Inspection·January 30, 2020

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** 3. Review of the medical record for Resident #110 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), cerebrovascular disease (stroke), and anxiety. Residents Affected - Few Review of the Medication Administration Record (MAR) dated 12/19, revealed Resident #110 was administered Coumadin (blood thinner) on 12/09/19, 12/10/19, and 12/11/19. Continued review of the MAR revealed the resident was administered Lovenox (blood thinner) on 12/12/19 and 12/13/19. Review of a discharge return anticipated MDS assessment dated [DATE], revealed no assessment of anticoagulant medication administered to Resident #110 during the seven day reference period. Interview on 01/29/20 at 1:50 P.M. with RN #239 confirmed Resident #110 was administered anticoagulant medication on five days during the seven day reference period for the MDS that was dated 12/15/19. RN #239 confirmed the discharge return anticipated MDS assessment dated [DATE] was not accurate. Based on medical record review, observation, and staff interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for residents. This affected three Residents (#46, #78, and #110) of 33 reviewed for MDS assessments. The facility census was 265. Findings include: 1. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including respiratory failure, chronic obstructive pulmonary disease, and unspecified hearing loss bilateral. Review of the the quarterly modification MDS assessment dated [DATE] revealed the resident was cognitively intact with no noted behaviors. The MDS revealed the resident had adequate hearing with no hearing aids. Observation and interview on 01/28/20 09:05 A.M. with Resident #47 revealed during the interview the resident was noted to be significantly hard of hearing, holding her hand up to her ear in attempt to better hear. Resident #47 revealed she was waiting to get hearing aids. Interview on 01/29/20 at 3:54 P.M. with Licensed Practical Nurse (LPN) #37 revealed she often is assigned to the care of Resident #47 and she had always been hard of hearing. Interview on 01/29/20 at 5:00 P.M. with Registered Nurse (RN/MDS) #239 confirmed Resident #47's MDS was coded in correctly and the resident did have in adequate hearing. 2. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including seizures, cerebral palsy, and bipolar disorder. Further review of the medical record revealed the resident has not been prescribed or treated for an infection since March of 2019. Review of the quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact. The MDS further revealed the resident was documented with Multidrug-Resistant Organism (MDRO) infection. Further review of the MDS assessment dated [DATE], 08/09/19, and 09/27/19 all documented the resident with an MDRO infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 2 of 13 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 01/30/2020 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview on 01/28/20 at 8:41 A.M., with Resident #78 revealed the Methicillin Resistant Staphylococcus Aureus (MRSA) in his knee was when he first arrived to the facility. The resident further revealed he has not had a MDRO since that time. Interview on 01/29/20 at 2:07 P.M. with RN/MDS #239 confirmed the coding for Resident #78's MDS assessments were coded incorrectly for MDRO. RN/MDS #239 confirmed the last time Resident #239 was documented being treated for infection was March of 2019 when he was receiving an antibiotic for cellulitis. Surveyor: [NAME], Kathyleen FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 3 of 13 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 01/30/2020 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #110 revealed the resident was admitted to the facility on [DATE]. Diagnoses included COPD, cerebrovascular disease, and anxiety. Review of the plan of care revealed Resident #110 was his/her own responsible party. Advanced care planning was to be reviewed upon admission, quarterly, and as needed. Review of the medical record from 10/19 to 12/19 for Resident #110 revealed no evidence of a care conference and no evidence Resident #110 was offered to participate in a care conference. Interview on 01/27/20 at 10:24 A.M. with Resident #110 revealed the resident was not offered or provided a care conference during the fourth quarter of 2019. The resident revealed the last care conference was held was during the month of 09/19. The resident reported care conference were suppose to be held quarterly. Interview on 01/28/20 at 2:36 P.M. with SS #51 revealed care conference were to be offered to all residents upon admission and quarterly. The SS #51 revealed the last care conference held for Resident #110 was in 09/19. Review of the facility policy titled, Resident/Resident Representative Care Conference dated 05/09/18 revealed residents will be informed on admission of a projected schedule for quarterly care conferences for the year, and reminded quarterly that they may schedule care conference meetings. Based on medical record review, staff interview, resident interview, and review of facility policy, the facility failed to conducted quarterly care conferences for residents. This affected four Residents (#39, #46, #78, and #110) of eight resident reviewed for care conferences. The facility census was 265. Findings include: 1. