Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Siena Woods Care Center during CMS and state inspections, most recent first.
Surveyors found that resident-designated refrigerators on multiple units contained unlabeled and undated food items, expired nutritional supplements, and unidentified liquids, despite posted instructions that resident foods must be labeled and dated. Staff, including CNAs and LPNs, confirmed these refrigerators were for resident food only and acknowledged that items were not properly labeled or dated and that required daily temperature logs were missing for several days or the entire month. On one unit, the ice machine scoop lacked a proper holder and was stored improperly, and a wet towel remained on the floor at the base of the ice machine after an overflow, contrary to expected practices.
Two residents who were dependent on staff for ADLs did not receive timely incontinence care and personal hygiene. One resident with multiple comorbidities and impaired cognition was found by a PT in a urine-soaked gown and bed with a strong urine odor after having not been changed overnight, and a CNA later acknowledged not knowing when the resident last received incontinence care or providing care before mid-morning. Another resident with multiple sclerosis, morbid obesity, and paraplegia, but intact cognition, had visible facial hair stubble, expressed not wanting to look like a man, and a CNA confirmed that shaving was only done on shower days; the facial stubble remained on later observation. These findings occurred despite a facility ADL policy stating residents would receive appropriate care, treatment, and services to carry out ADLs.
A resident with a history of falls, cognitive intactness, and diagnoses including type 2 DM with neuropathy and spinal stenosis had a care plan and physician order requiring a reacher to be kept within reach while in bed as a fall-prevention intervention. On two separate observations by an LPN and the DON, the resident was found lying in bed with the reacher placed away from the bedside (on a chair or across the room), and both staff confirmed it was not within reach. This showed the facility did not implement the ordered and care-planned fall intervention for this resident.
Surveyors found that the facility did not keep its medication error rate below 5%, identifying six errors out of 25 opportunities (24% error rate). One resident with diabetes and tachycardia received a scheduled beta-blocker dose more than an hour late. Another resident with chronic kidney disease and type 2 DM had five medications ordered by mouth, including duloxetine, famotidine, MiraLAX, Norvasc, and metformin, but an LPN administered all of them via G-tube and later than the scheduled time. The DON confirmed there were no orders to give these medications via G-tube and that they were ordered only for oral administration.
Two residents with impaired cognition and swallowing needs did not receive their prescribed therapeutic diets and thickened liquids. One resident ordered a puree diet with thickened liquids and extra gravy at all meals was repeatedly fed without the required extra gravy and was given unthickened water at the bedside. Another resident ordered a dysphagia advanced diet with nectar thickened liquids, and allowed only regular texture foods for pleasure, was repeatedly given an unthickened dark soda. Staff, including CNAs, an RN, and a speech therapist, confirmed that the liquids were not thickened and that the orders did not permit regular liquids for pleasure, contrary to the facility’s therapeutic diet policy.
Staff failed to follow Enhanced Barrier Precautions (EBP) during high-contact care activities for three residents with wounds, an indwelling urinary catheter, and a G-tube. In separate observations, an LPN performed wound care without a gown, another LPN repositioned a resident with a catheter without a gown despite posted EBP signage, and a third LPN administered medications via G-tube without donning a gown, even though EBP orders and facility policy required gown and glove use for these high-contact tasks.
A resident with COPD and moderately impaired cognition was allowed to self-administer albuterol nebulizer treatments even though the care plan and physician orders did not indicate the resident was approved to self-administer medications. An LPN stated nurses filled the nebulizer chamber and kept the medication in the resident’s room, and the RN MDS Coordinator confirmed there was no physician order allowing self-administration due to safety.
Failure to Provide SNF ABN When Skilled Coverage Ended: The facility did not provide an SNF ABN to two residents when skilled services ended even though Medicare Part A skilled days remained and the residents stayed in the facility. One resident had metabolic encephalopathy and cognitive communication deficit with moderately impaired cognition, and the other had DM2, PVD, and osteomyelitis with intact cognition. The BOM confirmed both notices were not given.
Failure to implement care plan interventions for bed mobility and mood. One resident with DM neuropathy, spinal stenosis, and MDD had a care plan for a left quarter side rail to assist with bed mobility, but observation showed the rail was not attached and the resident said it had been missing for weeks. Another cognitively intact resident with depression had MDS/PPS and psychosocial findings of low mood and little interest, plus an order for Mirtazapine, but the comprehensive care plan did not document an implemented mood care plan.
