Complaint Investigation

Carecore At Mary Scott

April 30, 2026 · Dayton, OH · 3109 Campus Dr

Citations 1

CMS Rating 3/5

Beds 102

Provider ID 366122

Healthcare Facility

Carecore At Mary Scott

Dayton, OH · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

CARECORE AT MARY SCOTT in DAYTON, OH — inspection on April 30, 2026.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0689

Quality of Life and Care Deficiencies

Review of the Annual Minimum Data Set (MDS), dated [DATE] revealed Resident #59 was cognitively intact with a brief interview mental status (BIMS) of 15 out of

Review of the care plan, dated 06/20/18 revealed Resident #59 was at risk for injury related to elopement, not a wanderer, unsatisfied with guardian placement, has intent to leave facility, and Schizophrenia, with interventions of update boundaries, mental status and guardian guidance/consent.

Guardian sometimes gives permission for resident to sign self out.

Review of the Amended Letters of Guardianship, dated 06/09/22 revealed Resident #59 was deemed incompetent and a legal guardian was in place over person only through the probate court of [NAME] county, Ohio.

Review of the Release of Responsibility for Leave of Absence form, revealed between 12/26/25 and 04/20/26 Resident #59 signed herself out and went on unsupervised LOA's from the facility 159 times.

Interview on 04/28/26 at 10:34 A.M. with Resident #59's guardian confirmed she has asked the facility Director of Nursing (DON) and the Administrator for months to not let Resident #59 leave the facility unsupervised due to the resident having Schizophrenia and is not taking her medications.

Interview with Resident #59's guardian also confirmed despite the request the facility allows Resident #59 to go on unsupervised LOA's and she has seen the resident downtown at a bus stop punching people and at the bread store.

Interview on 04/28/26 at 2:26 P.M. with Regional Director of Clinical Operations (RDCO) #209 confirmed the facility has allowed Resident #59 to leave the facility unsupervised on a daily based because the resident has a BIMS of a 15, cognitively intact and because she has rights, Interview with RDCO #209 also confirmed Resident #59 has a guardian who has voiced she does not want the resident to go on LOA's.

Interview on 04/28/26 at 3:42 P.M. with Administrator and the DON confirmed they have allowed Resident #59 to leave the facility unsupervised on a daily basis, even though the guardian informed the facility to not let the resident leave.

Interview with the Administrator and DON confirmed they allowed Resident #59 to leave on her own because of resident rights and resident has a BIMS of 15, which means she is cognitively intact.

Interview with the Administrator and DON also confirmed that the facility has filed with the courts on resident's behalf for a new guardian.

This deficiency represents non-compliance investigated under Complaint Number 2983488.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DAYTON, OH, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CARECORE AT MARY SCOTT or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.