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including respiratory failure, malignant neoplasm (cancer) of the lung, and unspecified hearing loss bilaterally. Further review of the medical record revealed no documentation Resident #46 had, or ever been invited to a care conference since her admission conference on 09/23/19. Interview on 01/28/20 at 9:18 A.M., Resident #46 revealed she had not been invited to attend a care conference since initial review of her care. Interview on 01/28/20 at 2:38 P.M., Social Services (SS) #51 revealed residents were offered care conferences quarterly and by request. SS #51 verified Resident #46 had not been offered a care conference since her admission conference, and stated she should have been offered one in the fourth quarter of the year. 2. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including seizures, major depressive disorder, and bipolar disorder. Further review of the medical record revealed Resident #78 was last offered a care conference on 08/09/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 4 of 13 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 01/30/2020 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 01/28/20 at 8:41 A.M. with Resident #78 revealed he had not been offered a care conference since first arriving to the facility. Interview on 01/29/20 at 9:32 A.M., with SS #51 revealed Resident #78 was pretty vocal and lets staff know if he had any concerns. SS #51 revealed if a resident declined a care conference, the facility did not hold the conferences. SS #51 verified Resident #78 had not been offered a care conference since 08/19, and stated he should have been offered one in November when his quarterly MDS was completed. 3. Review of Resident #39's medical record revealed an admission date of 03/01/19 with diagnoses including hemiplegia and hemiparesis, schizophrenia, and type two diabetes mellitus. Review of the medical record revealed that Resident #39 had an admission care conference on 03/01/19 and a quarterly care conference on 08/26/19. The medical record revealed no evidence of an further care conferences being held. Interview with Resident #39 on 01/27/20 at 12:25 P.M. revealed she was not invited to care conferences and she had no knowledge of the facility completing quarterly care conferences. Interview with SS #51 on 01/30/20 at 11:56 A.M. revealed a care conference was completed for Resident #39 on 03/19/19 upon admission, and an additional care conference was held on 08/26/19 due to family member complaints. SS #51 confirmed there had not been any other care conference held for the resident. Lastly, SS #51 revealed the facility did not complete a quarterly care conference unless the resident requests one. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 5 of 13 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 01/30/2020 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview; the facility failed to follow up with therapy recommendations for a splint device. This affected one Resident (#195) of one reviewed for range of motion (ROM). The facility census was 265. Findings include: Review of the medical record for Resident #195 revealed the resident was admitted to the facility on [DATE]. Diagnoses include left hand contractures, digits three through five, Parkinson's disease, and dementia without behavioral disturbances. Review of Resident #195's Occupational Therapy (OT) Discharge summary dated [DATE], revealed the resident's therapy goals were to increase left hand, digits three through five, extension to increase functional use of left hand, to prevent decline in ROM. Prognoses was good with consistent staff follow-through. Splint/orthotic recommendations were posey palm protector to left hand as tolerated. Discharge recommendations were bilateral orthotic with staff assistance and continued ROM. Review of the plan of care for Resident #195 revealed the plan of care did not identify the resident's left and right hand contractures or identify the utilization of a hand orthotic. Observation on 01/27/20 at 11:25 A.M. revealed Resident #195 had contractures of the left and right hand. There was no palm protector in place. Observation of the resident's room revealed two hand orthotics, one located on the resident's dresser and the other located on the resident's chair. Interview with the resident confirmed the resident was supposed to wear the hand orthotics every day, however staff would not assist the resident with orthotic placement. Interview on 01/27/20 at 11:37 A.M. with licensed practical nurse (LPN) #177 revealed it was the responsibility of the state tested nurse aid (STNA) to assist resident with orthotic placement. LPN #177 revealed Resident #195 was suppose to be wearing the