A resident with MS, morbid obesity, paraplegia, and an open wound did not receive quarterly care conferences as required. The resident was cognitively intact and dependent on staff for toileting and transfers, and the last documented care conference had been months earlier. The SSD confirmed the lapse and stated the staff member who had been conducting care conferences was no longer employed.
Failure to Provide and Document Resident Activities: A resident with MS, paraplegia, morbid obesity, and legal blindness was care planned for 1:1 in-room activities and support based on her interests and functional limits, but the activity record showed long gaps with little to no documented activity and several entries that were only descriptions of the resident resting, watching TV, or needing assistance. The resident said in-room activities were not provided as required, and the AM acknowledged missing documentation and that the entries were not actual activities.
A facility failed to provide ordered adaptive feeding equipment and meal setup for three residents. One resident with dementia and arthritis did not receive a spouted cup lid or appropriate flatware, another resident with CKD and DM did not receive meals in separate bowls as ordered, and a third resident with Parkinson’s disease and dysphagia did not receive a straw, cut meats, or weighted utensils. Staff and the ADON/DM verified the ordered items were not provided as required.
Improper garbage and refuse storage was observed in the kitchen when a large bin without a lid was found full of garbage near a food prep area, another bin had garbage sitting on top of the lid, and a third bin was overflowing so the lid could not close. An HCSG policy stated that appropriate lids are provided for all containers and that garbage and refuse are to be removed from the kitchen area routinely during the day.
A facility failed to document an assessment of a new wound for a resident with multiple health conditions, including peripheral vascular disease. Despite a physician's order to reduce pressure on the resident's right heel, a wound was discovered but not documented with measurements or a description. An LPN confirmed the wound was 100% black necrotic tissue and dry, and the facility lacked a policy for documenting new wounds.
A resident with severe cognitive impairment was found with medications left at the bedside, despite not being approved to self-administer. An LPN confirmed leaving Gabapentin and Buspirone HCl on the resident's table, contrary to facility policy requiring staff to remain with residents until medications are taken.
A facility failed to ensure a resident with a PEG tube and severe cognitive impairment, who was supposed to be NPO, did not receive oral feedings. The resident was mistakenly started on a regular diet without verifying with the physician, leading to coughing or choking episodes. Staff interviews confirmed the oversight, and the facility lacked a policy for verifying diet orders.
A resident with multiple comorbidities and a history of lower extremity ulcers developed a pressure wound on the right heel. When the wound was discovered, an LPN did not document a thorough assessment, including measurements or a wound bed description, as required. The facility also could not provide a policy for documentation of new pressure wounds.
The facility failed to offer annual influenza vaccines to its residents, affecting three reviewed residents and potentially impacting 80 out of 82 residents. The deficiency was due to the loss of the infection control nurse and reorganization of the position, leading to a lack of documentation that vaccines were offered. The ADON confirmed the issue, and the pharmacy technician verified vaccine deliveries, but the Influenza Vaccine Report only noted two residents as ineligible.
The facility failed to administer medications as ordered for four residents, affecting their treatment for conditions such as seizures, depression, and chronic diseases. An LPN confirmed the discrepancies in the MAR, indicating non-compliance with the facility's medication administration policy.
A facility failed to initiate timely treatment for a pressure ulcer in a resident with multiple medical conditions, including malnutrition and diabetes. Despite a treatment plan being ordered, documentation showed a delay in starting the treatment, confirmed by the DON. This deficiency highlights non-compliance with the facility's Skin and Wound Management Program policy.
A resident with severe cognitive impairment and incontinence was not provided timely care by an STNA, as observed over a three-hour period. The resident's care plan required regular incontinence care, but the STNA failed to check the resident, resulting in a heavily saturated incontinence brief. This incident highlights a breach in the facility's policy on providing appropriate care for residents unable to perform activities of daily living independently.
A facility failed to follow infection control precautions during wound care for a resident with severe cognitive impairment and stage four pressure ulcers. An LPN did not wear a gown as required by the facility's enhanced barrier precautions policy, which mandates gown and glove use during high-contact care activities to prevent the spread of multi-drug resistant organisms.
