State inspectors recommend fine in dementia freezer death at Trotwood nursing home

A nurse aide failed to investigate when a door alarm was triggered that allowed an 86-year-old woman with dementia to wander off a fourth floor and into a walk-in freezer where she was found dead six hours later at a Trotwood nursing facility, an Ohio Department of Health investigation shows.

The report said the nurse aide at Maria-Joseph Nursing & Rehabilitation thought the alarm was triggered by another staff member. The report also says a dietary worker failed to lock the kitchen door when leaving.

Requests for comment from Maria-Joseph Nursing & Rehabilitation by the Dayton Daily News were not returned. The nursing facility said in the review that it had made a number of corrective training steps with all employees.

ExploreOhio Department of Health investigates Trotwood nursing home freezer death

The facility was cited by the inspectors, asked to work on a plan of correction with the state, and in addition, state inspectors have recommended a federal fine, though U.S. Centers for Medicare and Medicaid makes the final call on issuing a fine. No fine has been listed online by Centers for Medicare and Medicaid.

The correction plan the facility worked with the inspectors on does not mean that Maria-Joseph agrees with the citations. The facility “maintains that the alleged deficiencies do not individually or collectively jeopardize the health and safety of residents.”

Previously, a spokesperson said in a public statement that Maria-Joseph is committed to resident safety.

“The staff and residents at Maria-Joseph Nursing and Rehabilitation Center are very saddened by the loss of one of our residents. We are, on all levels, assisting in the investigation of this tragic incident. We continuously strive to ensure the safety of the residents in our care. Due to the status of the open investigation, we are unable to comment further at this time.”

The department of health launched its investigation after authorities found 86-year-old Sofiya Perel dead inside a walk-in freezer Sept. 15 at Maria-Joseph Nursing & Rehabilitation Center, 4830 Salem Ave.

The state said the facility failed to provide adequate supervision to prevent a cognitively impaired resident from escaping from a secured dementia unit.

“The resident eloped from a secured unit on the fourth floor through the stairwell exit door located at the southernmost point of the secured unit. The resident was found on the second floor of the Emma building in the kitchen, inside of walk-in cooler deceased,” the report says.

ExploreTrotwood police probe death of dementia patient found in freezer

Investigators said they interviewed the nurse aide about silencing the alarm and was told “she had seen another aide coming down the hall and assumed she had triggered the alarm. That is why she didn’t check the stairwell before silencing the alarm.”

Inspectors also reported the facility failed to notify the state of an allegation of neglect which resulted in bodily harm within 24 hours. The state inspectors came up with a plan of correction, which the facility is implementing.

Part of this plan includes that starting Sept. 16, for four weeks, the administrator or designee completed random weekly audits and interviews of staff and residents to ensure allegations of neglect were reported within 24 hours to the state agency.

Some other parts of the correction plan include that the staff were also re-educated on the facility’s elopement policies, a quality assurance committee meeting for four weeks to review the action plan, and a supervisor conducting daily audits for four weeks to make sure the kitchen is secured correctly.

24/7 Alzheimer’s Helpline

Caregivers can call the Alzheimer’s Association at 1-800-272-3900 any time for support and resource information, including for questions about wandering.

Long-Term Care Ombudsman

For people with questions or concerns about nursing home and assisted living resident rights, the State Long-Term Care Ombudsman is a free resource at or 1-800-282-1206. The ombudsmen can help resolve disputes and advocate for residents’ rights to be upheld.