hand orthotics every day, but was unsure of the orthotic schedule. LPN #177 verified Resident #195 was not wearing the hand orthotics at this time. LPN #177 assisted the resident with donning the bilateral hand orthotics during this interview. Interview on 01/30/20 at 11:32 A.M. with Physical Therapy Program Manager (PTPM) #360 revealed recommendations were made in 08/19 for Resident #195 to wear a posey palm protector on the left hand. Interview with PTPM #360 revealed at the end of therapy services, the therapy recommendations were given to the nursing department. Interview on 01/30/20 at 12:07 P.M. with Registered Nurse (RN) #106 revealed when therapy made recommendations for a resident, therapy would notify nursing of the recommendation, such as a splint device or ROM, and a restorative program would be started for the resident. RN #106 further revealed documentation of the restorative therapy program and schedule would be in the resident's plan of care. RN #106 confirmed there was no order for Resident #195 to have a left hand orthotic, and there was no documentation of staff assisting Resident #195 with hand orthotic placement. The RN confirmed the therapy recommendation for the left hand posey palm protector for Resident #195 was missed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 6 of 13 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 01/30/2020 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation,staff interview, and review of facility policy, the facility failed to follow physician's oxygen administration orders for two Residents (#90 and #227) of three reviewed of oxygen administration. The facility census was 265. Residents Affected - Few Findings include: 1. Review of Resident #90's medical record revealed an admission date of 04/18/19 with diagnoses including non-Hodgkin's lymphoma, and chronic obstructive pulmonary disease (COPD). Review of Resident #90's physician orders revealed an order dated 08/18/19 to administer oxygen at four liters per minute (LPM) via nasal cannula to maintain the resident's oxygen saturation level above 90%. Review of Resident #90's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident was cognitively intact. The MDS further revealed the resident utilized oxygen. Observation of Resident #90 on 01/27/20 at 11:25 A.M. revealed the resident had an oxygen concentrator set to deliver oxygen at the rate of 2 LPM via a nasal cannula. Interview with Licensed Practical Nurse (LPN) #25 on 01/27/20 AT 11:29 A.M. confirmed Resident #90's oxygen concentrator was set at two LPM and the order was for four LPM. 2. Review of Resident #227's medical record revealed an admission date of 12/07/12 with diagnoses including heart failure, chronic obstructive pulmonary disease (COPD), shortness of breath, and dependence on supplemental oxygen. Review of Resident #227's physician order dated 09/25/18 revealed to administer oxygen at two LPM, via nasal cannula to maintain oxygen saturation above 90% as needed for dyspnea. Review of Resident #227's care plan dated 06/13/19 revealed the resident required oxygen related to pneumonia, respiratory failure, and bipap (for sleep apnea) with interventions to administer oxygen as ordered and oxygen levels were to be kept at the desired level set by the physician. Observation of Resident #227 on 01/27/20 at 10:42 A.M. revealed the oxygen concentrator was set to three LPM. Interview with State Tested Nurses Aide (STNA) #55 on 01/27/20 at 10:45 A.M. confirmed Resident #227's oxygen concentrator was set to deliver oxygen at a rate of 3 LPM. Review of the facility policy titled Oxygen Administration, dated 08/25/12, revealed to set the oxygen to the prescribed flow rate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 7 of 13 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 01/30/2020 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 medical record review, staff interview, and review of facility policy, the facility failed to timely report medication irregularities to the physician. This affected one Resident (#6) of five reviewed for unnecessary medications. The facility census was 265. Findings include: Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, heart disease, psychosis, and obsessive-compulsive disorder. Review of physician orders dated 05/05/19 revealed Resident #6 was ordered Prozac (antidepressant/psychotropic) 20 milligrams (mg) daily for obsessive-compulsive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was severely cognitively impaired. The MDS revealed the resident received both antipsychotic and antidepressant medications seven of the seven day look back period. There had been no gradual dose reduction (GDR) attempted and the physician had not documented a GDR as clinically contraindicated. Review of the Monthly Medication Review (MMR) completed on 11/20/19 revealed Resident #6's medications were reviewed by the facility pharmacist, however no recommendations were noted. Interview on 01/29/20 at 6:08 P.M., with the Director of Nursing (DON) revealed the pharmacist did not provide the