Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sycamore Trails Post Acute during CMS and state inspections, most recent first.
The facility failed to administer medications timely, affecting four residents. A resident with Alzheimer's received morning meds late, while another with DM II and CHF faced delays due to staffing. A third resident missed Morphine doses, and a fourth with bipolar disorder did not receive Oxycodone for over a week. The facility's policy requires timely administration, but this was not followed.
A resident with severe cognitive impairment and multiple diagnoses was affected by medication administration errors, resulting in a 5.4% error rate. An LPN crushed and administered Potassium Chloride ER, contrary to guidelines, and failed to administer K-Phosphate due to missing packaging. The errors were confirmed through interviews and observations.
A facility failed to administer medications per physician orders and maintain proper Controlled Drug Records (CDR) for a resident with multiple health conditions. The MAR showed missed doses of Ativan, Clindamycin, Methocarbamol, and Dilaudid, with discrepancies in the CDR for Lorazepam and missing records for Dilaudid. The DON confirmed these issues, noting the responsible nurse was no longer employed, and the facility's policy on medication documentation was not followed.
A CNA failed to perform proper hand hygiene after providing incontinence care to a resident with moderate cognitive impairment. Despite following initial procedures, the CNA did not remove gloves or wash hands before handling clean linens and the resident's TV remote, contrary to facility policy. This deficiency was noted during a complaint investigation.
A resident with multiple diagnoses, including schizoaffective disorder, was affected by the facility's failure to discontinue a previous 10 mg dose of Olanzapine when the dose was increased to 20 mg, resulting in a total of 30 mg being administered. This was confirmed by the Clinical Services Manager, contrary to the facility's policy requiring psychotropic medications to be prescribed at the lowest possible dosage.
A resident was left with medications at their bedside, including Tylenol, gabapentin, Clindamycin, and Oxycodone, without being observed taking them. The nurse admitted to leaving the medications, and the facility's policy requiring observation was not followed.
A resident with intact cognition and requiring supervision for daily activities did not receive the prescribed antibiotic, Imipenem-Cilastatin, due to a pharmacy error. The medication was ordered intramuscularly but was not delivered, and the administration record showed missed doses. The pharmacist noted the order was flagged as a duplicate due to a previous intravenous order, leading to the prescription being profiled but not filled.
A resident with multiple health conditions, including left hemiplegia and brain cancer, fell out of bed during a bed bath due to inadequate staff assistance. The STNA providing care was alone and unable to prevent the fall when the resident attempted to scratch his back, resulting in a forehead laceration. The facility's policy on fall prevention was not adequately followed, contributing to the incident.
A resident with multiple medical conditions was found with a medication cup containing tablets on their bedside table, which they had not taken. The facility's policy requires staff to observe residents consuming medications, but this was not done. The ADON confirmed the medications were prescribed for earlier administration.
The facility failed to ensure the activities program was directed by a qualified professional, affecting all 79 residents. The Activity Director was promoted from a housekeeper position without the necessary training or education. Despite performing various duties, the AD confirmed the lack of formal qualifications. A Senior Social Worker provided guidance and audits but acknowledged the AD's lack of qualification. This deficiency was identified during a complaint investigation.
The facility failed to provide meals per resident choice and the planned menu, affecting three residents and potentially impacting 78 residents. Observations revealed discrepancies between meal tickets and served meals, and the facility was out of milk, leading to unapproved menu changes without consulting the dietician.
The facility failed to prevent residents from possessing illegal drugs and did not provide adequate supervision during meals. One resident with a history of substance abuse was found with fentanyl, another resident was given a pain pill by a fellow resident, and a third resident with severe cognitive impairment was left unsupervised during meals.
The facility failed to update the care plan for a resident with a history of substance abuse, despite finding illegal substances and a critical incident requiring Narcan. The care plan did not include interventions for substance abuse risk.
The facility failed to follow treatment orders for a resident with a left below knee amputation, resulting in missed daily dressing changes. Despite clear physician orders and the resident's care plan, the dressing was not changed as required, leading to non-compliance identified during a complaint investigation.
The facility failed to administer medications as ordered by the physician for two residents. One resident did not receive Estrogens Conjugated Vaginal Cream on multiple occasions due to staff being unaware of its location. Another resident did not receive a newly prescribed antibiotic, Doxycycline, in a timely manner despite its availability in the facility's pyxis.