Failure to Label, Date, and Monitor Resident Food Refrigerators and Ice Handling
Penalty
Summary
Surveyors identified a failure to properly label, date, and monitor food stored in resident-designated refrigerators on multiple units, as well as improper ice handling practices. On the Secured Care Unit, a refrigerator designated for resident use contained an unlabeled and undated lunch bag that an LPN confirmed was not for a resident, and six opened containers of nutritional supplements dated 12/18/25 that were expired. The temperature log for this refrigerator had no recorded temperatures for several consecutive days (02/04/26 through 02/08/26), despite the LPN acknowledging that daily temperature monitoring was required. In the same area, the ice machine’s scoop lacked a holder and was stored on a table with the dipper side up, and a wet towel was on the floor at the base of the ice machine; the LPN stated the ice machine had overflowed earlier in the week and verified the towel should not remain on the floor. On Unit 400, surveyors observed a resident-designated refrigerator containing two bags of unidentified foods with no labels or dates, a box of food dated 01/21/26 with no label, an undated bag of bread, and three pitchers of unidentified liquid that were unlabeled and undated, despite a sign on the door stating that foods must be labeled and dated. A CNA confirmed the refrigerator was for resident food storage only and verified the items were undated and unlabeled. On the Rehabilitation Unit, the resident-designated refrigerator contained an open bag of food with no label and an opened gallon container of brown liquid dated 02/07/26 that was not labeled with identifying information. An LPN on that unit confirmed the refrigerator was only for resident food storage, acknowledged the items should have been labeled, and verified there was no refrigerator temperature log for the month of February, despite the requirement for daily temperature monitoring. Review of the facility’s 2022 policy titled “Food From Approved Source” showed staff were to assist with proper food storage and handling of foods brought into the facility and that food would be dated as appropriate.
Failure to Provide Timely Incontinence Care and Personal Hygiene Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and personal hygiene assistance to residents who were dependent on staff for ADLs. One resident with diabetes mellitus type 2, chronic kidney disease, hypertension, and impaired cognition was documented as frequently incontinent of bowel and bladder and dependent on staff for toileting hygiene. Her care plan required staff assistance with ADLs on a daily basis. On the morning in question, a CNA started her shift at 7:00 A.M. but did not round with the off-going CNA and did not know when the resident last received incontinence care. At approximately 9:45 A.M., a PT entered the resident’s room for an evaluation and found the resident lying in bed with a urine-soaked gown, a large wet area on the bed, and a strong urine odor in the room. The PT assisted the resident to the bathroom to get her out of the wet gown. An LPN then entered, acknowledged the need to clean the resident, and later seated her in a chair while waiting for a CNA to change the bed linens. The resident reported that staff had not changed her incontinence product during the night and that she had remained in the wet gown until the PT arrived. A second resident, with multiple sclerosis, morbid obesity, paraplegia, and intact cognition, was dependent on staff for personal hygiene. During an interview and observation, this resident was noted to have facial hair stubble and stated she was aware of it and did not want to look like a man. A CNA confirmed the presence of facial hair and stated that residents receive shaving assistance on their shower days. A subsequent observation showed that the facial stubble was still present. The facility’s ADL policy stated that residents would be provided with care, treatment, and services as appropriate to carry out ADLs. The survey findings concluded that the facility failed to provide timely incontinence care and personal hygiene to residents requiring assistance, affecting two residents reviewed for ADLs.
Failure to Maintain Required Fall-Prevention Device Within Reach
Penalty
Summary
Surveyors identified a deficiency related to accident prevention and supervision for a resident with a known history of falls. Resident #9 was admitted with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, spinal stenosis, and major depressive disorder. An MDS 3.0 assessment documented that the resident was cognitively intact but dependent on staff for toileting and bathing and required supervision for personal hygiene. The resident’s care plan, dated 06/19/25, noted an actual fall and included an intervention to ensure a reacher (grabber) was accessible to the resident while in bed. A physician order dated 06/20/25 further specified that the resident required a reacher within reach every shift as an intervention. Despite these documented interventions and orders, observations on two separate days showed the reacher was not within the resident’s reach while he was in bed. On 02/17/26 at 11:00 A.M., an LPN observed Resident #9 lying in bed with the reacher placed on a chair against the opposite wall, and confirmed it was not within reach. On 02/18/26 at 10:30 A.M., the DON also observed the resident lying in bed with the reacher located across the room, again confirming it was not within reach. These findings demonstrated that the facility failed to implement the ordered and care-planned fall intervention for this resident with a history of falls.
