Brickyard Healthcare -Sycamore Village Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the kitchen was maintained in a safe and sanitary condition in 1 of 1 kitchen reviewed. This deficient practice had the potential to affect 95 of 95 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure privacy was provided for a resident during care for 1 of 1 resident randomly reviewed for privacy. (Resident 5)

Inspectors wroteBased on interview and record review, the facility failed to ensure staff obtained another weight after a documented weight gain for 1 of 3 residents reviewed for quality of care. (Resident 23)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was kept safe during care and transfers for 1 of 4 residents reviewed for accidents. (Resident C)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were dated when opened in 1 of 3 medication carts reviewed for medication storage. (East Hall)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure compromised controlled substance medications were not stored in the medication cart for 2 of 4 medication carts observed for medication storage. (North cart and South cart)

Inspectors wroteBased on interview and record review, the facility failed to ensure the SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) forms were accurately completed for 2 of 3 residents discharged from Medicare services and remained in the facility. (Resident 45 and 91)

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Record Review (PASARR) evaluations were updated and accurate for 2 of 4 residents reviewed for PASARR. (Resident 95 and 52)

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician ordered parameters to hold blood pressure medications were followed for 1 of 1 resident reviewed for quality of care. (Resident 87)

Inspectors wroteBased on interview and record review, the facility failed to ensure an admission weight was obtained for 2 of 5 residents reviewed for nutrition. (Resident D and H)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure policy and procedures were followed for medications administered through a gastrostomy tube (g-tube) for 1 of 1 resident reviewed for a gastrostomy tube. (Resident 67)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order, a care plan, a signed consent, and an assessment was obtained prior to the use of side rails for 1 of 7 residents reviewed for accidents. (Resident 95)

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmaceutical services were obtained and maintained timely to support a resident's healthcare needs for 1 of 5 residents reviewed for pain management. (Resident E)

Inspectors wrote2. During observations, on 12/12/24, 12/13/24, and 12/17/24, no enhanced barrier precautions (EBP) sign was noted outside Resident 61's room per the physician's order. During observations, on 12/18/24 and 12/19/24, both an enhanced barrier precautions and Contact Precaution signs were noted in the hallway outside the resident's door. The clinical record for Resident 61 was reviewed on 12/16/24 at 10:09 a.m. The diagnoses included, but were not limited to, enterocolitis due to clostridium difficile (C-diff), urinary tract infection, retention of urine, and benign prostatic hyperplasia with lower urinary tract symptoms. A current physician's order, dated 8/20/24, indicated enhanced barrier precautions were to be in place and a sign was to be outside the resident's room. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were being supervised when a staff member physically kicked a resident in his back for 1 of 3 residents reviewed for abuse. (Resident B) The deficient practice was corrected on 10/15/2023, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to notify residents' family representatives prior to staff spending the residents' personal funds for 4 of 4 residents reviewed for protection of resident funds. (Residents B, E, F and D)

Inspectors wrote4. During an interview, on 9/27/23 at 4:07 p.m., Resident D's family member indicated the BOM gave permission for Unit Manager 10 to use the resident's money to buy clothes for the resident. The facility did not get her consent to spend the money. Unit Manager 10 had spent some of the money for herself. The record for Resident D was reviewed on 9/27/23 at 4:07 p.m. Diagnoses included, but were not limited to, dementia, generalized anxiety disorder, down syndrome, and a communication deficit. An investigation report, dated 9/25/23, indicated Unit Manager 10 made the following purchase, on 8/8/22 at 7:12 p.m.: a. The receipt total was $1,122.32. b. Unit Manager 10's charge card ending in 4201 was charged $300. c. The rest of the bill was paid with the resident's funds totaling $900 in cash. $77.68 was issued in change. d. A total of $200 in Kohl's cash was issued. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure activities were offered daily for 5 of 5 residents reviewed for activities. (Resident 18, 23, 29, 43 and 85)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were dressed in regular clothing like other residents unless their preferences were identified for alternative clothing for 1 of 1 resident reviewed for dignity. (Resident 75)

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a blood glucose level greater than the physician's call orders for 1 of 1 resident reviewed for notification. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse for 1 of 1 resident reviewed for abuse. (Resident C)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive care plan was implemented to address a resident's preferences for 1 of 1 resident reviewed for dignity. (Resident 75)

Inspectors wroteBased on interview and record review, the facility failed to ensure there was communication between the hospice company and the facility for care provided by the hospice staff for 1 of 1 resident reviewed for hospice. (Resident 73)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's contracted fingers/hands were assessed and to provide services for the contractures for 1 of 2 residents reviewed for limited range of motion. (Resident 73)

Inspectors wroteBased on interview and record review, the facility failed to provide enough staff to prevent low weekend staffing reported in the third quarter to the Pay-Roll Based Journal (PBJ) staffing report and to provide staff to have activities for the residents on the 100 and 200 halls.

Inspectors wrote2. The record for Resident J was reviewed on 9/27/23 at 4:19 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, anxiety disorder, cognitive communication deficit, insomnia, anxiety, dementia in other diseases, and psychosis related to dementia and depression. A physician's order, dated 8/23/23, indicated Risperdal (a medication for schizophrenia) 0.5 mg daily for psychosis with dementia. An IDT (interdisciplinary team) note, dated 3/1/23 at 5:55p.m., indicated a new order for Risperdal 0.25 mg (milligrams) was given by the psychiatric nurse practitioner. The resident's husband and hospice were made aware of the new order. The resident would be observed routinely for signs and symptoms of side effects to the medication. AIMs (Abnormal Involuntary Movement scale) assessment completed and would be completed routinely while taking antipsychotic medication. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who requested dental services had the paperwork completed and was scheduled for the dentist for 1 of 2 residents reviewed for dental. (Resident H)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff sanitized their hands during dining service, staff used gloves to touch medications and a resident's Foley (indwelling urinary) catheter was off the floor for 1 of 2 dining rooms observed, 1 of 7 residents observed for medication administration and 1 of 1 resident reviewed for urinary catheters. (Activity Staff 2, Resident M, and Resident 35)