The facility failed to administer physician-ordered medications and ensure timely ordering and availability, affecting four residents. Medications were frequently not administered or documented as not available, indicating systemic issues with medication management.
Medication Administration Delays and Omissions
Penalty
Summary
The facility failed to administer medications in a timely manner, affecting four residents. Resident #29, diagnosed with Alzheimer's disease, COPD, and DM II, received morning medications after 12:00 P.M. instead of the scheduled time. Resident #73, with DM II, CHF, and chronic kidney disease, did not receive morning medications until after 12:00 P.M. due to staffing issues, as confirmed by the Assistant Director of Nursing. Resident #10, suffering from COPD, anxiety, depression, and convulsions, did not receive prescribed doses of Morphine Sulfate ER from 12/14/24 to 12/16/24, as verified by the Regional Nurse. Resident #44, diagnosed with bipolar disorder, ADHD, and peripheral vascular disease, did not receive Oxycodone from 11/28/24 to 12/06/24 due to unavailability, as confirmed by RN #80. The facility's policy on administering medications, revised in April 2019, mandates that medications be administered in a safe and timely manner as prescribed. However, observations and interviews revealed that the facility did not adhere to this policy, resulting in delayed or missed medication administration for the affected residents. The deficiency was investigated under Complaint Number OH00160232, highlighting non-compliance with the facility's own medication administration policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders, resulting in a medication error rate of 5.4 percent. This deficiency was identified during a review of medical records, observations, interviews, and policy reviews. Specifically, Resident #14, who has severe cognitive impairment and multiple diagnoses including Alzheimer's disease, type two Diabetes Mellitus, and atrial fibrillation, was affected. The resident was prescribed K-Phos Oral tablet 500 mg to be administered as 250 mg three times a day and Potassium Chloride 20 mEq Extended-Release to be given once daily. On the observed date, an LPN crushed the Potassium Chloride ER 20 mEq and administered it to the resident, which is against the guidelines as extended-release tablets should not be crushed. Additionally, the K-Phosphate was not administered because the packaging did not contain a dose. The LPN confirmed these actions during an interview, and the Regional Nurse verified that extended-release potassium should not be crushed. This incident was part of a complaint investigation, indicating non-compliance with medication administration protocols.
Medication Administration and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to administer medications according to physician orders and did not maintain proper Controlled Drug Records (CDR) for a resident. The resident, who was cognitively intact, had multiple diagnoses including chronic obstructive pulmonary disease, breast cancer, major depressive disorder, and bone cancer. The Medication Administration Record (MAR) showed that several medications, including Ativan, Clindamycin, Methocarbamol, and Dilaudid, were not administered on multiple occasions throughout October. Additionally, the CDR for Lorazepam indicated that doses were signed out but not documented as administered in the MAR, and there was no CDR for Dilaudid. The Director of Nursing confirmed the discrepancies and noted that the nurse responsible for those shifts was no longer employed, preventing further information gathering. The facility's policy requires that medication administration be recorded immediately after administration and reviewed at the end of each medication pass. The failure to adhere to these guidelines resulted in the identified deficiencies, as confirmed by the Director of Nursing during the investigation.
Inadequate Hand Hygiene After Incontinence Care
Penalty
Summary
The facility failed to ensure appropriate hand hygiene was performed following incontinence care for a resident. During an observation, a CNA was seen providing incontinence care to a resident with moderate cognitive impairment and multiple diagnoses, including idiopathic aseptic necrosis of the right femur and major depressive disorder. The CNA followed proper procedures initially by washing hands, applying gloves, and using clean wipes for each swipe while cleaning the resident's peri-area and sacrum/coccyx area. However, after completing the incontinence care, the CNA did not remove the gloves or perform hand hygiene before continuing to handle clean linens, the resident's TV remote, and the bed remote. The CNA admitted during an interview that she did not remove her gloves or perform hand hygiene after the incontinence care, as she believed there was no cross-contamination. This action was contrary to the facility's policy on incontinence care, which requires removing gloves and washing hands after washing all soiled skin areas. The deficiency was identified during a complaint investigation, highlighting a lapse in following infection prevention and control protocols.