Medication Administration Errors Resulting in Elevated Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying six errors out of 25 opportunities, resulting in a 24% error rate. For one resident with type 1 diabetes mellitus, underweight, and tachycardia, the medical record showed an order for carvedilol (Coreg) 12.5 mg by mouth twice daily, scheduled for 9:00 A.M. Observation and interview on 02/11/26 at 10:31 A.M. revealed that LPN #66 administered the Coreg at 10:31 A.M., and the nurse confirmed this was outside the one-hour window for the scheduled 9:00 A.M. dose. Another resident, with chronic kidney disease stage two and type 2 diabetes mellitus, had physician orders for duloxetine 60 mg, famotidine 20 mg, MiraLAX 17 gm, Norvasc 2.5 mg, and metformin 500 mg twice daily, all ordered to be given by mouth and scheduled for 9:00 A.M. Observation and interview on 02/11/26 at 11:30 A.M. showed that LPN #59 administered all five medications via the resident’s gastrostomy tube instead of orally and confirmed that these medications, including metformin, were scheduled for 9:00 A.M. and that she always administered them late. The DON later verified there were no orders for these medications to be given through the G-tube and that they were ordered only by mouth. These findings were cited under Complaint Number 1363724 (OH00165691).
Failure to Provide Physician-Ordered Therapeutic Diets and Thickened Liquids
Penalty
Summary
Surveyors identified that the facility failed to ensure residents received their physician-ordered therapeutic diets. One resident with impaired cognition, few teeth, and a need for maximum assistance with feeding was ordered a regular puree diet with thickened liquids and extra gravy with all meals. Review of the resident’s meal ticket confirmed the extra gravy requirement. On multiple observed meal times, CNAs were feeding this resident without any extra gravy on or near the tray, and a bedside water pitcher contained liquids that were not nectar thickened as ordered. Staff verified that the extra gravy was not provided and that the water in the pitcher was not thickened, despite acknowledging that the resident sometimes needed additional gravy to ensure a smooth swallow. Another resident with diagnoses including hemiplegia, convulsions, cerebral infarction, dementia, and aphasia, and who was totally dependent on staff for feeding, had a physician order for a regular dysphagia advanced diet with nectar thickened liquids, with permission for regular texture foods for pleasure only. During observations, this resident was repeatedly provided a dark soda poured into a cup with a straw that was not thickened. A CNA confirmed the liquid was not thickened. Later, an RN and a speech therapist both verified that the physician’s order allowed regular texture foods for pleasure but did not include regular consistency liquids for pleasure. The facility’s own therapeutic diet policy stated that therapeutic diets are ordered by the physician to increase nutrients or provide foods residents are able to eat, yet the ordered diet consistencies were not followed for these residents.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently followed Enhanced Barrier Precautions (EBP) for high-contact resident care activities as ordered and as required by facility policy and CDC guidance. For one resident with multiple sclerosis, morbid obesity, a stage four pressure ulcer, and an open wound to the left lower leg, physician orders required EBP with PPE during high-contact care, including wound care. During an observed dressing change, the LPN entered the room with wound supplies, placed them on a clean bedside table, washed his hands, and began wound care wearing only gloves and no gown, despite the wound care being considered high-contact care under EBP. The LPN later acknowledged that a gown had been required for this high-contact wound care activity. Another resident with neuromuscular dysfunction of the bladder and an indwelling urinary catheter had an EBP order related to the catheter. An LPN was observed repositioning this resident in bed without wearing a gown, even though an EBP sign on the cart at the doorway specified that a gown should be worn for high-contact activities, including repositioning; the LPN confirmed a gown should have been worn. A third resident with dysphagia and a G-tube had an EBP order related to the G-tube. An LPN entered the room to administer medications via the G-tube and did not don a gown before performing this high-contact care activity, later confirming that a gown should have been worn. The facility’s infection preventionist stated that getting staff to follow EBP was an ongoing issue, despite her providing consistent reminders when on the floor.
