Cycle 1
Health 2024-02-15 · Fire 2024-02-15
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Miamisburg, OH
Sycamorespring Of Miamisburg
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2164 E Central Ave, Miamisburg, OH
(937) 384-4308
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carespring
Operator or chain grouping
Approved since
1995-03-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 4 overall / 4 health / 3 staffing / 5 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
0.94
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.22
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.56
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.60
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,927
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.50% · Performance 24.51% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.44
Baseline 6.94% · Performance 6.51% · Measure score 4.44 · Achievement 4.44 · Improvement 1.73
Total nurse turnover
0
Baseline 62.64% · Performance 64.66% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.43
Baseline 2.75 hours · Performance 3.33 hours · Measure score 1.43 · Achievement 0.89 · Improvement 1.43
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.17% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 241 · Observed rate 14.94% · Lower 95% interval 9.9% |
| Discharge to community | 59.29% |
50.57%
8.7 pts better
|
Better than the National Rate · Eligible stays 257 · Observed rate 52.14% · Lower 95% interval 52.52% |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 157 · Denominator 157 |
| Falls with major injury | 1.91% |
0.77%
1.1 pts worse
|
Numerator 3 · Denominator 157 |
| Discharge self-care score | 52.08% |
53.69%
1.6 pts worse
|
Numerator 25 · Denominator 48 |
| Discharge mobility score | 64.58% |
50.94%
13.6 pts better
|
Numerator 31 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 1.27% |
2.29%
1 pts better
|
Numerator 2 · Denominator 157 · Adjusted rate 0.86% |
| Healthcare-associated infections requiring hospitalization | 6.51% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 141 · Observed rate 5.67% · Lower 95% interval 4.19% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 142 |
| Staff flu vaccination coverage | 23.08% |
42%
18.9 pts worse
|
Numerator 45 · Denominator 195 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 32 · Denominator 48 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 112 · Denominator 112 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 45.88% |
25.2%
20.7 pts better
|
Numerator 39 · Denominator 85 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.8 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.1 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.5% |
94.5%
About the same
|
95.5%
1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.3%
0.9 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.6% · Q4 6.5% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 31.9% |
26.1%
5.8 pts worse
|
11.4%
20.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q2 26.3% · Q3 39.7% · Q4 16.7% · 4Q avg 31.9% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
6.2%
0.5 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 0.0% · Q3 7.3% · Q4 5.7% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.3% |
25.4%
5.1 pts better
|
19.6%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 22.4% · Q3 19.0% · Q4 16.4% · 4Q avg 20.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.0% |
11.5%
10.5 pts better
|
16.7%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 2.2% · 4Q avg 1.0% · 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 | 2.7% |
7.7%
5 pts better
|
16.3%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.7% · Q4 3.8% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.8% |
6.2%
3.4 pts better
|
14.9%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 1.9% · Q4 8.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.2%
0.2 pts worse
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · 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 | 28.4% |
21.7%
6.7 pts worse
|
19.8%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 28.6% · Q3 27.6% · Q4 27.6% · 4Q avg 28.4% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
3.7%
0.6 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.1% · Q3 3.2% · Q4 3.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
78.1%
21.7 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.0% |
12.5%
3.5 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 16.5% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.2%
0.3 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.7% · Q3 0.8% · Q4 0.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.6% |
75.6%
15 pts better
|
79.7%
10.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.6% |
25.1%
2.5 pts worse
|
23.9%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.6% · Observed 31.3% · Expected 27.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-03-05 · Fire 2020-03-05
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-02-20 · Fire 2019-02-20
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-15
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-02-27
F · Potential for more than minimal harm
2024-02-15
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-02-27
F · Potential for more than minimal harm
2024-02-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-27
F · Potential for more than minimal harm
2020-03-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-03-27
F · Potential for more than minimal harm
2020-03-05
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2020-03-27
E · Potential for more than minimal harm
2020-03-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-27
E · Potential for more than minimal harm
2020-03-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-03-27
F · Potential for more than minimal harm
2019-02-20
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-03-12
F · Potential for more than minimal harm
2019-02-20
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 2019-03-12
E · Potential for more than minimal harm
2019-02-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-03-12
E · Potential for more than minimal harm
2019-02-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-03-12
E · Potential for more than minimal harm
2019-02-20
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2019-03-12
E · Potential for more than minimal harm
2019-02-20
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2019-03-12
E · Potential for more than minimal harm
2019-02-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-03-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-12
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-11-12
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 2024-11-20
D · Potential for more than minimal harm
2024-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-02-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-27
D · Potential for more than minimal harm
2020-03-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2020-03-27
D · Potential for more than minimal harm
2020-03-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2020-03-27
D · Potential for more than minimal harm
2020-03-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-03-27
J · Immediate jeopardy
2019-02-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-03-12
F · Potential for more than minimal harm
2019-02-20
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2019-03-12
D · Potential for more than minimal harm
2019-02-20
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2019-03-12
D · Potential for more than minimal harm
2019-02-20
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-03-12
D · Potential for more than minimal harm
2019-02-20
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-03-12
D · Potential for more than minimal harm
2019-02-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-03-12
D · Potential for more than minimal harm
2019-02-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-03-12
D · Potential for more than minimal harm
2019-02-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-03-12
D · Potential for more than minimal harm
2019-02-20
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 2019-03-12
D · Potential for more than minimal harm
2019-02-20
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 2019-03-12
C · Minimal harm
2019-02-20
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-03-12
Penalties and ownership
What sits behind the stars
Ownership
Carespring Health Care Holdings LP
5% Or Greater Direct Ownership Interest · Organization
Barry N Bortz 06042009 Tr
5% Or Greater Indirect Ownership Interest · Organization
Bortz Family Irrevocable T/A
5% Or Greater Indirect Ownership Interest · Organization
Carespring Health Care Management, LLC
Operational/Managerial Control · Organization
Chirumbolo, Christopher
Corporate Officer · Individual
Davis, Bridget
W-2 Managing Employee · Individual
Eppers, David
5% Or Greater Indirect Ownership Interest · Individual
Eppers, David
Corporate Officer · Individual
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