Failure to Discontinue Previous Dose of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary psychotropic medications by not maintaining the lowest ordered dose of an antipsychotic medication. A resident with diagnoses including cerebral palsy, schizoid disorder, anxiety disorder, depression, and pseudobulbar affect was affected. The resident was cognitively intact according to a quarterly Minimum Data Set. The physician initially ordered Olanzapine 10 mg to be administered at bedtime for schizoaffective disorder. However, an outpatient psychiatry note indicated an increase to 20 mg due to auditory verbal hallucinations. Despite the order to increase Olanzapine to 20 mg, the resident continued to receive both the 10 mg and 20 mg doses at bedtime, resulting in a total of 30 mg being administered. This error was confirmed by the Clinical Services Manager, who acknowledged that the 10 mg dose should have been discontinued when the 20 mg dose was ordered. The facility's policy on chemical restraint use mandates that psychotropic medications be prescribed at the lowest possible dosage for the shortest period and are subject to gradual dose reduction and re-review. This oversight was identified during an investigation under Complaint Number OH00157578.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly administered to residents, as evidenced by an incident involving a resident who was left with medications at their bedside. The resident, who was cognitively intact and had a medical history including a displaced comminuted fracture of the left tibia, injury of the popliteal artery, comminuted fracture of the left fibula, and asthma, was observed with five pills in a medication cup on their bedside table. The resident confirmed that the nurse had left the medications for them to take on their own. The nurse, identified as RN #100, admitted to leaving the medications, which included Tylenol, gabapentin, Clindamycin, and Oxycodone, at the resident's bedside without observing the resident take them. This was confirmed by the Clinical Services Managers, who acknowledged that the nurse should have observed the resident taking the medications. The facility's policy requires that residents be observed after medication administration to ensure the dose is completely ingested, which was not followed in this case. The incident was investigated under Complaint Number OH00157578.
Significant Medication Error Due to Unfilled Antibiotic Order
Penalty
Summary
The facility failed to ensure that antibiotics were administered as ordered by the physician, resulting in a significant medication error for a resident. The resident, who had intact cognition and required supervision for daily activities, was prescribed Imipenem-Cilastatin to be administered intramuscularly four times daily. However, the medication was not delivered by the pharmacy, and the administration record showed that the doses were not given as scheduled. The issue was discovered by a registered nurse who contacted the pharmacy, only to find out that the medication order had not been filled or sent out. Further investigation revealed that the ordered route for the medication was no longer available, and the medication could be administered intravenously instead. The pharmacist explained that the system had flagged the order as a duplicate because the resident had a previous order for the same medication intravenously before a recent hospitalization. As a result, the prescription was profiled but not filled. This oversight led to the resident not receiving the prescribed antibiotic treatment as ordered, constituting a significant medication error.
Inadequate Supervision During Bed Bath Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate staff assistance during a bed bath, resulting in an avoidable fall for Resident #70. The resident, who was cognitively intact and dependent on staff for bathing, toileting, hygiene, and transfers, was at high risk for falls due to conditions including diabetes mellitus, malignant neoplasm of the brain, left hemiplegia, depression, and obesity. On the day of the incident, State tested Nursing Assistant (STNA) #275 was providing a bed bath to Resident #70 and rolled the resident onto his left side to wash his back. During this process, the resident attempted to scratch his back, lost balance, and rolled out of bed onto the floor, resulting in a forehead laceration that required a suture. The incident was documented in a nurse progress note, which stated that STNA #275 notified Licensed Practical Nurse (LPN) #205 of the fall. Upon entering the room, LPN #205 found Resident #70 lying prone with a laceration to the left eyebrow and a puddle of bright red drainage pooling under his face and head. The resident was transported to the Emergency Department (ED) for evaluation and treatment. An Interdisciplinary Team (IDT) meeting was held to review the fall, and it was noted that the environment was well-lit and free from debris prior to the fall. The resident reported that he reached his arm around to scratch his back, which led to the fall. Interviews with the Director of Nursing (DON) and STNA #275 confirmed the details of the incident. The DON stated that the level of care required for Resident #70 varied from day to day due to his brain cancer. STNA #275 confirmed that she was the only staff member present during the bed bath and that Resident #70's bed did not have grab bars. She believed that the resident required two-person assistance for bathing due to balance difficulties and recent health decline. The facility's policy on fall prevention was reviewed, which indicated that staff should identify individuals at risk for falls and implement pertinent interventions to prevent such incidents.