Failure to Determine Clinical Appropriateness for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure the interdisciplinary team determined whether a resident was clinically appropriate to self-administer medications before allowing the resident to do so. Resident #11 was admitted with chronic obstructive pulmonary disease (COPD) and had moderately impaired cognition on the MDS assessment. The care plan addressed altered respiratory status and directed staff to administer medications as ordered, observe labs, and monitor response to medication and treatment, but it did not state that the resident was able to self-administer any medication. The physician orders for albuterol sulfate inhalation nebulization solution did not state that Resident #11 could self-administer the medication. During observation and interview, an LPN stated that Resident #11 self-administered the nebulizer treatment, with nurses filling the chamber for the resident and keeping the nebulizer with medication in the resident’s room at all times. The RN MDS Coordinator confirmed that Resident #11 did not have a physician order to self-administer any medications due to safety.
Failure to Provide SNF ABN When Skilled Coverage Ended
Penalty
Summary
The facility failed to provide residents with a Skilled Nursing Facility Advanced Beneficiary Notice on Non-coverage (SNF ABN) when skilled services ended, even though skilled days remained and the residents stayed in the facility. This deficiency affected two of three residents reviewed for beneficiary notices, including one resident with metabolic encephalopathy and cognitive communication deficit who had moderately impaired cognition on the MDS and had Medicare Part A coverage with skilled services effective from 12/22/25 through 02/06/26 before the payor source changed to MyCare Medicaid on 02/07/26. There was no evidence that the resident or representative received an SNF ABN when skilled services ended, and the BOM confirmed the notice was not given and that skilled days were left. A second resident with type two diabetes mellitus, peripheral vascular disease, and osteomyelitis was cognitively intact and had Medicare Part A coverage with skilled services effective from 08/07/25 through 10/25/25 before the primary payor source changed to Medicaid on 10/26/25. There was no evidence that the resident or representative received an SNF ABN when skilled services ended, and the BOM confirmed the notice was not given and that skilled days were left.
Failure to Implement Care Plan Interventions for Bed Mobility and Mood
Penalty
Summary
The facility failed to implement Resident #9’s care plan intervention for a left quarter side rail on the bed. Resident #9 was admitted with diagnoses including type two diabetes mellitus with diabetic neuropathy, spinal stenosis, and major depressive disorder. The MDS assessment showed the resident was cognitively intact, dependent on staff for toileting and bathing, and required supervision with personal hygiene. The care plan dated 08/18/25 identified decreased mobility, pain, and self-care deficit and included a left quarter side rail to assist with bed mobility, but observation on 02/17/26 and again on 02/18/26 showed the bed did not have the quarter side rail attached. The resident stated he had not had the quarter side rail for movement in the last five weeks and confirmed he did need it. The facility also failed to implement a mood care plan for Resident #10. Resident #10 was admitted on 06/20/24 with a diagnosis of depression and was cognitively intact per the quarterly MDS. The PPS discharge assessment and psychosocial quarterly assessment documented little interest or pleasure in doing things and feeling down, depressed, or hopeless for two to six days during the two-week look-back period, and both indicated a mood care plan was in place. The physician orders included Mirtazapine 7.5 mg at bedtime starting 02/04/26. However, review of the comprehensive care plan showed no documentation that a mood care plan had been implemented, and the MDS Nurse verified this during interview.
Failure to Hold Quarterly Care Conferences
Penalty
Summary
The facility failed to hold quarterly care conferences for Resident #65, who was admitted on 09/06/23 with diagnoses including multiple sclerosis, morbid obesity, paraplegia, and an open wound to the left lower leg. The quarterly MDS assessment showed the resident was cognitively intact, required supervision with eating, maximum assistance with bed mobility, and was dependent on staff for toileting and transfers. Record review showed the last documented care conference for Resident #65 was on 09/03/24. During interview, the resident stated she had a concern because a conference had not been offered for a while. The Social Services Designee confirmed the last care conference date and stated the staff member who had been doing the care conferences was no longer employed at the facility and that she was in the process of getting them scheduled. Facility policy stated residents have a right to participate in treatment and receive advance notice of care planning conferences.
