Health inspection·September 18, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few bed, resident slid down and was lowered to the floor. Review of the witness statement undated from CNA #369 revealed when entering the room, Resident #78 was on the floor, sitting by the bed. CNA #369 stated he provided lifting assistance with CNA #483 to lift Resident #78 off the floor and onto the bed. Once in bed Resident #78 was maneuvered to a proper position with a draw sheet. Review of the witness statement dated 09/02/25 from Registered Nurse (RN) #301 revealed she worked with Resident #78 on 08/25/25 and she was not notified of any incidents involving the resident. Interview on 09/16/25 at 9:24 A.M. with Resident #78's family member stated Resident #78 was having increased pain the week of 08/25/25 and it kept getting worse. Resident #78's family member stated the resident's left knee was swelling up, she didn't know why because she didn't receive any reports of any incidents or accidents involving the resident. Resident #78's family stated the resident had a camera in the resident's room so she went back through and watched the videos. Resident #78's family member stated she found on 08/25/25 at around 10:05 P.M. Resident #78 was transferring herself while staff stood by and the resident was supposed to have assistance. Resident #78's family member stated the resident fell on the floor in front of the bed. Resident #78's family member revealed the facility had not reported any incidents to her. Resident #78's family member stated she called the facility and reported the fall and requested x-rays of Resident #78's left leg. When the x-rays came back with a fracture, Resident #7 was sent to the ER. Interview on 09/17/25 at 7:49 A.M. with ADON #343 revealed Resident #78 experienced a fall on 08/25/25 but the incident was not reported until 09/01/25. ADON #343 confirmed she completed the investigation of the fall involving Resident #78. ADON #343 confirmed Resident #78 was assessed on 09/01/25, the physician was notified and the resident was sent to the hospital related to a fractured left femur. Interview on 09/17/25 at 8:35 A.M. with Director of Nursing (DON) and Administrator confirmed staff did not report a fall for Resident #78 until they received a call from the resident's family member on 09/01/25 reporting Resident #78 was having increased pain and she watched the videos and seen the resident fall on 08/25/25. The DON and Administrator stated Resident #78's family member had notified the facility about the fall due to the resident's complaints of pain. The DON and Administrator reported Resident #78's family member observed a fall on the video recording device on 08/25/25 at 10:05 P.M. The DON and Administrator confirmed the facility immediately began the investigation and two CNA's (#473 and #483) were terminated due to failing to follow facility protocol of reporting a fall when it happened. The DON and Administrator confirmed the facility investigated and had witness statements competed from all the CNA's involved the night of the incident on 09/02/25. Review of the video recording dated 08/25/25 at 10:05 P.M. revealed Resident #78 was in her room with one male and one female employee. The female employee had her hands on the wheelchair handles, while the male employee is to the right of the resident approximately three feet away. Resident #78 was in a sitting position at the edge of the of the wheelchair seat, close to the bed. Resident #78 is noted with her left arm on the bed, with her elbow bent as if she is pushing, trying to transfer herself. At 10:05:26 P.M. Resident #78 asks what's that then you hear a noise and the resident slips down between the bed and the wheelchair. At no time before this did the staff in the room attempt to assist Resident #78. At 10:05:27 P.M. the male employee leaned over, reaches for the resident under her arms. Resident #78 screams, the male employee steps away from the resident and the female employee leaves the room. The video continues until 10:07:21 P.M. with the male employee standing by the back wall behind the resident observing the resident. Another male employee was observed entering Resident #78's room and assisting with transferring the resident back to bed. Review of the facility policy titled Fall and Accident Management dated 08/2019 revealed after a fall the physician and the responsible party will be notified. Nursing completes documentation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366000 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sycamorespring of Miamisburg 2164 E Central Ave Miamisburg, OH 45342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete related to the occurrence. The deficient practice was corrected on 09/05/25 when the facility implemented the following corrective actions: On 09/01/25, Resident #78 was assessed by RN #301, the physician was notified, and the resident was sent to the hospital for evaluation and treatment. The Administrator and DON began an investigation regarding Resident #78's fall. On 09/02/25, the DON or designee reviewed Resident #78's medical record including but not limited to medication administration records, progress notes and care plans. Resident #78's care plan was updated as needed by the DON. On 09/02/25 through 09/04/25, the DON or designee interviewed current interviewable residents to determine if there were any falls or incidents that occurred that were not documented in the medical record. No issues were noted. On 09/02/25 through 09/04/25, the DON or designee completed head to toe assessments on current non-interviewable residents to determine if there were any concerns for bruising, abrasions, swelling, complaints of pain that could be the result of an undocumented fall. No issues were noted. On 09/02/25, the DON or designee reviewed current residents' progress notes from the last 14 days to review for any possible injuries that may be related to an undocumented fall. No issues were noted. On 09/02/25, the DON or designee reviewed fall documentation from current residents experiencing a fall in the last 14 days to ensure an adequate assessment and documentation was completed, intervention implemented post fall, and notifications of responsible party and physician timely after a fall. No issues were noted. On 09/02/25, the DON, Director of Rehab and/or designee reviewed current residents' care plans to reflect accurate transfer assistance. On 09/02/25, the DON or designee provided in-service training to all nursing staff. This in-service included ensuring residents experiencing a fall and/or that have been lowered to the floor are reported to the nurse, ensuring the resident is adequately assessed by the nurse following incidents, ensuring the fall is documented in the medical record, and that the physician and responsible party are notified timely of a resident fall. Additionally, the in-service training included ensuring residents are provided with transfer assistance according to the care plan. The in-service training was completed by 09/05/25. A Quality Assurance (QA) meeting was held on 09/03/25 at 12:30 P.M. with the Administrator, Medical Director, Regional Director of Operations, DON, [NAME] President of Nursing, and Corporate QA Nurse. This deficiency represents non-compliance investigated under Complaint Number 2609393. Event ID: Facility ID: 366000 If continuation sheet Page 3 of 3