Failure to Observe Medication Administration
Penalty
Summary
The facility failed to ensure that staff observed a resident consume medications, which is a violation of their medication administration policy. The incident involved a resident who was admitted with medical diagnoses including urinary tract infection, sepsis, diabetes mellitus, hypothyroidism, and congestive heart failure. The resident was cognitively intact but required substantial assistance with daily activities. Physician orders for the resident included hydralazine and levothyroxine, which were to be administered at specific times. During an observation, a medication cup containing two tablets was found on the resident's bedside table, and the resident stated that the nurse had brought the medications earlier, but he had not taken them yet. The resident was unaware of what medications were in the cup. The Assistant Director of Nursing confirmed the presence of the medications and identified them as those prescribed for administration at 6:00 A.M. The facility's policy requires that medications be administered as prescribed and that residents be observed to ensure the dose is ingested, which was not followed in this case.
Unqualified Activity Director in Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, affecting all 79 residents. The personnel record review revealed that the Activity Director (AD) was initially hired as a housekeeper and later promoted to the position of Activity Director without the necessary training or education. The AD confirmed that she had not received any formal education or training to qualify for the role, despite performing duties such as completing resident assessments, care plans, attending care conferences, conducting Resident Council meetings, and preparing the monthly activity calendar. Interviews with the AD and the Senior Social Worker (SSW) further confirmed the deficiency. The SSW, a regional employee who assisted the AD, stated that she provided monthly guidance and conducted random audits of resident activity documentation and charts. Despite this support, the SSW acknowledged that the AD was not qualified for the position. The deficiency was identified during a complaint investigation, highlighting the facility's failure to ensure the activities program was led by a qualified individual.
Failure to Provide Meals Per Resident Choice and Planned Menu
Penalty
Summary
The facility failed to provide meals per resident choice and per the facility planned menu, affecting three residents and potentially impacting 78 residents who receive their meals from the facility. On the morning of 05/13/24, the breakfast trays for three residents did not match the posted menu or the residents' meal tickets. For instance, one resident received bacon and toast instead of cold cereal and a bagel, while another resident did not receive the cereal they had ordered. The facility was out of milk that morning, leading to unapproved menu changes without consulting the dietician. Further observations on 05/14/24 revealed that a resident's lunch tray did not include the requested cheeseburger, extra lemonade, and vegetable soup. The Dietary Manager confirmed that the kitchen was out of vegetable soup and acknowledged that staff did not inform her of the resident's alternative requests. The Dietary Manager also admitted that the dietician was not contacted prior to making breakfast meal substitutions. This deficiency was investigated under Complaint Number OH00153743.
Failure to Prevent Drug Possession and Ensure Supervision
Penalty
Summary
The facility failed to provide adequate intervention and supervision to ensure residents did not possess illegal drugs and/or drugs not prescribed to them. Resident #54, who had a history of cocaine abuse and was admitted to hospice, was found with a vape pen and later a plastic baggie with an unknown substance, which was later confirmed to be fentanyl. Despite multiple incidents and drug screenings, there was no care plan related to illegal drug use for Resident #54. The facility staff were aware of the situation but did not take sufficient action to prevent further occurrences or ensure the resident's safety, including contacting the Ombudsman for assistance with alternative placement options. Resident #47, who had intact cognition, was given a pain pill by another resident, Resident #74, who was found with Percocet and other loose pills in her purse. The facility staff monitored Resident #47's vitals for 24 hours following the incident, but there was no indication of any adverse effects. The facility failed to prevent the distribution of medication between residents, which posed a significant risk to their health and safety. Resident #27, who had severe cognitive impairment and required supervision for eating due to dystonia, was observed feeding himself without any staff supervision on multiple occasions. This lack of supervision was due to a miscommunication between the aides assigned to his care. The facility's failure to implement the care plan for Resident #27's risk of aspiration and ensure adequate supervision during meals put the resident at risk of choking or other complications related to his condition.
