CareCore at Mary Scott: Opioid Theft Unreported - OH
That same night, the overnight nurse called the Director of Nursing at home. The medication looked wrong, she said. It was lighter in color than it should be, thinner in consistency. The seal had been broken on arrival. There was no prescription paperwork. Questions were circulating among staff about who had changed the dosage and where the script even was.
Nothing happened.
Eight days later, on June 20, police arrived at the facility. The daughter had filed a report: her mother's oxycodone had been stolen. A licensed practical nurse told the officers the medication wasn't missing at all — it was secured in a lock box. The officers left.
The Director of Nursing later confirmed to inspectors that the facility never reported the allegation to the Ohio Department of Health. The reason given: they believed the medication count was accurate, so there was nothing to report.
A review of the state's ODH Gateway Application found no self-reported incident on file for the resident, identified in the inspection report as Resident #79, related to any allegation of misappropriation of her medication.
Resident #79 was admitted to CareCore at Mary Scott on March 5, 2025, with a constellation of serious diagnoses, including osteomyelitis, a tracheostomy, a history of laryngeal cancer, and a respiratory system neoplasm. She did not eat by mouth. She was cognitively intact and independent with her daily activities. On June 30, a physician order was entered for the liquid oxycodone — 20 milliliters via G-tube every three hours as needed for pain.
The timeline reconstructed by the facility itself shows the warning signs stacked up quickly. The bottle arrived June 12 with a broken seal and no paperwork. By June 13, the overnight nurse was calling the DON at home to describe medication that looked physically altered. By June 20, police were on the property because the family believed a theft had occurred.
The facility's own controlled substances policy, dated November 2022, required that medications be counted upon delivery, with both the receiving nurse and the person delivering the medication counting together and both signing the controlled substance record. The Narcotic Administration Sheet showed 250 milliliters signed in on June 12. It contained no notation that the seal was broken when the bottle arrived. There were no doses documented as administered.
The DON confirmed to inspectors on August 12 that staff did not verify with the daughter how much oxycodone had been in the bottle before she brought it in. There was no baseline count. There was no way to know, at intake, whether anything had already been removed.
The inspection, conducted as a complaint investigation, cited the facility for failing to report an allegation of misappropriation to the state agency. The level of harm was assessed as minimal harm or potential for actual harm, and the finding affected one resident out of three reviewed for misappropriation issues.
What the inspection record does not resolve is what the overnight nurse saw when she described medication that looked light and thin. It does not say whether anyone tested the contents of that bottle, or whether the oxycodone Resident #79 received for her pain in the weeks that followed was what it was supposed to be. The facility's position, that the count was accurate and therefore no report was required, answers a narrow question about quantity. It does not answer the nurse's question from the night of June 13, which was about what was actually in the bottle.
Resident #79 was cognitively intact throughout. She knew what was happening around her.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carecore At Mary Scott from 2025-08-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 4, 2026 · Our methodology
CARECORE AT MARY SCOTT in DAYTON, OH was cited for violations during a health inspection on August 12, 2025.
That same night, the overnight nurse called the Director of Nursing at home.
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.