Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Sycamorespring Of Miamisburg during CMS and state inspections, most recent first.
Medication error rate exceeded the allowed threshold after surveyors found three errors in 33 medication opportunities, resulting in a 9.09% error rate. An LPN did not give a resident Flonase nasal spray because it was not available, and an RN did not administer fluorometholone eye drops and Refresh eye drops to another resident because those medications were also not available. Facility policy stated medications were to be given per physician orders.
A resident with a g-tube and cognitive impairment was on EBP per the care plan, but an RN administered meds via the g-tube without donning a gown. The RN confirmed the resident was on EBP due to the g-tube, and the facility policy required gown and gloves for residents with feeding tubes during high-contact care.
A resident with severe cognitive impairment and dependence on staff for transfers was allowed to attempt a wheelchair-to-bed transfer while staff stood by, resulting in the resident slipping to the floor between the bed and wheelchair without hands-on assistance. Staff then lifted the resident back to bed without notifying an RN, documenting the fall, or informing the physician or responsible party, contrary to the care plan and facility policy. Over the following days, the resident experienced increasing pain and swelling of the left leg, which the family noticed; after reviewing the room camera footage, the family reported the fall to the facility and requested imaging. X‑rays subsequently showed a minimally displaced distal femur fracture, and the resident was transferred to the hospital for evaluation and nonoperative management.
A facility failed to issue a 30-day discharge notice for a resident transitioning from Medicare Part A to private pay. The resident, with multiple medical conditions and cognitive impairment, required significant assistance. The resident's family was informed of the need for Medicaid application, but due to the lack of a power of attorney, the process was delayed. The facility had no long-term care beds available, and the family chose to take the resident home. The facility's policy allows for transfers even with a pending Medicaid application, but the absence of a discharge notice led to the deficiency.
A facility failed to document wound care for a resident with multiple medical conditions, including an unstageable pressure ulcer. Despite staff confirming daily wound care was performed, the November records lacked documentation from the 1st to the 11th. The DON admitted the treatment order was not correctly entered into the EHR, but staff were aware of the need for daily care. This deficiency was investigated under a complaint.
A facility failed to ensure proper hand hygiene and enhanced barrier precautions during incontinence care for a resident with an indwelling urinary catheter. An STNA did not don a gown and used the same soiled gloves to clean a bowel movement and then apply clean linens and a dry incontinence brief, violating the facility's hand hygiene and infection control policies.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. Based on medical record review, observation, staff interview, and review of facility policy, surveyors identified three medication errors over 33 medication opportunities, resulting in a 9.09% medication error rate. The deficiency affected two of the three residents observed for medication administration, and the facility census was 93 residents. For one resident with diagnoses including peripheral vascular disease, atrial fibrillation, and dysphagia, the physician ordered Flonase nasal spray once daily, but an LPN did not administer it because the medication was not available. For another resident with diagnoses including schizoaffective disorder, major depressive disorder, and convulsions, orders were in place for fluorometholone eye drops twice daily and Refresh eye drops twice daily, but an RN did not administer either medication because the drops were not available. The facility policy stated that patients would be given medications per physician orders and that if there were issues with physician orders, the nurse would contact the physician for clarification.
Failure to Follow Enhanced Barrier Precautions During G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were followed during medication administration for one resident. Resident #3 was admitted with diagnoses including schizoaffective disorder, major depressive disorder, and convulsions, and the MDS indicated the resident was cognitively impaired and dependent with ADLs. The care plan stated the resident required tube feeding related to an anoxic brain injury and that staff were to maintain EBP because of the presence of a gastrostomy tube. During observation, an RN administered medications via the resident’s g-tube without donning a gown before the procedure. When interviewed shortly afterward, the RN confirmed the resident was on EBP due to the g-tube and acknowledged that she had not donned a gown prior to administering the medications. The facility policy identified EBP as an infection control intervention requiring gown and gloves during high-contact resident care activities and indicated EBP for residents with indwelling medical devices including feeding tubes.
