Millersburg, OH

Sycamore Run Nursing And Rehab Ctr

4-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

6180 State Route 83 N, Millersburg, OH

(330) 674-0015

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

108

Certified beds

Average residents

88

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Foundations Health Solutions

Operator or chain grouping

Approved since

1995-10-18

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

63 facilities

Chain averages 4 overall / 4 health / 2 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.44

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.12

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.03

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.59

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.56

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.12

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.35

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.34

CMS adjusted RN staffing hours

Adjusted total hours

2.79

CMS adjusted total nurse staffing hours

Case-mix index

1.76

Higher values indicate more complex resident acuity

RN turnover

11%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

36%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,550

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

35.81

Composite VBP score used to determine payment impact.

Payment multiplier

0.9894

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

2.97

Baseline 5.71% · Performance 6.95% · Measure score 2.97 · Achievement 2.97 · Improvement 0

Total nurse turnover

6.61

Baseline 40.51% · Performance 36.67% · Measure score 6.61 · Achievement 6.61 · Improvement 1.95

Adjusted total nurse staffing

1.16

Baseline 2.48 hours · Performance 3.03 hours · Measure score 1.16 · Achievement 0 · Improvement 1.16

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.95%	10.72% 1.2 pts worse	No Different than the National Rate · Eligible stays 54 · Observed rate 16.67% · Lower 95% interval 8.77%
Discharge to community	44.31%	50.57% 6.3 pts worse	No Different than the National Rate · Eligible stays 28 · Observed rate 35.71% · Lower 95% interval 27.57%
Medicare spending per beneficiary	0.89	1.02 0.1 pts better
Drug regimen review with follow-up	71.88%	95.27% 23.4 pts worse	Numerator 23 · Denominator 32
Falls with major injury	3.13%	0.77% 2.4 pts worse	Numerator 1 · Denominator 32
Discharge self-care score	31.82%	53.69% 21.9 pts worse	Numerator 7 · Denominator 22
Discharge mobility score	40.91%	50.94% 10 pts worse	Numerator 9 · Denominator 22
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 32 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.95%	7.12% 0.2 pts better	No Different than the National Rate · Eligible stays 29 · Observed rate 6.9% · Lower 95% interval 3.47%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 108
Staff flu vaccination coverage	18.25%	42% 23.8 pts worse	Numerator 25 · Denominator 137
Discharge function score	40.91%	56.45% 15.5 pts worse	Numerator 9 · Denominator 22
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.1	1.8 0.7 pts better	1.9 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.5	1.8 0.3 pts better	1.8 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.7%	92.4% 5.3 pts better	93.4% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 100.0% · Q3 100.0% · Q4 91.8% · 4Q avg 97.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.7%	94.5% 0.2 pts better	95.5% 0.8 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.7%
Percentage of long-stay residents experiencing one or more falls with major injury	2.9%	3.3% 0.4 pts better	3.3% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.3% · Q3 2.3% · Q4 3.5% · 4Q avg 2.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	81.4%	26.1% 55.3 pts worse	11.4% 70 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 61.7% · Q2 82.5% · Q3 92.7% · Q4 89.3% · 4Q avg 81.4%
Percentage of long-stay residents who lose too much weight	4.8%	6.2% 1.4 pts better	5.4% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 5.3% · Q3 6.4% · Q4 3.8% · 4Q avg 4.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	34.4%	25.4% 9 pts worse	19.6% 14.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 34.2% · Q2 33.8% · Q3 33.3% · Q4 36.2% · 4Q avg 34.4%
Percentage of long-stay residents who received an antipsychotic medication	31.0%	11.5% 19.5 pts worse	16.7% 14.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 31.2% · Q3 32.7% · Q4 32.7% · 4Q avg 31.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	1.7%	7.7% 6 pts better	16.3% 14.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 1.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	1.6%	6.2% 4.6 pts better	14.9% 13.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.4% · Q3 2.6% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.2% 0.2 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.5% 0.5 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.1%	21.7% 0.4 pts worse	19.8% 2.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 28.0% · Q3 17.5% · Q4 21.5% · 4Q avg 22.1%
Percentage of long-stay residents with pressure ulcers	0.7%	3.7% 3 pts better	5.1% 4.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	75.4%	78.1% 2.7 pts worse	81.7% 6.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 73.0% · Q2 73.0% · Q3 78.6% · Q4 76.5% · 4Q avg 75.4%
Percentage of short-stay residents who had an outpatient emergency department visit	19.6%	12.5% 7.1 pts worse	12.0% 7.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 20.0% · Expected 11.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.5%	1.2% 0.3 pts worse	1.6% 0.1 pts better	Short Stay · 2024Q4-2025Q3 · Q3 4.8% · 4Q avg 1.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	64.1%	75.6% 11.5 pts worse	79.7% 15.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 64.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	16.9%	25.1% 8.2 pts better	23.9% 7 pts better	Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 16.0% · Expected 22.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-16 · Fire 2025-01-16

5 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2022-12-07 · Fire 2022-12-07

6 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2019-10-24 · Fire 2019-10-24

6 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-16

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2025-02-13

F · Potential for more than minimal harm 2025-01-16

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-02-13

F · Potential for more than minimal harm 2025-01-16

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-02-13

F · Potential for more than minimal harm 2025-01-16

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-02-13

E · Potential for more than minimal harm 2025-01-16

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-02-13

F · Potential for more than minimal harm 2022-12-07

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-12-28

F · Potential for more than minimal harm 2022-12-07

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-12-28

F · Potential for more than minimal harm 2022-12-07

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2022-12-28

F · Potential for more than minimal harm 2019-10-24

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2019-11-21

F · Potential for more than minimal harm 2019-10-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-11-21

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-21

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Not marked corrected

D · Potential for more than minimal harm 2025-01-16

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-02-13

D · Potential for more than minimal harm 2025-01-16

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2025-02-13

D · Potential for more than minimal harm 2025-01-16

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-02-13

D · Potential for more than minimal harm 2025-01-16

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-02-13

D · Potential for more than minimal harm 2024-03-25

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-04-11

D · Potential for more than minimal harm 2023-11-15

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-12-07

D · Potential for more than minimal harm 2023-11-15