Sienna Skilled Nursing: Wound Care Failures Ignored - OH
The wound went without any documented treatment from August 21 through September 3, 2025, according to a federal inspection report filed following a complaint investigation. The facility's own licensed practical nurse and interim director of nursing confirmed it. There was no order for treatment. There was no physician notification. The wound nurse did not assess the ulcer until September 26, five weeks after the resident's admission, because the resident happened to be in dialysis on the day the wound nurse visits the facility.
That was the reason given. The resident was in dialysis.
The inspection, conducted November 17, 2025, found the failures ran deeper than a single missed appointment. Weekly pressure ulcer assessments required under the facility's own written policy were not completed for multiple weeks, including the periods ending August 28, September 4, September 11, September 18, and September 25. The nurse responsible for those assessments, identified in the report as LPN #108, told inspectors he had not completed the weekly pressure ulcer assessment forms during that stretch. He said he was still learning. He had documented the wound area on a different form, classifying it as moisture-associated skin damage rather than a pressure ulcer, which meant it was tracked as a different kind of injury entirely.
The interim director of nursing, identified as DON #140, reviewed those non-pressure assessments and told inspectors she felt they were comprehensive. The inspection report notes she said this even though the assessments did not document the stage of the pressure ulcer and did not include wound bed appearance, wound edges, type of drainage, or any of the other characteristics the facility's own guidelines required.
The facility's policy on wound documentation is not vague. It calls for weekly assessments that capture location, stage, dimensions, undermining, tunneling, wound base descriptions, drainage, wound edges, odor, pain, and progress. The interim DON confirmed none of that was there. She felt the forms were comprehensive anyway.
The resident's admission records compounded the problem. The MDS assessment, a standardized federal form used to capture a resident's condition at key intervals, did not reflect the pressure ulcer at all. LPN #120, who completed the admission and five-day assessments, confirmed to inspectors on September 29 that the forms were inaccurate and did not reflect the resident's wound on the date of admission. She said she would modify the MDS assessment, which by that point was weeks old.
There was also no evidence the resident's physician had ever assessed the pressure ulcer. The interim DON confirmed this.
Pressure ulcers on the sacrum, the bony prominence at the base of the spine, are among the most serious wounds that can develop in a bedridden or mobility-limited patient. Left unmonitored and untreated, they can progress from surface-level skin breakdown to deep tissue destruction reaching bone. The 13-day gap in documented treatment at Sienna represents the period during which the wound's trajectory was essentially unknown to anyone responsible for managing it.
The facility has written policies for nearly every piece of this. One policy states the physician and responsible party would be notified promptly of any newly identified skin area and that treatment would be initiated according to physician order. Another states a care plan would be developed and updated routinely. A third states the skin grid would be updated every seven days until the area resolved.
None of that happened on the timeline the policies describe.
The inspection was triggered by a formal complaint, assigned complaint number 2608722. The harm level was classified as minimal harm or potential for actual harm, affecting a small number of residents. That classification reflects the regulatory framework's language, not necessarily what the resident with the untreated sacral wound experienced during those 13 days, or during the five weeks that passed before the wound nurse reached them.
By the time the wound nurse assessed the ulcer on September 26, the resident had been in the facility for over a month.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sienna Skilled Nursing & Rehabilitation from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
SIENNA SKILLED NURSING & REHABILITATION in WINTERSVILLE, OH was cited for violations during a health inspection on November 17, 2025.
The facility's own licensed practical nurse and interim director of nursing confirmed it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.