Failure to Provide and Document Resident Activities
Penalty
Summary
Provide activities to meet all resident's needs. Based on record review, policy review, and resident and staff interviews, the facility failed to ensure activities were offered and/or provided for Resident #65. Resident #65 was admitted on 09/06/23 with diagnoses including multiple sclerosis, morbid obesity, and paraplegia. The care plan identified the resident as dependent on staff for emotional, intellectual, physical, and social needs due to cognitive deficits, physical limitations, legal blindness, and needing assistance with reading and organizing things, with planned 1:1 room visits on scheduled days and activities offered during those visits. An intervention dated 12/26/23 stated the resident would be provided 1:1 bedside/in-room visits and activities if unable to attend out-of-room events. The MDS assessments showed the resident valued books, newspapers, magazines, keeping up with the news, group activities, religious services or practices, and listening to music. However, the activity record from 04/01/25 to 02/12/26 showed long gaps with no documented activities in multiple months, and several entries reflected non-activity descriptions such as resting with a cover over the head, watching television, requesting to get up, or needing help finding a writing tablet. The resident stated on 02/10/26 that the facility did not provide in-room activities as required. The Activity Manager acknowledged on 02/12/26 that the resident was to be offered one-on-one activities in her room three times a week and that documentation was missing to verify activities were offered; he also acknowledged that the recorded entries were descriptions rather than activities. The facility policy titled Resident Life Enrichment stated the facility would develop and implement activities reflecting resident interests and functional abilities, maintain attendance records, and evaluate activity effectiveness at least quarterly.
Failure to Provide Ordered Adaptive Feeding Equipment
Penalty
Summary
The facility failed to ensure residents received adaptive eating equipment and assistance as ordered for three residents reviewed for adaptive equipment. Resident #79 had diagnoses including atherosclerosis, diabetes, dementia, and osteoarthritis, and the MDS showed intact cognition with set-up assistance for feeding. Physician orders and the meal ticket indicated the resident was to receive a two-handled cup with a spout lid for liquids, but observations showed the resident was given a two-handled cup without the spout lid, and at another observation a plastic lid covering was used instead of the ordered spouted lid. The resident stated she had not received the spouted lid for several weeks and had difficulty safely drinking and feeding herself with the equipment provided. Resident #79 was also observed receiving straight-handled flatware and having difficulty getting food to her mouth without spilling. The resident stated she had not been evaluated for other flatware and had trouble using the straight spoon and fork. A CNA verified the resident did not have the spouted lid and had difficulty drinking and eating without the ordered adaptive equipment. The ADON also verified the resident should have received the spouted lid and stated the resident was spilling food with the straight-handled spoon and could benefit from an evaluation of adaptive flatware. Resident #10, who had chronic kidney disease and diabetes and required supervision with eating, had an order for food to be served in separate bowls at mealtimes. Observations showed the resident received meat, vegetable, and starch on one plate and no bowls were present, while the resident was attempting to feed herself in bed. Resident #10 stated she could feed herself better when the food was in bowls. Resident #57, who had Parkinson's disease and dysphagia and was independent with feeding, had orders for cut meats, a lid and straws for drinks, and weighted gray utensils at all meals. Observations showed the resident received a cup with no straw, chicken that was not cut off the bone, and no weighted utensils. The resident stated these items helped her remain independent with feeding, and the DM verified the missing straw, uncut chicken, and absence of weighted utensils.
Improper Garbage and Refuse Storage in Kitchen
Penalty
Summary
Garbage and refuse were not properly placed inside lidded garbage containers in the kitchen. During observation and interview, a large garbage bin on wheels with no lid was found full of garbage next to a food prep area. A garbage bin near a kitchen hand wash station by the freezer had garbage sitting on top of the lid, and another garbage bin near the hand wash station by the kitchen entry doors was full and overflowing, preventing the lid from closing. The Kitchen District Manager confirmed the bin without a lid, the bin with garbage on top of the lid, and the overflowing bin. The facility policy stated that appropriate lids are provided for all containers and that garbage and refuse are to be removed from the kitchen area routinely during the day.
