facility spread sheet dated 11/29/23 revealed for lunch, residents on regular diets were to receive one eight-ounce ladle of chicken and dumplings, and residents on a puree diet were to receive two number eight scoops (four ounce portion) of pureed chicken and dumplings. Observation on 11/29/23 from 11:40 A.M. to 12:40 P.M. of the entire tray line revealed DC #160 served all of the residents on a regular diet one number eight (four ounce) scoop of chicken and dumplings and served all of the residents on a puree diet one number eight (four ounce) scoop of pureed chicken and dumplings. Interview on 11/29/23 at 12:43 P.M. with Dietary Manager #122 confirmed the recipe for the puree chicken and dumplings had not been followed which resulted in the residents on a puree not receiving a grain for the meal, the residents on a regular diet should have been served one eight ounce ladle instead of the four ounce portion they received, and the residents on a puree diet should have received two four ounce portions instead of the four ounce portion they received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366331 If continuation sheet Page 11 of 14 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 366331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Skilled Nursing & Rehabilitation 250 Cadiz Road Wintersville, OH 43953 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interviews, and facility policy review, the facility failed to ensure staff members were properly washing their hands in the kitchen to prevent contamination. This had the potential to affect all 81 residents who received food from the kitchen. The facility identified all residents as receiving food from the kitchen. The facility census was 81. Findings include: Observation on 11/29/23 from 11:40 A.M. to 12:40 P.M. with Dietary Manager #122 of the lunch tray line revealed the following concerns: a. At 12:01 P.M. Dietary Aide #168 was observed taking a food cart to the main dining room and came back into the kitchen at 12:02 P.M. and immediately grabbed another cart without washing her hands and proceeded to the tray line where she placed drinks on tray, placed dome lid on plate, and placing trays in cart. b. At 12:07 P.M. Dietary Aide #168 was observed taking a food cart out of the kitchen and came back into the kitchen at 12:09 P.M. and immediately grabbed another cart without washing her hands and proceeded to the tray line where she placed drinks on tray, dome lid on the plate, and placing trays in cart. c. At 12:20 P.M. Dietary Aide #136 was observed touching her nose with her finger while on tray line and did not wash her hands. d. At 12:21 P.M. Dietary Aide #168 was observed touching her face with her hands while on tray line and did not wash her hands. e. At 12:22 P.M. Dietary Aide #136 was observed scratching her nose with her finger while on tray line and did not wash her hands. f. At 12:23 P.M. Dietary Aide #168 was observed touching her glasses with her hand while on tray line and did not wash her hands. g. At 12:23 P.M. Dietary Aide #168 was observed taking one meal tray out of the kitchen into the main dining room and came back into the kitchen at 12:23 P.M. and placed the tray on top of a dish machine rack and didn't wash hands prior to returning to the tray line. h. At 12:24 P.M. Dietary Aide #168 was observed taking a food cart out of the kitchen and came back into the kitchen at 12:25 P.M. and didn't wash hands prior to returning to the tray line. i. At 12:27 P.M. Dietary Aide #168 was observed touching her eyeglasses and her mouth with her hand and didn't wash her hands. j. At 12:28 P.M. Dietary Aide #136 was observed touching her nose with her hand while on tray line and didn't wash her hands. k. At 12:29 P.M. Dietary Aide #168 was observed taking a food cart out of the kitchen and came back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366331 If continuation sheet Page 12 of 14 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 366331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Skilled Nursing & Rehabilitation 250 Cadiz Road Wintersville, OH 43953 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 0812 Level of Harm - Minimal harm or potential for actual harm into the kitchen at 12:30 P.M. and proceeds to reach into the one door freezer to grab a plastic cup filled with ice cubes and goes back to the tray line without washing her hands. l. At 12:31 P.M. Dietary Aide #168 was observed taking a food cart out of the kitchen and came back into the kitchen at 12:31 P.M. and proceeded to pull a food cart over to the tray line without washing her hands. Residents Affected - Many Interview on 11/29/23 at 12:43 P.M. Dietary Manager #122 confirmed the areas of concern while on tray line and stated hands should be washed upon entering the kitchen and anytime staff touch their face. Review of the undated facility policy Handwashing revealed all employees should wash their hands thoroughly with soap and water when arriving in kitchen and after contact with bodily fluids. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366331 If continuation sheet Page 13 of 14 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 366331 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sienna Skilled Nursing & Rehabilitation 250 Cadiz Road Wintersville, OH 43953 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on medical record review and staff interview the facility failed to ensure staff members documented resident care provided appropriately. This affected one resident (#74) of one resident reviewed for nephrostomy tubes. The facility census was 81. Findings include: Review of Resident #74's medical record revealed an admission date of 11/13/23 with diagnoses that included cervical cancer with metastasis to the liver and hydronephrosis with the use of bilateral nephrostomy tubes (tubing inserted through the abdomen into the kidney to drain urine). Physician's orders on 11/14/23 revealed orders for nephrostomy tube care to be completed every shift. Additional orders on 11/16/23 indicated to flush nephrostomy tubing every three days. Review of the Treatment Administration Record (TAR) on 11/28/23 at 1:50 P.M. revealed the resident's bilateral nephrostomy tubes were already flush for 11/28/23 dayshift by Registered Nurse (RN) #121. On 11/28/23 at 1:55 P.M., interview with RN #121 revealed she had documented on the TAR she had completed the bilateral nephrostomy tube flush, but had not actually completed the flush as ordered. She indicated that she planned to complete the flush when she had time to complete. RN #121 verified care should not be documented as provided prior to completing and documented after completing the care. Review of the TAR on 11/29/23 at 11:55 A.M. revealed the resident's bilateral nephrostomy tubes were already cleaned for 11/29/23 dayshift by RN #143. On 11/29/23 at 12:00 P.M., interview with RN #143 revealed she had documented on the TAR she had completed the bilateral nephrostomy care but had not actually provided the care as ordered. RN #143 verified care should not be documented as provided prior to completing and documented after completing the care. On 11/29/23 at 1:05 P.M., interview with the Director of Nursing indicated staff members should not document resident care provided before providing care, only after care is completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366331 If continuation sheet Page 14 of 14