Health inspection·June 8, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, menu review, and staff and resident interview, the facility failed to ensure food choices were provided for resident meals. This affected one (#348) of one residents reviewed for choices. The census was 235. Findings included: Medical record review for Resident #348 revealed an admission date of 09/23/20. Medical diagnoses included peripheral vascular disease, heart failure, and non-Alzheimer's dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #348 was severely cognitively impaired and his functional status was extensive assistance for bed mobility, transfers, and toileting. The resident required limited assistance for eating. Review of the breakfast menu on 06/06/23 revealed there was choice of juices, sausage links, choice of cereal, pancakes, hash browns, water, margarine, and syrup. Review of the breakfast menu on 06/07/23 revealed choice of juices, ham and cheese pocket, hash browns, choice of cereal, choice of milk, and water. There was no choices listed on the menu referring to mechanical soft diets. Observation and interview at the same time on 06/06/23 at 9:05 A.M. revealed Resident #348 was sitting in the dining room at the table with his breakfast meal in front of him. State Tested Nurse Aide (STNA) #154 delivered the meal to Resident #348, and when asked if the resident was given a choice of cereal, STNA #154 stated Resident #348 was not asked if he wanted cereal. Observation of the breakfast meal for Resident #348 and interview on 06/07/23 at 9:14 A.M. revealed the resident had scrambled eggs, two sausage links, one slice of toast, milk, orange juice, and water. Resident #348 stated at that time he would like some cereal if the staff would give it to him, and verified he did not get a choice of what he wanted to eat for his meals. Interview with STNA #241 on 06/07/23 at 9:17 A.M. stated in the month she had been at the facility, the staff did not ask the residents what they want for breakfast. STNA #241 stated Resident #348 was on a mechanical soft diet, but when asked if he could have oatmeal with his breakfast she went over to the servery and got Resident #348 oatmeal. Interview with Dietary Manager #86 on 06/07/23 at 12:54 P.M. indicated residents on a mechanical soft diet could have cereal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 2 of 10 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 06/08/2023 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 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on personal funds account review and staff interview, the facility failed to notify residents or their representatives of the need to spend down personal funds once the account reached $200 less than the Supplemental Security Income (SSI) resource limit of one person. This affected 19 (#3, #15, #20, #37, #41, #43, #44, #45, #54, #101, #111, #124, #127, #158, #183, #195, #198, #227, and #448) of 19 residents reviewed for personal funds. The census was 235. Residents Affected - Some Findings included: 1. Review of Resident #3's personal funds account revealed a balance as of 06/07/23 of $20,424.70. 2. Review of Resident #15's personal funds account revealed a balance as of 06/08/23 of $2,534.72. 3. Review of Resident #20's personal funds account revealed a balance as of 06/01/23 of $2,366.34. 4. Review of Resident #37's personal funds account revealed a balance as of 06/05/23 of $22,686.10. 5. Review of Resident #41's personal funds account revealed a balance as of 06/02/23 of $4,664.31. 6. Review of Resident #43's personal funds account revealed a balance as of 06/08/23 of $5,835.42. 7. Review of Resident #44's personal funds account revealed a balance as of 06/02/23 of $2,399.76. 8. Review of Resident #45's personal funds account revealed a balance as of 06/02/23 of $6,641.78. 9. Review of Resident #54's personal funds account revealed a balance as of 06/07/23 of $3,694.30. 10. Review of Resident #101's personal funds account revealed a balance as of 06/01/23 of $3,728.40. 11. Review of Resident #111's personal funds account revealed a balance as of 06/07/23 of $3,583.82. 12. Review of Resident #124's personal funds account revealed a balance as of 06/02/23 of $6,223.07. 13. Review of Resident #127's personal funds account revealed a balance as of 06/07/23 of $5,198.70. 14. Review of Resident #158's personal funds account revealed a balance as of 06/07/23 of $8,656.77. 15. Review of Resident #183's personal funds account revealed a balance as of 06/07/23 of $8,069.18. 16. Review of Resident #195's personal funds account revealed a balance as of 06/07/23 of $6,069.32. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 3 of 10 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 06/08/2023 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 0569 17. Review of Resident #198's personal funds account revealed a balance as of 06/08/23 of $2,510.67. Level of Harm - Minimal harm or potential for actual harm 18. Review of Resident #227's personal funds account revealed a balance as of 06/02/23 of $2,244.31. 