Health inspection·August 12, 2025

F 0610 Respond appropriately to all alleged violations. 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, staff interviews, review of the Ohio Department of Health (ODH) Gateway Application, review of a facility timeline, review of a Narcotic Administration Sheet and policy review, the facility failed to report an allegation of misappropriation to the State Agency. This affected one (#79) out of three residents reviewed for misappropriation. The facility census was 77. Findings include: Review of the medical record for Resident #79 revealed an admission date of 03/05/25 with diagnoses of osteomyelitis, type 2 diabetes mellitus without complications, neoplasm of unspecified behavior of respiratory system, retropharyngeal and parapharyngeal abscess, personal history of malignant neoplasm of larynx, and tracheostomy status. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact, did not eat anything by mouth, and was independent with all activities of daily living. Review of the physician orders revealed an order dated 06/30/25 for Oxycodone Oral Solution 5 milligrams (mg)/5 milliliters (ml), give 20 ml via G-Tube every three hours as needed for pain. Interview on 08/12/25 at 11:52 A.M. with the Director of Nursing (DON) confirmed the facility accepted the liquid Oxycodone from Resident #79's daughter on 06/12/25, and the staff did not verify with the daughter the amount of oxycodone that was remaining in the bottle. Interview with the DON also confirmed on 06/20/25 the daughter reported someone had stolen Resident #79's oxycodone and called the police. Interview confirmed the facility did not report the allegation to the State Agency and accusation of theft for Resident #79 because they knew the medication was accurate. Review of the ODH Gateway Application revealed there was no self-reported incident (SRI) involving an allegation of misappropriation of medication for Resident #79. Review of a facility timeline for Resident #79 investigation revealed on 06/12/25 Resident #79's daughter had brought in a bottle of Oxycodone. Facility staff reported they couldn't accept the bottle. Resident #79 and the family were escorted to the medication cart by Licensed Practical Nurse (LPN) #294. On 06/13/25 the 7:00 P.M. to 7:00 A.M. nurse called the DON at home and stated that Resident #79's medication appeared suspicious, she described it as being light in color and appeared thin. Nurse also stated it was reported that seal was not intact when Resident #79's daughter delivered the medication. There were also questions regarding where the script was and who changed the dosage. There was no paperwork reportedly turned in by the family or resident. On 06/20/25 the police arrived at the facility on Resident #79 due to daughter making a report on missing oxycodone. LPN #294 informed police oxycodone was not missing, it was in a lock box. Review of the Narcotic Administration Sheet revealed on 06/12/25, 250 ml of Oxycodone was signed in. The Narcotic Administration Sheet does not contain any documentation that the seal was broke when the medication was received. There was not any doses documents as administered. Review of the Controlled Substances policy dated November 2022 revealed controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together, and that both individuals sign the designated controlled substance record. This deficiency Residents Affected - Few (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 3 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 08/12/2025 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)