F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observations and staff interviews, the facility failed to provide a dignified environment for
residents while eating meals in the both dining rooms on the behavioral unit. This affected four (Resident
#7, #77, #217 and #509) of 33 residents reviewed for respect and dignity. The facility census was 266.
Findings include:
1. Review of medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses
including Alzheimer's disease, anxiety, depression, renal failure, thyroid disorder, arthritis, and
osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/18/18, revealed
Resident #7's cognition was severely impaired, and was totally dependent on staff with activities of daily
livings (ADLs).
Review of medical record revealed Resident #509 was admitted to the facility on [DATE]. Diagnoses
included hypertension, hyperlipidemia, Alzheimer's disease, anxiety, and respiratory failure. Review of the
MDS assessment, dated 08/12/18, revealed Resident #509's cognition was severely impaired and was
totally dependent on staff with ADLs.
Observations on 11/05/18 at 12:30 P.M. revealed Resident #7 and Resident #509 waited to be fed while
their food was in front of them and as other residents sitting at the table were eating. Resident #7 and
Resident #509 had to wait for twenty minutes to be fed. Resident #7 was putting her fingers in her mouth
and biting on them. State Tested Nursing Assistants (STNA) #797 and STNA #842 were going to feed the
residents the food until the surveyor requested the food temperature to be taken. The vegetable lasagna
was tempted at 123 degrees Fahrenheit (F). After warming the food, STNA #842 proceeded to take a
spoon of puree vegetable lasagna and blow on Resident #7's food before feeding her.
Interview on 11/05/18 at 12:50 P.M., revealed STNAs #797 and #842 stated they had to make sure
everyone had their food and was eating before they were able to feed Resident #7 and Resident #509.
STNA #842 stated she did not want to feed Resident #7 hot food so she was trying to cool it off but realized
it was not a good idea after she did it.
2. Review of medical record revealed Resident #77 was admitted to the facility on [DATE]. Diagnoses
included Alzheimer's disease, dementia, depression and psychotic disorder. Review of the quarterly MDS
assessment, dated 08/21/18, revealed Resident's #77's cognition was severely impaired and required
supervision and cueing from staff for eating.
Review of medical record revealed Resident #217 was admitted to the facility on [DATE]. Diagnoses
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
365322
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365322
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maria Joseph Living Care Center
4830 Salem Avenue
Dayton, OH 45416
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
included Alzheimer's disease, anxiety disorder, depression, manic depression, psychotic disorder, and
Schizophrenia. Review of the quarterly MDS assessment, dated 10/09/18, revealed Resident #217's
cognition was severely impaired and required supervision and cueing from staff for eating.
Observations on 11/05/18 at 5:55 P.M., revealed STNA #814 was feeding Resident #77 and Resident #509
while standing up. STNA #814 was walking from side of the dining table to the other side feeding both
residents. Resident #509 had to wait 20 minutes before being fed. Resident #509 did not have food in front
of her but other residents sitting at the table were eating their meal. STNA #817 was feeding Resident #217
standing up. There were three noted empty chairs in the dining room across from the main dining room.
Interview on 11/05/18 at 6:30 P.M., revealed STNA #814 and #817 both stated there were no chairs in the
dining room.
Interview on 11/06/18 11:23 A.M., revealed Registered Nurse Corporate (RNC) #880 stated residents
should be fed at eye level.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365322
If continuation sheet
Page 2 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365322
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maria Joseph Living Care Center
4830 Salem Avenue
Dayton, OH 45416
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident record review and staff interview, the facility failed to accurately complete Minimum Data Set
(MDS) assessments. The affected five (#15, #20, #31, #59, and #243) of 40 resident MDS assessments
reviewed. The census was 266.
Residents Affected - Some
Findings include:
1. Review of the medical record for Resident #15 revealed the resident was admitted to the facility on
[DATE]. Diagnoses included paraplegia and diabetes mellitus type one. Review of Resident #3's wound
consultant note, dated 10/16/18, revealed the resident had a stage three pressure wound (Full thickness
tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) located on the
right lateral malleolus. The measurement was one and eight tenths centimeters (cm.) length by two cm.
width by one tenth cm. depth.
Review of Resident #15's quarterly MDS assessment, dated 10/18/18, revealed no assessment of the
stage three pressure wound.
Interview on 11/08/18 at 1:37 P.M. with Regional MDS Nurse #875 verified Resident #15's quarterly MDS
assessment, dated 10/18/18, was not accurate and it did not include the assessment of the stage three
pressure wound.
