Dayton, OH

Siena Woods Care Center

4-star overall rating with 3-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

6125 N Main Street, Dayton, OH

(937) 278-8211

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 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

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Exceptional Living Centers

Operator or chain grouping

Approved since

1990-11-21

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

10 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

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

0.61

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.26

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.23

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

4.10

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.87

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.50

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.34

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.59

CMS adjusted RN staffing hours

Adjusted total hours

3.93

CMS adjusted total nurse staffing hours

Case-mix index

1.43

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

59%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,235

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

33.55

Composite VBP score used to determine payment impact.

Payment multiplier

0.9878

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

5.99

Baseline 6.08% · Performance 6.05% · Measure score 5.99 · Achievement 5.99 · Improvement 0

Total nurse turnover

1.11

Baseline 57.30% · Performance 59.14% · Measure score 1.11 · Achievement 1.11 · Improvement 0

Adjusted total nurse staffing

2.97

Baseline 4.41 hours · Performance 3.92 hours · Measure score 2.97 · Achievement 2.97 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.5%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 39 · Observed rate 10.26% · Lower 95% interval 6.4%
Discharge to community	63.09%	50.57% 12.5 pts better	No Different than the National Rate · Eligible stays 43 · Observed rate 58.14% · Lower 95% interval 48.17%
Medicare spending per beneficiary	1.14	1.02 0.1 pts worse
Drug regimen review with follow-up	96.3%	95.27% 1 pts better	Numerator 26 · Denominator 27
Falls with major injury	3.7%	0.77% 2.9 pts worse	Numerator 1 · Denominator 27
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	3.7%	2.29% 1.4 pts worse	Numerator 1 · Denominator 27 · Adjusted rate 2.9%
Healthcare-associated infections requiring hospitalization	6.05%	7.12% 1.1 pts better	No Different than the National Rate · Eligible stays 27 · Observed rate 0% · Lower 95% interval 2.94%
Staff COVID-19 vaccination coverage	43.81%	8.2% 35.6 pts better	Numerator 99 · Denominator 226
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 118
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	89.8%	92.4% 2.6 pts worse	93.4% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 90.9% · Q2 91.7% · Q3 100.0% · Q4 77.9% · 4Q avg 89.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	79.5%	94.5% 15 pts worse	95.5% 16 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 79.5%
Percentage of long-stay residents experiencing one or more falls with major injury	4.1%	3.3% 0.8 pts worse	3.3% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.6% · Q3 4.5% · Q4 0.0% · 4Q avg 4.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.4%	26.1% 25.7 pts better	11.4% 11 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4%
Percentage of long-stay residents who lose too much weight	10.1%	6.2% 3.9 pts worse	5.4% 4.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 9.5% · Q3 11.9% · Q4 6.3% · 4Q avg 10.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	13.3%	25.4% 12.1 pts better	19.6% 6.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 11.1% · Q3 10.2% · Q4 10.9% · 4Q avg 13.3%
Percentage of long-stay residents who received an antipsychotic medication	10.5%	11.5% 1 pts better	16.7% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 10.4% · Q3 13.3% · Q4 8.0% · 4Q avg 10.5% · 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	10.2%	7.7% 2.5 pts worse	16.3% 6.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 7.1% · Q3 13.5% · Q4 6.6% · 4Q avg 10.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	9.4%	6.2% 3.2 pts worse	14.9% 5.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.0% · Q3 14.8% · Q4 13.6% · 4Q avg 9.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.3%	0.2% 0.1 pts worse	1.0% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.0%	0.5% 0.5 pts worse	1.7% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	26.3%	21.7% 4.6 pts worse	19.8% 6.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 25.5% · Q3 22.6% · Q4 30.7% · 4Q avg 26.3%
Percentage of long-stay residents with pressure ulcers	7.3%	3.7% 3.6 pts worse	5.1% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 7.7% · Q3 5.6% · Q4 6.7% · 4Q avg 7.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	42.5%	78.1% 35.6 pts worse	81.7% 39.2 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 58.5% · Q2 55.3% · Q3 36.3% · Q4 24.0% · 4Q avg 42.5%
Percentage of short-stay residents who had an outpatient emergency department visit	0.0%	12.5% 12.5 pts better	12.0% 12 pts better	Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 14.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.9%	1.2% 0.3 pts better	1.6% 0.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	56.6%	75.6% 19 pts worse	79.7% 23.1 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 56.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	28.3%	25.1% 3.2 pts worse	23.9% 4.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 28.3% · Observed 45.0% · Expected 37.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-01-11 · Fire 2024-01-11

5 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Cycle 2 Health 2019-11-14 · Fire 2019-11-14

16 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

5 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 3 Health 2018-10-18 · Fire 2018-10-18

15 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-01-11

K344 · Smoke Deficiencies

Fire Safety

Have an alternate power supply for its alarm system.

Corrected 2024-02-05

F · Potential for more than minimal harm 2024-01-11

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-02-05

E · Potential for more than minimal harm 2024-01-11

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 2024-02-05

E · Potential for more than minimal harm 2024-01-11

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-02-05

F · Potential for more than minimal harm 2019-11-14

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2019-12-30

F · Potential for more than minimal harm 2019-11-14

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2019-12-30

E · Potential for more than minimal harm 2019-11-14

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2019-12-30

E · Potential for more than minimal harm 2019-11-14

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2019-12-30

E · Potential for more than minimal harm 2019-11-14

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2019-12-30

F · Potential for more than minimal harm 2018-10-18

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2018-11-19

E · Potential for more than minimal harm 2018-10-18

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2018-11-19

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-04-23

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-05-12

D · Potential for more than minimal harm 2025-04-23

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-05-12

D · Potential for more than minimal harm 2025-04-23

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2025-05-12

E · Potential for more than minimal harm 2025-01-08

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-01-20

E · Potential for more than minimal harm 2024-10-24

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-11-06

D · Potential for more than minimal harm 2024-09-26

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-11-06

D · Potential for more than minimal harm 2024-09-26

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-11-06

D · Potential for more than minimal harm 2024-09-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-11-06

G · Actual harm 2024-01-11

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-02-05

D · Potential for more than minimal harm 2024-01-11

F687 · Quality of Life and Care Deficiencies

Health

Provide appropriate foot care.

Corrected 2024-02-05

F · Potential for more than minimal harm 2019-11-14

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-14

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-14

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-14

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-14

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-14

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 2019-12-30

D · Potential for more than minimal harm 2019-11-14

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-14

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-14

F770 · Administration Deficiencies

Health

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected 2019-12-30

D · Potential for more than minimal harm 2019-11-14

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2019-12-30

C · Minimal harm 2019-11-14

F576 · Resident Rights Deficiencies

Health

Ensure residents have reasonable access to and privacy in their use of communication methods.

Corrected 2019-12-19

G · Actual harm 2018-10-18

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 2018-11-19

F · Potential for more than minimal harm 2018-10-18

F761 · Pharmacy Service Deficiencies

Health

Corrected 2018-11-19

F · Potential for more than minimal harm 2018-10-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2018-11-19

E · Potential for more than minimal harm 2018-10-18

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2018-11-19

E · Potential for more than minimal harm 2018-10-18

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2018-11-19

E · Potential for more than minimal harm 2018-10-18

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2018-11-19