Failure to Document New Wound Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment and documentation of a new wound for a resident, identified as Resident #25, who was admitted with multiple diagnoses including dysphagia, chronic obstructive pulmonary disease, and peripheral vascular disease. The resident was cognitively intact and required varying levels of assistance with daily activities. A physician's order was in place to reduce pressure on the resident's right heel and left stump. However, when a wound was discovered on the resident's right heel on February 11, 2025, the facility did not document an assessment of the wound, including measurements and a description of the wound bed, in the medical record. Interviews with a Licensed Practical Nurse (LPN) confirmed that the wound was not assessed or documented as required, and the wound bed was described as 100% black necrotic tissue and dry, with no drainage. The facility was unable to provide a policy for documentation requirements for a new wound. This deficiency was identified during an investigation under Complaint Numbers OH00164982 and OH00164075, indicating non-compliance with the requirement to document new wounds accurately.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside, affecting one resident. The resident, who has severe cognitive impairment and is not approved to self-administer medications, was observed with a medication cup containing two pills on the bedside table. The resident expressed an intention to take the medications, which included Gabapentin and Buspirone HCl. Interviews with two LPNs confirmed that the medications were left on the resident's bedside table, and the resident is not authorized to self-administer medications. The facility's policy on medication administration requires that medications be administered by authorized personnel and that staff remain with the resident until the medication is swallowed. The policy explicitly states that medications should not be left in a resident's room without orders to do so.
Failure to Adhere to NPO Orders for Resident with PEG Tube
Penalty
Summary
The facility failed to ensure that a resident who was not able to eat by mouth (NPO) did not receive oral feedings. This deficiency affected one resident who had severe cognitive impairment and was dependent on staff for all activities of daily living. The resident had a PEG feeding tube and was not supposed to be on a mechanically altered or therapeutic diet. However, upon admission, the resident was started on a regular diet with regular texture and thin liquids without verifying with the physician whether the resident should be NPO. This led to the resident being fed orally by staff, which resulted in coughing or choking episodes. The medical record review revealed that the resident was admitted with multiple diagnoses, including acute respiratory failure with hypoxia and food in the respiratory tract. Despite these conditions, the initial physician orders did not include a diet order, and a regular diet was started without proper verification. A subsequent physician order confirmed the resident should be NPO, but the facility failed to adhere to this order. Interviews with staff confirmed the oversight, and the facility was unable to provide a policy for verifying diet orders, contributing to the deficiency.
Failure to Complete Pressure Ulcer Assessment Upon Discovery
Penalty
Summary
A deficiency was identified when the facility failed to ensure a thorough assessment of a pressure ulcer upon its discovery for one resident. The resident, who had multiple diagnoses including dysphagia, COPD, chronic venous hypertension with bilateral lower extremity ulcers, peripheral vascular disease, and a below-the-knee amputation, was dependent on staff for most activities of daily living. Physician orders were in place to reduce pressure on the right heel and left stump by floating them off the bed at all times. On a specific date, wound care was provided to the right heel, and a treatment order was initiated. However, subsequent skin observation tools did not document new skin concerns, and a wound observation tool later noted a pressure wound to the right heel without staging or a complete assessment. Interview with an LPN confirmed that when the wound on the right heel was first found, no assessment was documented in the medical record to include measurements or a description of the wound bed. The LPN described the wound as 100% black necrotic tissue, dry, and without drainage, and acknowledged that it was expected to complete a change in condition or skin assessment with measurements and description when a new wound was found. The facility was unable to provide a policy for documentation requirements for new pressure wounds.