Unassisted Transfer, Unreported Fall, and Delayed Identification of Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance during a transfer and to timely report and assess a fall, resulting in actual harm to a resident. The resident had vascular dementia with behavioral disturbance, a history of left femur fracture, and major depressive disorder, and was assessed as having severe cognitive impairment and being dependent on staff for all transfers. The resident’s care plan identified a risk for falls related to impaired mobility and required staff assistance with transfers, repositioning, and mobility, as well as notification of the physician and responsible party for all falls. On the evening in question, two CNAs were involved in transferring the resident from a wheelchair to the bed. According to a late-entry nursing note and CNA witness statements, the resident was being pivoted or transferred to the bed when she slipped or slid off the edge of the bed and ended up on the floor. Another CNA reported entering the room and finding the resident on the floor sitting by the bed, then assisting with lifting the resident back into bed and repositioning her with a draw sheet. The RN assigned to the resident that night stated she was not notified of any incident involving the resident. No fall was documented at that time, and the physician and responsible party were not notified as required by the care plan and the facility’s fall and accident management policy. A video recording from the resident’s room showed the resident in a wheelchair near the bed with a female employee at the wheelchair handles and a male employee standing about three feet away. The resident placed her left arm on the bed and appeared to be attempting to transfer herself while staff stood by. The video showed the resident slipping down between the bed and the wheelchair, with no staff attempting to assist her before the fall. After the fall, the male employee briefly reached under the resident’s arms, then stepped away, and the female employee left the room; another male employee later entered and assisted in transferring the resident back to bed. The fall was not reported to facility leadership until days later, when the resident’s family member, who had observed the incident on the room camera and noted the resident’s increasing pain and swelling of the left knee, contacted the facility and requested x‑rays. Subsequent imaging revealed a minimally displaced fracture of the left distal femur, and the resident was sent to the hospital for evaluation and treatment, where nonoperative management was chosen after discussion with the family.
Failure to Issue 30-Day Discharge Notice for Resident Transitioning to Private Pay
Penalty
Summary
The facility failed to ensure a resident was permitted to stay once their payer source changed from Medicare Part A to private pay. The resident, who had medical diagnoses including nontraumatic subarachnoid hemorrhage, cirrhosis, hepatic encephalopathy, anorexia, and congestive heart failure, was admitted with moderately impaired cognition and required significant assistance with daily activities. Upon exhausting Medicare services, the resident's daughter was informed that the resident would become private pay and requested the facility to begin the Medicaid process. However, the facility did not issue a 30-day discharge notice, and the resident's family ultimately took the resident home with home health services. The Social Service Director stated that the Medicaid process could not start without a power of attorney or guardianship due to the resident's cognitive impairment. The facility's administrator confirmed that there were no long-term care beds available and offered to assist with transferring the resident to another facility. Despite this, the family chose to take the resident home. The facility's policy allows for transfers and discharges even if a Medicaid application is pending, but the lack of a 30-day discharge notice and the communication regarding bed availability contributed to the deficiency.
Failure to Document Wound Care for Resident
Penalty
Summary
The facility failed to ensure proper documentation of wound care for a resident, identified as Resident #80, who was admitted with multiple medical diagnoses including respiratory failure, diabetes mellitus with chronic kidney disease, chronic venous hypertension, congestive heart failure, and schizoaffective disorder. The resident had moderately impaired cognition and was dependent on staff for various activities of daily living. A review of the medical record revealed that the resident had a moisture-associated skin damage and an unstageable pressure ulcer on the right buttock, which required specific wound care treatments. However, the November 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation to confirm that the wound care was performed as ordered from November 1 to November 11, 2024. Interviews with the resident and several staff members, including the Director of Nursing (DON), Licensed Practical Nurses (LPNs), and a Registered Nurse (RN), confirmed that the wound care was performed daily, despite the lack of documentation. The DON acknowledged that the order for the treatment was not entered correctly into the electronic health record (EHR), but staff were aware of the need for daily wound care due to the resident's condition. The facility's policy on skin preventive measures required staff to verify treatment orders after evaluation and documentation of wounds, which was not adhered to in this case. This deficiency was investigated under a specific complaint number.
Failure in Hand Hygiene and Barrier Precautions During Incontinence Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and enhanced barrier precautions during incontinence care for a resident. The resident, who had intact cognition, required assistance with daily activities and had an indwelling urinary catheter due to obstructive uropathy. The care plan for the resident included performing catheter care every shift, maintaining enhanced barrier precautions, and checking catheter tubing for kinks. However, during an observation, a State tested Nurse Aide (STNA) did not don a gown before or during the care, despite the resident being in enhanced barrier precautions due to the urinary catheter. The STNA performed hand hygiene and applied gloves but failed to change gloves after cleaning a large bowel movement from the resident. The STNA then proceeded to apply clean linens and a dry incontinence brief and adjusted the resident's bed while wearing the same soiled gloves. This action was in direct violation of the facility's hand hygiene policy, which requires staff to change gloves when moving from a contaminated body site to a clean body site and to remove gloves before touching non-contaminated items. The facility's infection control policy also mandates the use of gowns and gloves for high-contact resident care activities under enhanced barrier precautions.
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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) |
|---|---|---|---|---|
| Sycamore Trails Post Acute | 0.6 mi | ★★★★★ | 0 | 0 |
| Laurels Of West Carrollton The | 0.7 mi | ★★★★★ | 18 | 0 |
| Wood Glen Alzheimer's Community | 1 mi | ★★★★★ | 16 | 0 |
| Vienna Springs Health Campus | 1.6 mi | ★★★★★ | 1 | 0 |
| Kingston Of Miamisburg | 2.6 mi | ★★★★★ | 7 | 0 |
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