Cycle 1
Health 2023-06-08 · Fire 2023-06-08
11 health deficiencies
Top issue: Resident Rights (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Dayton, OH
Maria Joseph Living Care Center
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
4830 Salem Avenue, Dayton, OH
(937) 278-2692
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
266
Certified beds
Average residents
240
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
1974-03-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
63 facilities
Chain averages 4 overall / 4 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.79
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,555
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9925
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
5.10
Baseline 9.39% · Performance 6.93% · Measure score 5.10 · Achievement 3.04 · Improvement 5.10
Total nurse turnover
5.13
Baseline 46.26% · Performance 42.73% · Measure score 5.13 · Achievement 5.13 · Improvement 1.15
Adjusted total nurse staffing
1.61
Baseline 2.62 hours · Performance 3.29 hours · Measure score 1.61 · Achievement 0.73 · Improvement 1.61
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.65% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 13.33% · Lower 95% interval 7.3% |
| Discharge to community | 41.28% |
50.57%
9.3 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 27.66% · Lower 95% interval 28.6% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 17 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | 6.93% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 7.69% · Lower 95% interval 4.1% |
| Staff COVID-19 vaccination coverage | 2.5% |
8.2%
5.7 pts worse
|
Numerator 8 · Denominator 320 |
| Staff flu vaccination coverage | 3.05% |
42%
39 pts worse
|
Numerator 10 · Denominator 328 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
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 · Q1 91.1% · Q2 88.8% · Q3 88.4% · Q4 90.9% · 4Q avg 89.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.1% |
94.5%
0.4 pts worse
|
95.5%
1.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.3%
2.3 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.9% · Q3 1.3% · Q4 0.4% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 49.5% |
26.1%
23.4 pts worse
|
11.4%
38.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 47.1% · Q3 52.7% · Q4 61.4% · 4Q avg 49.5% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
6.2%
3.3 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 9.8% · Q3 10.3% · Q4 8.5% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.5% |
25.4%
12.1 pts worse
|
19.6%
17.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 37.1% · Q3 39.7% · Q4 37.0% · 4Q avg 37.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
11.5%
3.8 pts worse
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 13.0% · Q3 13.9% · Q4 18.3% · 4Q avg 15.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.6% |
7.7%
3.1 pts better
|
16.3%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 8.0% · Q3 2.8% · Q4 5.1% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
6.2%
1.2 pts better
|
14.9%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 7.8% · Q3 3.5% · Q4 5.3% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.1% |
0.5%
0.4 pts better
|
1.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.4% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.8% |
21.7%
3.9 pts better
|
19.8%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 18.1% · Q3 16.2% · Q4 16.3% · 4Q avg 17.8% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
3.7%
1.3 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 7.0% · Q3 3.9% · Q4 2.8% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.2% |
78.1%
27.9 pts worse
|
81.7%
31.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 68.0% · Q2 47.6% · Q3 38.2% · Q4 45.9% · 4Q avg 50.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
12.5%
4.4 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 10.0% · Expected 13.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.2%
0.3 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 3.8% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 68.1% |
75.6%
7.5 pts worse
|
79.7%
11.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 68.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.0% |
25.1%
2.1 pts better
|
23.9%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 25.0% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-30 · Fire 2020-01-30
11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-11-08 · Fire 2018-11-08
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-06-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-27
E · Potential for more than minimal harm
2023-06-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-06-27
E · Potential for more than minimal harm
2023-06-08
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-06-27
E · Potential for more than minimal harm
2023-06-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-27
E · Potential for more than minimal harm
2023-06-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-27
E · Potential for more than minimal harm
2023-06-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-27
E · Potential for more than minimal harm
2023-06-08
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 2023-06-27
E · Potential for more than minimal harm
2023-06-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-27
E · Potential for more than minimal harm
2020-01-30
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 2020-03-05
E · Potential for more than minimal harm
2020-01-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-05
E · Potential for more than minimal harm
2020-01-30
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 2020-03-05
E · Potential for more than minimal harm
2020-01-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-03-05
F · Potential for more than minimal harm
2018-11-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-12-06
E · Potential for more than minimal harm
2018-11-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-12-06
E · Potential for more than minimal harm
2018-11-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2018-12-06
E · Potential for more than minimal harm
2018-11-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-12-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-04
E · Potential for more than minimal harm
2023-06-08
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-06-27
E · Potential for more than minimal harm
2023-06-08
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-06-27
D · Potential for more than minimal harm
2023-06-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-27
D · Potential for more than minimal harm
2023-06-08
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-06-27
D · Potential for more than minimal harm
2023-06-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-27
D · Potential for more than minimal harm
2023-06-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-27
D · Potential for more than minimal harm
2023-06-08
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 2023-06-27
D · Potential for more than minimal harm
2023-06-08
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 2023-06-27
D · Potential for more than minimal harm
2023-03-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-16
F · Potential for more than minimal harm
2020-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-05
E · Potential for more than minimal harm
2020-01-30
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2020-03-05
E · Potential for more than minimal harm
2020-01-30
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 2020-03-05
D · Potential for more than minimal harm
2020-01-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2020-03-05
D · Potential for more than minimal harm
2020-01-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-03-05
D · Potential for more than minimal harm
2020-01-30
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2020-03-05
D · Potential for more than minimal harm
2020-01-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-03-05
D · Potential for more than minimal harm
2020-01-30
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 2020-03-05
D · Potential for more than minimal harm
2020-01-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-03-05
D · Potential for more than minimal harm
2020-01-30
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 2020-03-05
D · Potential for more than minimal harm
2020-01-30
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2020-03-05
F · Potential for more than minimal harm
2018-11-08
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 2018-12-06
F · Potential for more than minimal harm
2018-11-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-12-06
E · Potential for more than minimal harm
2018-11-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-12-06
E · Potential for more than minimal harm
2018-11-08
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 2018-12-06
D · Potential for more than minimal harm
2018-11-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-12-06
D · Potential for more than minimal harm
2018-11-08
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 2018-12-06
Penalties and ownership
What sits behind the stars
Ownership
Colleran Fam Tr Dated 01-01-2018
5% Or Greater Indirect Ownership Interest · Organization
Foundations Health LLC
5% Or Greater Direct Ownership Interest · Organization
Colleran, Brian
Operational/Managerial Control · Individual
Colleran, Brian
Corporate Director · Individual
Colleran, Brian
Corporate Officer · Individual
Foundations Health Solutions, LLC
Operational/Managerial Control · Organization
Krystowski, John
Corporate Officer · Individual
Price, Austin
Operational/Managerial Control · Individual
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