Failure to Offer Influenza Vaccines to Residents
Penalty
Summary
The facility failed to offer the annual influenza vaccines to its residents, affecting three residents who were reviewed for influenza vaccines and potentially impacting 80 out of 82 residents residing in the facility. The deficiency was identified through medical record reviews, staff interviews, and the Influenza Vaccine Report. Specifically, there was no documentation that residents with chronic conditions such as chronic obstructive pulmonary disease, dementia, pressure ulcers, and diabetes were offered or administered the influenza vaccine for the 2024-2025 season. The Assistant Director of Nursing (ADON) confirmed that the facility had not offered the vaccines due to the loss of the infection control nurse and subsequent reorganization of the position. The ADON also confirmed that consent paperwork was distributed to floor nurses to obtain resident consent for the vaccine, and the pharmacy was notified of the need for additional flu vaccines. However, there was no documentation that the vaccines were offered to the affected residents. The pharmacy technician confirmed the delivery of vaccine doses to the facility, but the Influenza Vaccine Report only documented that two residents were not eligible for the vaccine, with one having received it outside the facility and another refusing it. This deficiency was investigated under Complaint Number OH00160725.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as ordered by physicians, affecting four residents. Resident #47, with severe cognitive impairment and multiple diagnoses including seizures and chronic kidney disease, did not receive several medications as documented in the Medication Administration Record (MAR) on a specific date. These medications included Levothyroxine, Lexapro, Lipitor, MiraLax, Carvedilol, Gabapentin, Lacosamide, and Levetiracetam, which were not initialed as completed. Resident #66, diagnosed with moderate protein-calorie malnutrition and pressure ulcers, also experienced missed medication administrations. The MAR indicated that medications such as Atorvastatin, Cetirizine, Levothyroxine, Mirtazapine, Apixaban, Coreg, Gabapentin, and Nifedipine were not initialed as administered on specific dates. This resident required significant assistance with daily activities and had moderate cognitive impairment. Resident #80, who was cognitively intact but required assistance with daily activities, and Resident #91, with severe cognitive impairment and multiple diagnoses including depression and dementia, also had medications not administered as ordered. The MAR for Resident #80 showed missed doses of Latanoprost, Mirtazapine, Rosuvastatin, Vitamin D3, Zoloft, Levetiracetam, and Metformin. Resident #91's MAR indicated missed doses of Norco, Clobazam, Lacosamide, and Pregabalin. An interview with an LPN confirmed these discrepancies, and the facility's medication administration policy was not adhered to, leading to this deficiency.
Failure to Initiate Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to initiate timely treatment for a pressure ulcer in a resident, which was identified during a review of medical records, staff interviews, and policy review. The resident, who had multiple medical diagnoses including moderate protein calorie malnutrition, diabetes mellitus with neuropathy, hypertension, anxiety, and chronic kidney disease, was admitted with no pressure ulcers. However, a significant change Minimum Data Set (MDS) assessment later revealed a stage four pressure ulcer that developed after admission. A wound observation assessment noted an unstageable pressure ulcer on the resident's right buttock, and a treatment plan was ordered by a wound nurse practitioner. Despite the treatment plan being ordered, there was no documentation in the medical record to indicate that the treatment was initiated until several days later. The Director of Nursing confirmed the lack of documentation for the treatment start date. The facility's Skin and Wound Management Program policy aimed to prevent and heal pressure ulcers, but the delay in treatment initiation for the resident's pressure ulcer represents a deficiency in compliance with this policy.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as Resident #53, who was severely cognitively impaired and required substantial assistance with personal hygiene and toileting. The resident's care plan included interventions such as assisting with toileting needs daily, providing incontinence care every shift and as needed, and observing for symptoms of urinary tract infection. However, during an observation period from 9:05 A.M. to 12:00 P.M., it was noted that the State tested Nurse Aide (STNA) #159 did not provide incontinence care for the resident. At approximately 12:00 P.M., STNA #159 was observed removing the resident's heavily saturated incontinence brief and soiled bed linens, which were placed in a trash bag on the floor. The STNA confirmed that the brief was heavily saturated with urine, but refused to confirm whether the resident was checked for incontinence during the observation period. The facility's policy on activities of daily living and urinary continence management emphasized providing appropriate care and services for residents unable to carry out activities of daily living independently, which was not adhered to in this instance.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to infection control precautions during wound care for a resident, which was identified during a complaint investigation. The resident, who had severe cognitive impairment and was dependent on staff for various activities, had two stage four pressure ulcers and was on enhanced barrier precautions (EBP) due to a gastrostomy tube. The physician's orders required specific wound care procedures, including cleansing the sacral wound and applying calcium alginate and bordered gauze every shift. During an observation, an LPN performed hand hygiene and wore gloves while providing wound care but did not wear a gown, as required by the facility's EBP policy. The policy mandates the use of gowns and gloves during high-contact resident care activities, such as wound care, to prevent the spread of multi-drug resistant organisms. The LPN confirmed the resident was on EBP and acknowledged not wearing a gown during the procedure, which constituted a breach of the facility's infection control policy.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 530 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dayton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aventura At Carriage Inn | 0.4 mi | ★★★★★ | 13 | 0 |
| Riverside Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 21 | 1 |
| Stonespring Of Vandalia | 1.8 mi | ★★★★★ | 0 | 0 |
| Maria Joseph Living Care Center | 1.8 mi | ★★★★★ | 2 | 0 |
| Arc At Trotwood Llc | 2.1 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.