Cycle 1
Health 2025-09-16 · Fire 2025-09-16
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cincinnati, OH
Siena Gardens Rehabilitation & Transitional Care
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1055 State Route 125, Cincinnati, OH
(513) 449-3900
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
95
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
2018-09-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
63 facilities
Chain averages 4 overall / 4 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.88
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
3.14
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,960
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9911
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.73
Baseline 18.53% · Performance 21.09% · Measure score 0.73 · Achievement 0.73 · Improvement 0
Healthcare-associated infections
3.03
Baseline 5.68% · Performance 6.93% · Measure score 3.03 · Achievement 3.03 · Improvement 0
Total nurse turnover
10
Baseline 38.27% · Performance 24.00% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
1.42
Baseline 2.72 hours · Performance 3.31 hours · Measure score 1.42 · Achievement 0.80 · Improvement 1.42
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.83% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 104 · Observed rate 11.54% · Lower 95% interval 7.53% |
| Discharge to community | 55.56% |
50.57%
5 pts better
|
No Different than the National Rate · Eligible stays 77 · Observed rate 55.84% · Lower 95% interval 44.99% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 80 · Denominator 80 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 80 |
| Discharge self-care score | 39.29% |
53.69%
14.4 pts worse
|
Numerator 22 · Denominator 56 |
| Discharge mobility score | 33.93% |
50.94%
17 pts worse
|
Numerator 19 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 1.25% |
2.29%
1 pts better
|
Numerator 1 · Denominator 80 · Adjusted rate 1.57% |
| Healthcare-associated infections requiring hospitalization | 6.93% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 6.35% · Lower 95% interval 4.15% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 111 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 111 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 28 · Denominator 56 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 52 · Denominator 52 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 12.82% |
25.2%
12.4 pts worse
|
Numerator 5 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
92.4%
6.7 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 98.8% · Q3 98.9% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.8% |
94.5%
2.3 pts better
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.3%
1 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 3.4% · Q4 3.6% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 45.4% |
26.1%
19.3 pts worse
|
11.4%
34 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.1% · Q2 37.5% · Q3 39.5% · Q4 61.5% · 4Q avg 45.4% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
6.2%
1.8 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.9% · Q3 3.7% · Q4 3.8% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.6% |
25.4%
14.8 pts better
|
19.6%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 11.1% · Q3 12.0% · Q4 10.3% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.3% |
11.5%
4.2 pts better
|
16.7%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 5.8% · Q3 6.6% · Q4 7.2% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.0% |
7.7%
2.7 pts better
|
16.3%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 7.4% · Q3 8.5% · Q4 0.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.8% |
6.2%
2.4 pts better
|
14.9%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 5.1% · Q3 2.5% · Q4 0.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
0.5%
0.7 pts worse
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.2% · Q4 2.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.2% |
21.7%
6.5 pts better
|
19.8%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 18.1% · Q3 14.4% · Q4 15.7% · 4Q avg 15.2% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
3.7%
2.2 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.1% · Q3 1.1% · Q4 1.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
78.1%
17.7 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 94.1% · Q3 95.7% · Q4 97.0% · 4Q avg 95.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
12.5%
3.2 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 8.8% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
75.6%
16.1 pts better
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
25.1%
1.8 pts better
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 22.1% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-06 · Fire 2022-10-06
2 health deficiencies
Top issue: Administration (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-10-03 · Fire 2019-10-03
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-19
F · Potential for more than minimal harm
2022-10-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-10-19
E · Potential for more than minimal harm
2022-10-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-10-19
E · Potential for more than minimal harm
2022-10-06
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-10-19
E · Potential for more than minimal harm
2022-10-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-10-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-19
F · Potential for more than minimal harm
2019-10-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-10-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-09-19
D · Potential for more than minimal harm
2022-10-06
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-10-19
D · Potential for more than minimal harm
2022-10-06
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2022-10-19
D · Potential for more than minimal harm
2019-10-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-10-03
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-10-03
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-10-03
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-10-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-10-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-10-03
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-10-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-10-25
Penalties and ownership
What sits behind the stars
Ownership
Colleran Fam Tr Dated 01-01-2018
5% Or Greater Indirect Ownership Interest · Organization
Foundations Health LLC
5% Or Greater Direct Ownership Interest · Organization
Burnett, Stella
Operational/Managerial Control · Individual
Colleran, Brian
Operational/Managerial Control · Individual
Colleran, Brian
Corporate Director · Individual
Colleran, Brian
Corporate Officer · Individual
Foundations Health Solutions, LLC
Operational/Managerial Control · Organization
Krystowski, John
Operational/Managerial Control · Individual
Krystowski, John
Corporate Officer · Individual
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