Sycamore Trails Post Acute
450 Oak Ridge Boulevard, Miamisburg, OH 45342 · Montgomery County · 102 certified beds · avg 69 residents/day · certified since Sep 20, 1984
Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)
3/5
Health inspection rating (on-site)
2
Serious findings on record
$11,037
Fines, last 3 years
2.71
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jun 27, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 28, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 25, 2022 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 30, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (50)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 30, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Dec 30, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint |
| Nov 18, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Nov 18, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Sep 26, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint |
| Sep 26, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Sep 4, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jun 27, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 27, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Jun 27, 2024 | C · Minimal risk, facility-wide | The facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials. · from a complaint |
| May 16, 2024 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint |
| May 16, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 16, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| May 16, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| May 16, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Apr 25, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Mar 28, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Mar 28, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Dec 18, 2023 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Aug 31, 2023 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Aug 31, 2023 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Aug 31, 2023 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint |
| Aug 25, 2022 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Aug 25, 2022 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 25, 2022 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Aug 25, 2022 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 25, 2022 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 25, 2022 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Aug 25, 2022 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Aug 25, 2022 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Aug 25, 2022 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Aug 25, 2022 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 25, 2022 | D · Potential for harm, one-off | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. |
| Aug 25, 2022 | B · Minimal risk, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Aug 25, 2022 | B · Minimal risk, repeated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Jul 12, 2019 | E · Potential for harm, repeated | The facility did not properly protect the personal money residents deposited with it for safekeeping. |
| Jul 12, 2019 | E · Potential for harm, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Jul 12, 2019 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not provide routine dental care and 24-hour emergency dental care for residents. |
| Jul 12, 2019 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 14 | 0 | E |
| 2022 | 13 | 1 | G ▲ |
| 2023 | 4 | 0 | E |
| 2024 | 19 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $11,037.
| Date | Type | Amount / length |
|---|---|---|
| Jun 27, 2024 | Fine | $11,037 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Ohio avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.71 | 3.45 | 3.95 | bottom 9% in Ohio; bottom 6% in the U.S. |
| Registered Nurse hours | 0.60 | 0.60 | 0.69 | top 40% in Ohio; top 49% in the U.S. |
| Weekend total nurse staffing | 2.32 | 3.07 | 3.50 | bottom 6% in Ohio; bottom 5% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.50 | 0.42 | 0.48 | top 26% in Ohio; top 32% in the U.S. |
| Total nursing staff turnover (%) | 56.2 | 48.7 | 45.8 | bottom 28% in Ohio; bottom 23% in the U.S. |
| RN turnover (%) | 31.3 | 43.9 | 42.9 | top 30% in Ohio; top 32% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.43, RN 0.75, weekend 2.94. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| 450 Oak Ridge Boulevard Oh Owner LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Apt, Frederick | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/01/2024 |
| Apt, Frederick | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Chaney, Steve | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Chaney, Steve | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Hunter, Robert | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Jergensen, Joshua | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/01/2024 |
| Jergensen, Joshua | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2024 |
| Jergensen, Joshua | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Mitchell, John | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/01/2024 |
| Mitchell, John | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2024 |
| Mitchell, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Pacs Group, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Pacs Holdings, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Providence Group NH, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| SNF Oh Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Well Integra Master JV LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Well PM Holdco JV LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Welltower INC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Sycamorespring of Miamisburg | 0.6 mi | Miamisburg, OH | ★★★★★ | 4/5 | |
| Laurels of West Carrollton the | 1.2 mi | West Carrollton, OH | ★☆☆☆☆ | 2/5 | |
| Wood Glen Alzheimer's Community | 1.3 mi | Dayton, OH | ★★★☆☆ | 3/5 | |
| Vienna Springs Health Campus | 1.9 mi | Dayton, OH | ★★★★★ | 4/5 | |
| Kingston of Miamisburg | 2.5 mi | Miamisburg, OH | ★★★★☆ | 4/5 | |
| Centerville Health and Rehab | 3.3 mi | Dayton, OH | ★☆☆☆☆ | 2/5 | |
| Centerville Post Acute | 3.5 mi | Centerville, OH | ★★★☆☆ | 4/5 | |
| Walnut Creek Nursing Center | 3.6 mi | Kettering, OH | ★☆☆☆☆ | 2/5 | |
| Respiratory and Nursing Center of Dayton | 4.3 mi | Moraine, OH | ★★★★☆ | 3/5 | |
| Bethany Village | 5.1 mi | Dayton, OH | ★★★★★ | 5/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 365640.