19. Review of Resident #448's personal funds account revealed a balance as of 06/08/23 of $2,225.77. Residents Affected - Some Interview with Business Office Manager (BOM) #49 on 06/08/23 at 12:15 P.M. stated the staff who previously worked for her were not notifying residents or representatives of a need to spend down resident's personal funds accounts. BOM #49 stated the staff no longer worked at the facility, and the new staff she had were working to get the spend down notifications sent out. BOM #49 confirmed Resident #3, Resident #15, Resident #20, Resident #37, Resident #41, Resident #43, Resident #44, Resident #45, Resident #54, Resident #101, Resident #111, Resident #124, Resident #127, Resident #158, Resident #183, Resident #195, Resident #198, Resident #227, and Resident #448 all should have been notified to spend down their personal funds accounts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 4 of 10 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 06/08/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and resident and staff interview, the facility failed to assist dependent residents with activities of daily living (ADLs). This affected two (#103 and #110) of six residents reviewed for ADLs. The facility census was 235. Residents Affected - Few Findings include: 1. Review of Resident #103's medical record revealed admission to the facility on [DATE] with diagnoses of cerebral infarction, need for assistance with personal care, diabetes mellitus type II, dysphagia, repeated falls, and aphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #103 had moderate cognitive impairment. Resident #103's functional status was assessed as one to two person extensive assist with ADLs. The MDS assessment also revealed Resident #103 was frequently incontinent of urine and always incontinent of bowel. Review of the care plan dated 04/04/23 revealed Resident #103 may require assistance with ADLs and may be at risk for developing complications associated with decreased ADL self-performance. An intervention included in the care plan revealed Resident #103 needed assistance with grooming including nail care, shaving, and hair care. Review of state tested nurse aide (STNA) resident task documentation dated 05/25/23 through 06/07/23 revealed nail care was not provided for Resident #103 except on 06/05/23 at 2:59 P.M. and the resident refused care. Further review of the STNA task sheet documentation dated 06/07/23 at 6:59 A.M. revealed no nail care was provided and was marked as not applicable. Observation of Resident #103 on 06/05/23 at 2:30 P.M. and on 06/07/23 at 11:48 A.M. revealed Resident #103 had long finger nails with a black substance under all finger nails on both hands. Interview with Resident #103 on 06/07/23 at 11:48 A.M. state he received a shower the morning of 06/07/23 the nurse aide did not ask to cut or clean his finger nails. Interview with Registered Nurse (RN) #176 at 11:49 A.M. confirmed Resident #103's finger nails should have been cleaned and trimmed after his showers. 2. Review of the medical record for Resident #110 revealed an admission date of 11/13/21 with diagnoses including but not limited to type two diabetes, atherosclerotic heart disease, migraines, atrial fibrillation, supraventricular tachycardia, anxiety disorder, depressive disorder, diverticulosis of large intestine, anemia, myocardial infarction, cystitis, partial intestinal obstruction, and colostomy. Review of the quarterly MDS assessment date 04/15/23 revealed a cognitive assessment was not completed, and Resident #110 required extensive assistance with two staff members for bed mobility, transferred with assistance of one staff member, required limited assistance for eating, and extensive assistance for toileting. Review of the plan of care revealed Resident #110 may require assistance with ADLs and may be at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 5 of 10 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 06/08/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few risk for developing complications associated with decreased ADL self-performance. Interventions included bathing assistance was needed, encourage resident participation while performing ADLs, and grooming (nails/shave/hair) assistance was needed. Review of STNA resident tasks documentation for Resident #110 dated 05/08/23 through 06/08/23 was silent for any documentation related to hair shampooing. Observation on 06/08/23 at 10:40 A.M. of Resident #110 revealed the resident had long facial hair on the chin and neck. Resident #110's hair on the head was long and scraggly with an excessive oily appearance. Resident #110 had white flakes noted throughout the hair close to the scalp. Interview on 06/08/23 at 10:40 A.M. with Resident #110 states she had not had her hair washed for a long time, and was not able to remember when her hair was washed last. Resident #110 stated the staff used a waterless cap to wash her hair. Resident #110 stated she was able to shave her facial hair, but she no longer had the razor she used to keep in her cup on her bedside table, and she was not able to complete that task for an undetermined time. Interview on 06/08/23 at 10:45 A.M. with Director of Nursing (DON) #176 verified Resident #110's hair on her head appeared to be unwashed, and stated Resident #110's scheduled bathing days were Monday and Thursday on second shift. DON #176 further verified Resident #110's facial hair was longer than expected if it would have been shaved on her bathing days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 6 of 10 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 06/08/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ensure physician orders for a referral to a gynecologist were processed timely. This affected one (#184) of one residents reviewed for referrals to outside providers. The facility census was 235. Residents Affected - Few Findings include: Medical record review for Resident #184 revealed an admission of 01/24/23 with diagnoses including but not limited to bipolar disorder with severe psychotic features, diabetes, chronic obstructive pulmonary disease, anemia, morbid obesity, heart failure, mastitis without abscess, chronic pain syndrome, pulmonary embolism, major depressive disorder, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #184 had an intact cognition. Review of the physicians order for Resident #184 revealed an order for a referral to a gynecologist dated 05/07/23. Review of a progress note dated 05/07/23 at 4:27 P.M. revealed a new order given by the nurse practitioner to obtain a urinalysis and consult with a gynecologist due to Resident #184 complaining of pain in vaginal area. Interview on 06/06/23 at 10:50 A.M. with Resident #184 stated she was supposed to go to a gynecologist and she had not seen a gynecologist yet. Interview on 06/09/23 at 10:20 A.M. with Unit Manager Licensed Practical Nurse (LPN) #124 verified the referral for Resident #184 to see a gynecologist was not processed for Resident #184 to be seen in a timely manner, and an appointment was just scheduled on 06/08/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 7 of 10 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 06/08/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and resident and staff interview, the facility failed to ensure a physician order was in place for use of a continuous glucose monitoring device. This affected one (#28) of one residents reviewed for the provision of glucose monitoring devices. The facility census was 235. Findings include: Medical record review for Resident #28 revealed and admission date of 06/06/22 with diagnoses including but not limited to hypertensive heart, chronic kidney disease, fluid overload, morbid obesity, chronic obstructive pulmonary disease, major depressive disorder, hypertension, congestive heart failure, edema, diabetes mellitus, and interstitial pulmonary diseases. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was assessed with intact cognition. Resident #28 required extensive assistance for bed mobility, transfers, and toileting with two staff members. Resident #28 received insulin daily during the assessment period. Review of Resident #28's physician orders revealed an order for insulin glargine solution 10 units injected subcutaneously (SQ) once daily ordered on 05/29/23 and Humalog insulin to be administered per sliding scale SQ before meals and at bedtime ordered on 04/05/23. There were no orders for Resident #28 to have a continuous glucose monitoring device applied to the skin. Observation on 06/06/23 at 11:52 A.M. revealed a box on the bedside table in Resident #28's room which contained supplies for a continuous glucose monitoring system. Interview on 06/06/23 at 11:52 A.M. with Resident #28 stated the supplies for the continuous glucose monitoring device were mailed to her and staff apply the device every 14 days. Interview on 06/07/23 at 8:58 A.M. with Unit Manager Licensed Practical Nurse (LPN) #119 verified there was no physician order for Resident #20's continuous glucose monitoring system, and verified Resident #28 went to the hospital, and when she came back on the 05/29/23 it was not added to her physician orders. LPN #119 verified that she applied a new continuous glucose monitoring disc on Resident #28 on 06/07/23, and did not ensure the orders were processed before applying the device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 8 of 10 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 06/08/2023 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. Based on medical record review, observation, resident and staff interview, and policy review, the facility failed to medications were stored in a safe and secure manner. This affected one (#55) of three residents reviewed for medication storage. The facility census was 235. Findings include: Medical record review for Resident #55 revealed an admission date on 08/23/16 with diagnoses including but not limited to chronic obstructive pulmonary disease, hypothyroidism, neuralgia and neuritis, pain in shoulder, diabetes mellitus, and chronic pain. Review of a physician order dated 05/25/23 revealed Resident #55 was ordered the topical pain medication Voltaren gel one (1) percent (%) applied to the back daily. Observation on 06/06/23 at 10:31 A.M. of Resident #55's bathroom shelf revealed an open, half used, labeled tube of Voltaren gel 1%. Interview on 06/06/23 at 10:31 A.M. with Resident #55 stated he used the Voltaren gel on his shoulder and back, and the staff would apply it for him. Resident #55 stated a nurse gave it to him to use on his shoulder a while ago and told him to keep it. Interview on 06/06/23 at 10:40 A.M. with Licensed Practical Nurse (LPN) #94 verified Resident #55 did not have an order to keep the medication in his room, and verified the tube of Voltaren gel in his bathroom. Review of the facility policy titled, Medication Storage, dated 06/21/2017, revealed medication should only be accessible to licensed personnel and staff members authorized to administer medication. Further review of the policy revealed medication storage areas are to be kept secure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 9 of 10 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 06/08/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, menu review, and staff interview, the facility failed to ensure the planned menu was followed. This affected 32 (#22, #35, #38, #52, #78, #88, #94, #96, #102, #111, #118, #119, #136, #137, #141, #142, #149, #152, #161, #162, #170, #174, #181, #182, #186, #193, #204, #205, #206, #208, #225, and #450) of 32 residents who resided on the [NAME] Four unit. All 32 residents on the [NAME] Four unit were identified by the facility to received food by mouth. The census was 235. Findings included: Review of the planned breakfast menu for 06/06/23 revealed items consisting of a choice of juices, sausage links, choice of cereal, pancakes, hash browns, water, margarine, and syrup. Observation of the breakfast tray line on 06/06/23 at 9:00 A.M. on the [NAME] Four unit revealed there were no hash brown potatoes being served as indicated on the menu. Interview with Dietary Aide (DA) #158 on 06/06/23 at 9:03 A.M. stated she did not notice there were no hash browns to serve to the residents, and confirmed the menu indicated hash browns were to be served for the breakfast meal on 06/06/23. DA #158 stated there was not a substitute for the hash browns, and she did not know why hash browns were not prepared or why a substitution was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365322 If continuation sheet Page 10 of 10