Failure to Update Care Plan for Substance Abuse
Penalty
Summary
The facility failed to update the care plan for a resident to include their possession and suspected use of illegal substances. Resident #54, who had a history of cocaine abuse and was admitted to hospice, was found with a plastic baggie containing an unknown substance on the floor next to their bed. Despite the discovery and subsequent confirmation that the substance tested positive for fentanyl, the resident's care plan did not include any interventions related to illegal drug use or substance abuse risk. This deficiency was identified during a review of the resident's medical records and staff interviews. On a separate occasion, Resident #54 was found unresponsive with periods of apnea and agonal breathing, requiring the administration of Narcan, which revived the resident within 15 minutes. Despite these critical incidents, the facility did not update the care plan to address the resident's substance abuse issues. Interviews with the Clinical Registered Nurse confirmed that there was no care plan in place regarding the possession of and/or risk of substance abuse for Resident #54.
Failure to Follow Treatment Orders for Resident
Penalty
Summary
The facility failed to ensure treatment orders were completed as ordered for Resident #55, who was admitted with diagnoses including congestive heart failure, type two diabetes mellitus, depression, and a recent left below knee amputation. The resident's care plan included specific instructions for daily dressing changes to the surgical site, which were not followed. On 05/13/24, the resident expressed concern that his dressing had not been changed the previous day. An observation of the dressing change by the Assistant Director of Nursing (ADON) confirmed that the dressing was last changed on 05/11/24, indicating non-compliance with the physician's daily dressing change order. The deficiency was identified during a review of the medical record, staff and resident interviews, and direct observation. The resident's admission Minimum Data Set (MDS) indicated intact cognition and required extensive assistance for various activities. Despite the clear physician orders and care plan interventions, the facility did not perform the daily dressing changes as required, leading to a lapse in the resident's care. This deficiency was investigated under Complaint Numbers OH00153893 and OH00153743.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician, affecting two residents. Resident #134, who has diagnoses including paraplegia, schizophrenia, depression, and anxiety, did not receive Estrogens Conjugated Vaginal Cream on multiple occasions because it was reportedly unavailable. However, interviews with pharmacy staff revealed that the medication had been delivered to the facility on the specified dates. The Director of Nursing acknowledged that agency staff might have been unaware of the medication's location, leading to its non-administration as ordered. Resident #55, who has diagnoses including congestive heart failure, type two diabetes mellitus, and depression, did not receive a newly prescribed antibiotic, Doxycycline, in a timely manner. Although the medication was available in the facility's pyxis, it was not administered until the evening shift, despite being ordered in the morning. Interviews with the physician and pharmacist confirmed that the medication was readily available and should have been administered sooner. This deficiency represents ongoing noncompliance from a previous survey.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer physician-ordered medications and ensure medications were timely ordered and available for administration. This deficiency affected four residents, who experienced missed or delayed doses of critical medications. For instance, Resident #21 did not receive multiple medications on specific dates due to unavailability or lack of timely ordering, including Oxcarbazepine, Pepcid, and doxycycline monohydrate, among others. The MAR revealed several instances where medications were not signed off as administered or were documented as not available or on order. Resident #41 also experienced similar issues, with multiple medications not documented as given or marked as not available. These included Pentosan Polysulfate Sodium, buspirone, Insulin Lispro, and Nucynta, among others. The MAR for March and April 2024 showed numerous instances where medications were either not administered or not documented as given, indicating a systemic issue with medication management and availability. Resident #58 and Resident #63 faced inconsistencies in medication administration times and missed doses. Resident #58's medications, such as Depakote and levetiracetam, were not administered consistently or at the prescribed times. Similarly, Resident #63 had multiple medications, including Miralax, Nifedipine ER, and Lunesta, documented as not available or not administered. Interviews with nursing staff revealed that the facility frequently ran out of stock medications, and there was a lack of timely reordering, contributing to the ongoing issue of medication unavailability.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Miamisburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sycamorespring Of Miamisburg | 0.6 mi | ★★★★★ | 3 | 0 |
| Laurels Of West Carrollton The | 1.2 mi | ★★★★★ | 18 | 0 |
| Wood Glen Alzheimer's Community | 1.3 mi | ★★★★★ | 16 | 0 |
| Vienna Springs Health Campus | 1.9 mi | ★★★★★ | 1 | 0 |
| Kingston Of Miamisburg | 2.5 mi | ★★★★★ | 7 | 0 |
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