CareCore at Mary Scott: Trach Supply Failures - OH
A federal complaint inspection on August 12, 2025 found the facility had failed to keep a backup tracheostomy tube available for Resident 77, a patient with anoxic brain damage, epilepsy, chronic obstructive pulmonary disease, and acute on chronic systolic heart failure. The resident, who has been at the facility since March 2023, is cognitively impaired and entirely dependent on staff for every activity of daily living.
The care plan written the day after admission was direct: keep an extra trach tube and obturator at the bedside. If the tube is coughed out, attempt to reinsert it. A physician order from January 2025 called for trach care every day shift. A more recent order, dated August 11, spelled out the exact equipment required, down to the model number.
None of it was there.
At 7:20 in the morning on inspection day, Licensed Practical Nurse 234 confirmed to inspectors that no spare tracheostomy tube was available if the resident's current one became dislodged. The nurse went further, telling inspectors the facility does not always have the trach supplies that Resident 77 needs.
That admission, offered without apparent alarm, is its own kind of finding.
When the LPN Unit Manager, identified as LPN 294, learned inspectors were asking questions, she arrived at the room carrying a tracheostomy tube, placing it at the resident's bedside as the interview was underway. She said it was the tube Resident 77 used.
It was not. The tube she brought had a cuff. Resident 77 does not have a cuffed tracheostomy. There was no physician's order for a cuffed tracheostomy. The unit manager confirmed both facts herself during the same conversation.
The difference is not trivial. A cuffed trach tube seals the airway differently than an uncuffed one and is used for different clinical purposes. Inserting the wrong type in an emergency, on a patient with anoxic brain damage who cannot communicate distress or self-advocate in any way, is not a safe fallback. It is a different problem layered on top of the original one.
The facility's own tracheostomy care policy, updated as recently as January 10, 2025, states that a replacement trach tube must be available at the bedside at all times. The policy existed. The order existed. The care plan existed. The supply did not.
CMS rated the violation at the level of minimal harm or potential for actual harm. One resident was reviewed for trach care and found to have this gap. The facility census at the time of inspection was 77 residents.
What the inspection captures is a particular kind of institutional failure, one that does not require a single catastrophic event to be serious. Resident 77 has not, as far as the inspection report documents, suffered a trach dislodgement without a spare on hand. The harm here is the sustained exposure, the accumulated shifts during which the backup was simply absent, the nurse who said the supplies are not always there as though that were an acceptable feature of the situation rather than the problem itself.
The unit manager's response when inspectors arrived, rushing in with a replacement tube that turned out to be the wrong one, suggests a facility moving to correct the appearance of a deficiency rather than the deficiency itself.
Resident 77 cannot speak for the situation. The record speaks instead: brain-damaged, dependent on staff for everything, breathing through a tube, and relying on a facility that acknowledged it does not always have what that tube requires.
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.
Download the official CMS inspection PDF from Medicare.gov
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.
The resident, who has been at the facility since March 2023, is cognitively impaired and entirely dependent on staff for every activity of daily living.
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.