2. Review of the medical record for Resident #20 revealed the resident was admitted to the facility on
[DATE]. Diagnoses included multiple sclerosis and hemiplegia.
Review of a wound consultant note dated 10/16/18 revealed Resident #20 had a stage two pressure wound
(partial thickness tissue loss of dermis presenting as a shallow open ulcer with a red-pink wound bed,
without slough) located on the right medial calcaneous. The measurement was four cm. length by two and a
half cm. width by one tenth cm. depth.
Review of a MDS assessment dated [DATE], revealed the resident was inaccurately assessed as not
having a pressure ulcer at the time of assessment.
Interview on 11/08/18 at 1:38 P.M. with Regional MDS Nurse #875 verified Resident #20's MDS
assessment dated [DATE] was not accurate and verified it should have stated the resident had one stage
two pressure ulcer.
3. Review of the medical record for Resident #59 revealed the resident was admitted to the facility on
[DATE]. Diagnoses included anxiety.
Review of a medication administration record (MAR), dated 08/2018, revealed no documentation of
antianxiety medication administered to Resident #59.
Review of the quarterly MDS assessment, dated 08/22/18, revealed Resident #59 was to have received
antianxiety medication on seven days during the seven day reference period.
Interview on 11/07/18 at 3:47 P.M. with Licensed Practical Nurse (LPN) #658 verified Resident #59's
quarterly MDS assessment, dated 08/22/18, was not accurate reflecting the resident's antianxiety
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365322
If continuation sheet
Page 3 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365322
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maria Joseph Living Care Center
4830 Salem Avenue
Dayton, OH 45416
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
medications.
Level of Harm - Minimal harm
or potential for actual harm
4. Review of the medical record for Resident #243 revealed the resident was admitted to the facility on
[DATE]. Diagnoses included diabetes mellitus type two.
Residents Affected - Some
Review of the medical record for Resident #243 from 10/04/18 to 10/11/18 revealed no documentation of
insulin administration.
Review of an admission MDS assessment, dated 10/11/18, revealed Resident #243 was assessed to have
received insulin injections on seven days of the seven day reference period.
Interview on 11/08/18 at 1:48 P.M. with Regional MDS Nurse #875 verified Resident #243's admission MDS
assessment dated [DATE] was not accurate reflecting the resident's insulin.
5. Review of the medical record for Resident #31 revealed the resident was admitted to the facility on
[DATE]. Diagnoses included paranoid schizophrenia and major depressive disorder.
Review of Resident #31's preadmission screening and resident review determination summary report,
dated 03/02/16, revealed the resident had a serious mental illness.
Review of Resident #31's annual MDS assessment, dated 02/01/18, revealed no documentation of a
serious mental illness.
Interview on 11/08/18 at 1:49 P.M. with Regional MDS Nurse #875 verified Resident #31's annual MDS
assessment dated [DATE] was not accurate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365322
If continuation sheet
Page 4 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365322
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maria Joseph Living Care Center
4830 Salem Avenue
Dayton, OH 45416
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview, the facility failed to timely and accurately respond to pharmacy
recommendations for one (#160) of five residents reviewed for unnecessary medications. The facility
census was 266.
Findings Include:
Review of Resident #160's medical record review revealed the resident was admitted to the facility on
[DATE] with diagnoses including dementia with out behavioral disturbances and anxiety disorder. The
diagnosis of Schizoaffective disorder was not listed as a diagnosis.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/01/18, revealed the resident had
cognitive impairment. The resident is coded as having the diagnosis of non-Alzheimer's dementia, anxiety,
depression and Parkinson's disease. Schizoaffective disorder was not marked as a diagnosis for the
resident.
Review of the pharmacy recommendation, dated 06/21/18, revealed the resident was receiving the
antipsychotic agent Seroquel, but lacked allowable diagnosis to support its use. The recommendation had a
list of approved diagnosis and the physician circled Schizoaffective disorder and checked the box that he
agreed on the recommendation and signed the recommendation with the a date in the signature line of
September 2018, three months after the pharmacy recommendation.
Review of the Medication Administration Record (MAR) revealed the Seroquel dose and reason for the
medication had the supporting diagnosis of psychosis and not Schizoaffective disorder.
During an interview with Licensed Practical Nurse #619 on 11/08/18 at 10:03 A.M. confirmed there was no
diagnosis of Schizoaffective disorder in the resident's medical record.
