Maria Joseph Living Care: Blood Pressure Med Errors - OH
The violations occurred at Maria Joseph Living Care Center, where federal inspectors found Registered Nurse #22 administered Coreg to Resident #10 despite explicit physician orders to withhold the drug when his systolic blood pressure dropped below 110.
On June 28, the resident's morning blood pressure measured 96 — well below the safety threshold. The nurse gave him the medication anyway and signed the record as administered.
She repeated the violation on July 6 when his pressure was 100, and again on July 12 when it dropped back to 96. Each time, she documented giving the Coreg despite the dangerous readings.
Resident #10 had been admitted to the 245-bed facility in May with end-stage renal disease, diabetes, depression and hypertension. His physician had prescribed Coreg 6.25 milligrams twice daily but included clear instructions to hold the medication if his systolic pressure fell below 110 millimeters of mercury.
The resident required extensive assistance with basic activities. He needed supervision for eating and two-person help for bed mobility and toileting. Despite his physical limitations, his mental status remained intact with a cognitive assessment score of 15.
When confronted by inspectors on September 11, Nurse #22 admitted she had not actually given the medication on any of the three dates. She claimed she believed documenting the low blood pressure readings somehow indicated she had withheld the drug.
"RN #22 explained she believed because she documented the blood pressure was outside of the parameters, it meant she did not give it," the inspection report states.
But the medication administration records told a different story. On all three occasions, she had clearly marked the Coreg as given, creating false documentation that could have misled other medical staff about the resident's treatment.
The nurse also claimed ignorance of basic electronic charting functions. She told inspectors she didn't know the computer system offered specific codes to indicate when medications were held due to parameter violations, or how to access nursing notes that would clarify her actions.
The Director of Nursing acknowledged the documentation failures when interviewed the same day. She confirmed that the medication administration records for June 28, July 6 and July 12 did not accurately reflect that the medication had been withheld per physician parameters.
Coreg, known generically as carvedilol, is a beta-blocker commonly prescribed for high blood pressure and heart conditions. Giving the medication when a patient's blood pressure is already dangerously low can cause it to drop further, potentially leading to dizziness, fainting, falls, or more serious cardiovascular complications.
The resident was hospitalized sometime after the July incidents and never returned to the facility. The inspection report does not specify whether his hospitalization was related to the medication errors.
Accurate medication documentation is a fundamental nursing responsibility and federal requirement. The records serve as the primary communication tool between healthcare providers about what treatments a resident has received.
False documentation can have cascading effects. Other nurses, doctors, or pharmacists who rely on the records might make treatment decisions based on incorrect information about what medications were actually administered.
The violation was discovered during a complaint investigation at the facility, though the specific nature of the original complaint was not disclosed in the inspection report.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the case illustrates how documentation errors can mask potentially serious medication safety issues.
The resident's case raises questions about nursing supervision and training at the facility. A registered nurse's claim that she didn't understand basic electronic charting functions or medication administration protocols suggests possible gaps in staff competency or orientation.
Resident #10's complex medical conditions — including end-stage kidney disease and diabetes — made accurate medication management particularly critical. Patients with multiple chronic conditions face higher risks from medication errors due to their fragile health status.
The facility has not yet submitted its plan of correction to address the documentation failures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Maria Joseph Living Care Center from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
MARIA JOSEPH LIVING CARE CENTER in DAYTON, OH was cited for violations during a health inspection on September 11, 2025.
On June 28, the resident's morning blood pressure measured 96 — well below the safety threshold.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.