recommendations for Resident #6 to the facility. Interview conducted on 01/29/20 at 6:20 P.M., with the facility Pharmacist #375 revealed at the end of the day after completing MMR reviews he generates reports and provides the facility with written and electronic copies of his recommendations for the physician. PH #375 revealed in November 2018 he recommended a GDR for Resident #6's Prozac. PH #375 stated the written copy must not have printed, however they facility also received the information electronically. PH #375 further revealed he did not notice the next month the recommendations he had made were not addressed, therefore he re-recommended the GDR again. Review of the facility policies titled, Medication Regimen Review dated 11/28/17 revealed medication irregularities would be sent over by the pharmacist with 72 hours of identified irregularity, and written report would be provided via email, fax, ect. to the resident's attending physician, the DON, and the medical director. The facility would ensure each resident's drug regimen remained free of unnecessary drugs, and resident who use psychotropic medications receive GDR's in an effort to discontinue there drugs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 8 of 13 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 01/30/2020 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview; the facility failed to hold Coumadin (blood thinner) as ordered for one Resident (#415) of six reviewed for unnecessary medications. The facility census was 265. Residents Affected - Few Finding include: Review of the medical record for Resident #415 revealed the resident was admitted to the facility on [DATE]. Diagnoses include disorder of kidney and ureter, malignant neoplasm (cancer) of endometrium, and atrial fibrillation (irregular heartbeat). Review of laboratory test results dated 01/27/20 revealed Resident #415's international normalized ratio (INR) (a test that measures the time for the blood to clot) was 3.6. The reference range for INR was documented as standard anticoagulant 2.0-3.0, and aggressive anticoagulant 2.5-3.5. The Certified Nurse Practitioner (CNP) ordered to hold two doses of Coumadin and restart on 01/29/20. Review of the Medication Administration Record (MAR) dated 01/20 revealed Resident #415 was administered Coumadin on 01/27/20 and 01/28/20. Interview on 01/30/20 at 8:39 A.M. with Licensed Practical Nurse (LPN) #28 confirmed the CNP was notified of Resident #415's abnormal INR results and gave an order to hold the Coumadin on 01/27/20 and 01/28/20. The LPN revealed she forgot to write the order to hold Coumadin and it was administered to the resident on 01/27/20 and 01/28/20 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 9 of 13 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 01/30/2020 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 - Few 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, staff interview, and review of facility policy, the facility failed to properly store medications. This affected one of four medication rooms, and one medication cart of seven observed. The facility census was 93. Findings include: 1. Observation of the Brunner 3 medication room refrigerator on 01/30/20 art 10:32 A.M. revealed a open bottle of influenza vaccine (Afluria) dated opened 10/08/19. Review of an informational insert included in the Afluria medication box revealed that after the stopper of the vial was pierced it should be discarded after 28 days. Registered Nurse (RN) #36 confirmed during an interview on 01/16/20 at 10:32 A.M. that the opened Afluria bottle was outdated and should have been discarded. 2. A medication cart on the Brunner 2 was observed with RN #136 on 01/30/20 at 10:44 A.M. The medication cart was sitting in the hallway between rooms [ROOM NUMBERS]. Further observation revealed that the medication cart was unlocked and a nurse was not in direct view. RN #136 confirmed during the observation that the cart was unlocked and a nurse was not in direct view of it. Interview with Licensed Practical Nurse (LPN) #25 on 01/30/20 at 10:49 A.M. confirmed that she left the cart unlocked before entering room [ROOM NUMBER]. LPN #25 stated that a state tested nursing assistant (STNA) was beside the medication cart when she entered room [ROOM NUMBER]. Review of the facility's policy titled Medication Storage dated 06/21/17 revealed that medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. Outdated medications should be disposed of according to procedures for medication destruction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 10 of 13 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 01/30/2020 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to complete resident labs as ordered by the physician. This affected one Resident (#6) of five reviewed for unnecessary medications. The facility census was 265. Residents Affected - Few Findings include: Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses psychosis, hyperlipidemia, Alzheimer's Disease, and hypertension. Review of physician orders