During an interview with the Director of Nursing (DON) on 11/08/18 at 11:36 A.M. confirmed there was no
diagnosis of Schizoaffective disorder in the resident's medical record and the physician had signed the
pharmacy recommendation from 06/21/18 three months later to add Schizoaffective disorder to the
diagnosis list for Resident #160 to support the use of the Seroquel.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365322
If continuation sheet
Page 5 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365322
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maria Joseph Living Care Center
4830 Salem Avenue
Dayton, OH 45416
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation of medication carts, staff interview, and review of the facility's policy, the facility failed to
properly store, label and date the resident's medications. This affected three residents, Resident #47, #51
and #59. This affected three of seven medication carts observed. The facility census was 266.
Findings include:
1. During an observation of a medication cart on the Brunner two hallway on 11/08/18 at 10:24 A.M.
revealed an opened and undated 10 milliliter (ml.) vial of Humalog (insulin) labeled with Resident #51's
name was found in the top drawer. Interview with Licensed Practical Nurse (LPN) #509 confirmed during
the time of observation that the Humalog vial belonging to Resident #51 was opened and undated.
2. During an observation of a medication cart on the Brunner three hallway on 11/08/18 at 10:33 A.M.
revealed four loose medications were observed in a small plastic medication cup in the second drawer. The
medication cup was unlabeled.
Interview with LPN #617 on 11/08/18 at 10:35 A.M. identified the medications as aspirin (can treat pain,
fever, headache, and inflammation), vitamin D, Lisinopril (treats high blood pressure), and Norvasc (treats
high blood pressure). LPN #617 stated the medications were that of Resident #47 and confirmed the were
unlabeled and loose in the medication cup.
3. During an observation of a medication cart on the [NAME] three hallway on 11/08/18 at 10:47 A.M.
revealed a 50 ml. vial of Lidocaine (treats irregular heartbeats) one percent was found opened and undated
in the bottom drawer. The Lidocaine vial was labeled with the name of Resident #59. LPN #619 confirmed
the Lidocaine vial belonging to Resident #619 was opened and undated during the time of observation.
Review of the facility's policy titled Medication Storage revealed outdated medications are immediately
removed form stock and disposed of. Transfer of medications to one container to another is not permitted.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365322
If continuation sheet
Page 6 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365322
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maria Joseph Living Care Center
4830 Salem Avenue
Dayton, OH 45416
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, staff interview, and facility policy review, the facility failed to ensure food was stored
and served in a sanitary manner. This had the potential to affect all residents residing in the facility except
for four residents (Resident #150, #170, #205, and #253) identified by the facility as receiving nothing by
mouth (NPO). The facility census was 266.
Findings include:
Observation of the facility kitchen on 11/05/18 between 9:20 A.M. and 9:45 A.M. revealed the walk-in
refrigerator consisted of a container of coleslaw with an expiration date of 11/01/18, expired bologna dated
10/28/18 and a bag of walnuts dated 03/20/18. In the freezer, there were a bag of bacon bits dated
05/12/12, a box of donuts with a date of 10/13/18, a box of 12-pound beef patties uncovered and exposed
to the air in the freezer and a container of roast pork with no date.
An interview was conducted with Dietary Supervisor (DS) #580 on 11/05/18 at 9:45 A.M., verified all items
in the refrigerator and freezer that were opened must have an opened date and a used by date. DS #580
was unable to verify some of the dates if it did not say expired by.
Review of the facility's list of residents who receive nothing by mouth revealed Resident #150, #170, #205
and #253 were nothing by mouth.
Review of the facility policy titled Date Labeling- Use by Dates for Perishable Food, dated February 2016,
revealed items must be dated after opening with an Open date and a Use by date. The use-by-date will be
seven days, (today plus six days), unless the original manufacturer expiration date was before the seven
days (meaning, the food service operation may not exceed a manufacture's use-by-date).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365322
If continuation sheet
Page 7 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365322
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Maria Joseph Living Care Center
4830 Salem Avenue
Dayton, OH 45416
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on staff interview, review of facility policy and review of a facility plan, the facility failed to monitor
their water system for the prevention of Legionella. This had the potential to affect all 266 residents residing
in the facility.
Residents Affected - Many
Findings include:
Review of the facility's Legionella plan revealed there was no risk assessment or a flow diagram was
present.
Review of the undated facility policy titled Legionella dated 06/02/17 revealed the facility's plan to prevent
Legionella included the facility would identify control measures and monitor water temperatures, sanitizer
levels and disinfectant levels.
Interview on 11/06/18 at 11:15 A.M. with Maintenance Director #643 provided verification of the lack of a
risk assessment for the Legionella pathogen. He further verified there has been no in-facility testing of the
water quality.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365322
If continuation sheet
Page 8 of 8