Health inspection·December 27, 2024

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, review of a transportation communication log, resident and staff interviews, and facility policy review, the facility failed to provide proper and timely care/services to ensure a medical procedure was completed. This affected one (#9) of three residents reviewed for outside medical appointments. The census was 83. Residents Affected - Few Findings Include: Resident #9 was admitted to the facility on [DATE]. His diagnoses were rhabdomylosis, congestive heart failure, alcohol dependence, alcoholic hepatitis, alcohol abuse, hepatic encephalopathy, dementia, depression, hypertension, and tobacco use. Review of Resident #9's minimum data set (MDS) assessment, dated 10/29/24, revealed he had a mild cognitive impairment. Review of Resident #9's Central Appointment Communication Sheet, dated 10/18/24, revealed he was to have an orthopedic appointment on 11/20/24. Handwritten on this form, it stated, rescheduled per [physician], awaiting cardiac clearance. There was no date as to when this order was given by the physician. Also, there were no progress notes in his medical record to support this appointment was scheduled, why it needed to be rescheduled, when it was to be rescheduled for, and when the appointment to get cardiac clearance was to be completed. Also, there was no documentation to support/confirm this was cardiac clearance or dental clearance. Review of Resident #9 Dental Clearance form, dated 10/31/24, revealed the original documented date for his hip surgery was scheduled for 11/25/24. However, Resident #9 did not receive dental clearance until 12/04/24. Review of Resident #9 progress notes, dated 10/15/24 to 11/25/24, revealed no documentation to support whether Resident #9 had his hip surgery completed as scheduled on 11/25/24. Additionally, there was no documentation to support the reason why, or documentation to support when the surgery was rescheduled for. Review of Resident #9 Central Appointment Communication Sheet, dated 11/27/24, revealed he was to have an appointment on 12/02/24 regarding laboratory and scan work to be completed. Review of his medical record found no evidence this appointment was completed. Review of Resident #9 medical records found no evidence that his total hip replacement surgery was scheduled for 12/09/24. Review of facility transportation communication log, dated December 2024, revealed Resident #9 was transportation was scheduled for a surgery to be completed on 12/09/24. There was no documentation to support whether this surgery was completed. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 366122 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 366122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Mary Scott 3109 Campus Dr Dayton, OH 45406 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)