dated 05/05/19 revealed Resident #6 was ordered laboratory draws for the comprehensive metabolic panel (CMP), lipid panel, and hemoglobin A1C (blood sugar) blood test in one week and every six months. Review of the facility laboratory results sheets dated 05/13/19 reveled all three labs were noted completed as ordered. Review of the six month draw dated 11/01/19 revealed Resident #6's CMP was completed however the lipid panel and A1C were not. Interview on 01/30/20 at 9:18 A.M., with Corporate Registered Nurse (CRN) #350 verified the facility did not complete the lipid and A1C lab in November 2019 as ordered. Review of the facility policy titled, Diagnostic Testing dated 11/22/16 revealed the facility would assist the residents in receiving physician ordered laboratory services, and obtain laboratory test in accordance with physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 11 of 13 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 01/30/2020 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 - Some 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 review of facility policy, the facility failed to properly date and label food storage items in the kitchen to avoid contamination and spoilage. This had the potential to affect 264 out of 265 residents. The facility identified one resident (#521) as nothing by mouth (NPO). Findings include: Observation of the kitchen on 01/27/20 at 8:17 A.M. with Dietary Supervisor #196 revealed a bag of sausage links in the freezer which were opened to air and undated, a pouch of opened whipped topping in the refrigerator was undated, a bag of gravy mix open and undated in the dry food section, a bag of buns that were open to air and undated in the bread storage area, a pouch of grits open and undated in the dry food storage, and a bag of shredded lettuce in plastic wrap that was open and undated inside the refrigerator. Interview with Dietary Supervisor #196 on 0/27/20 at 9:00 A.M. confirmed the above food items were opened and undated but should have been dated when opened. Review of the facility policy titled Food Storage- Labeling and Dating, dated 07/18, revealed food items must be dated after opening with an open date and a use by date and all food items should be securely closed to avoid being exposed to the air. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 12 of 13 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 01/30/2020 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 observation, interview, and review of the facility's Legionella documentation the facility failed to have an adequate implemented Legionella program. This had the potential to affect all of the residents of the facility. The facility also failed to obtain an order for isolation precautions. This affected one Resident (#116) of two reviewed for infections. The facility census was 265. Residents Affected - Many Findings include: 1. Review of documentation titled Monitoring Control Measures to Prevent Growth and Spread of Legionella revealed that a control limit be be checked was chlorine > (greater than) .3. Further review revealed that levels documented were 8.1 on 01/02/19, 7.4 on 02/03/19, 7.4 on 03/04/19, 7.3 on 04/02/19, 7.3 on 05/18/19, 7.3 on 06/20/19, 7.3 on 07/02/19, 7.6 on 08/01/19, 7.4 on 09/05/19, 7.4 on 10/10/19, 7.4 on 11/01/19, 7.3 on 12/05/19, and 7.3 on 01/20/20. The facility was unable to provide a completed Centers for Disease Control and Prevention (CDC) toolkit for water management to prevent Legionella growth. Interview on 01/30/20 at 1:06 P.M. with the Maintenance Director (MD) #227 revealed the facility's Legionella prevention program binder was unable to be found. MD #227 stated the the documentation provided was put together on the day prior, 01/29/20. MD #227 confirmed that the facility had not completed the Centers for Disease Control and Prevention (CDC) toolkit for water management to prevent Legionella growth. MD #227 stated he was checking chlorine levels in the facility monthly with a test kit. A water test for chlorine levels was observed on 01/30/20 at 1:20 P.M. with MD #227. The water sample was obtained in a bathroom near the maintenance store room. Using a water test kit MD #227 checked water from a sink and arrived at a chlorine level of 2.1. MD #227 was unable to identify if the level obtained was in milligrams (mg) per liter or parts per million (ppm). Observation of the test kit revealed it tested for levels of chlorine from 0 to 4 mg per liter. MD #227 confirmed that he had been documenting levels from 7.3 to 8.1 and was unable to state how he had determined those levels using the current test kit. MD #227 confirmed that the control limit listed on the Monitoring Control Measures to Prevent Growth and Spread of Legionella document was >.3, and was unable to verify why he had documented 7.3 to 8.1. The Administrator confirmed during an interview on 01/30/20 at 1:57 P.M. that the facility's Legionella prevention program was not adequate and not implemented correctly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 13 of 13