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

Staffing

Hours and turnover

RN hours / resident day

0.61

Registered nurse staffing

LPN hours / resident day

1.26

Licensed practical nurse staffing

Aide hours / resident day

2.23

Nurse aide staffing

Weekend hours

3.50

Weekend nurse staffing

RN turnover

67%

Annual RN turnover

Total nurse turnover

59%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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