Sycamore Care Strategies

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent a resident who was at risk for elopement from leaving the facility property for 1 of 3 residents reviewed for accidents. (Resident C)This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on April 11, 2026, when the facility failed to provide adequate supervision to prevent Resident C from exiting the facility property at approximately 2:30 P.M. during an outdoor activity. Resident C was left on the front porch without staff supervision for approximately five minutes and located approximately 0.8 miles from the facility by a community bystander. The Facility Administrator was notified of the Immediate Jeopardy on 4/15/26 at 2:55 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 1 of 3 resident bathrooms and 1 of 1 shared shower rooms. A shared restroom had a musty odor, discolored tile, damaged areas on the walls, dust buildup on an overhead heater, debris buildup behind a commode, and an exposed area with a sticky trap, dead insects, and droppings. A shared resident restroom contained two uncovered urine sample hats, two packages of briefs, and a pack of wipes on the floor next to the commode. (West Hall shower room, room [ROOM NUMBER], room [ROOM NUMBER])

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity for 1 of 2 days during dining observations. Staff was feeding a resident but not engaged with the resident, a resident asked for water and staff did not get it for her, a resident was told she would get coffee and did not receive it, and food was not served in a timely manner. (Main dining room, East Hall tray pass, [NAME] Hall tray pass)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 3 of 3 residents reviewed for physical restraints and 2 of 5 residents reviewed for unnecessary medications. Side (bed) rails used for mobility were marked as physical restraints, residents were marked as taking a hypnotic and an opioid but one was not administered. (Resident 7, Resident 23, Resident 25, Resident 28, Resident 30)

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a resident specific comprehensive care plan for 1 of 3 residents reviewed for falls, 1 of 5 residents reviewed for unnecessary medications, and 1 of 2 residents reviewed for nutrition. Resident's call light and reaching device were not within the resident's reach, a resident taking an antipyschotic did not have a care plan, and a resident that was an assist to feed was not assisted by staff. (Resident 9, Resident 30, Resident 1)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents observed for incontinence care, 1 of 1 reviewed for wound care, 2 of 2 residents getting vital signs during medication administration, and 1 random observation of 2 residents. Staff did not change gloves or sanitize her hands between soiled to clean tasks. Staff performed handwashing for less then 20 seconds before and after wound care. A blood pressure cuff and pulse oximeter were not disinfected between residents. Proper Personal Protective Equipment (PPE) was not worn when transferring a resident on Enhanced Barrier Precautions (EBP). (Resident 2, Resident 22, Resident 26, Resident 29, Resident 1, Resident 25, Resident 30)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary, and homelike environment for residents for 1 of 1 shower rooms, 3 of 16 resident rooms/bathrooms observed for environment, and 3 random observations. The shower room grout was soiled and water was leaking from the hand held shower head, resident wheelchairs and a Broda chair had leather flaking off the arm rests, an entrance door to room had cracked, sharp plastic on the bottom, carpeting was loose causing an uneven floor surface, and a resident's recliner had a strong odor of urine. (Shower Room, room [ROOM NUMBER]A, Resident 29, room [ROOM NUMBER], room [ROOM NUMBER], Resident 7, Resident 8)

Inspectors wroteBased on interview and record review, the facility failed to clarify a code status for 1 of 1 residents reviewed for advance directives. A resident's current physician's order did not match the signed Indiana Physician Orders for Scope of Treatment form. (Resident 29)

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate notice of charges for services covered and services not covered under Medicare for 2 of 2 residents reviewed for beneficiary notices. Resident's and/or their representative did not receive an Advanced Beneficiary Notice (ABN) when their Medicare Part A services terminated and they remained in the facility. (Resident 5, Resident 14)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was diagnosed with dementia, received the appropriate treatment and services to attain or maintain her highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents reviewed for dementia care. A high risk to fall resident repeatedly trying to get out of her chair was not offered an activity or change in environment. (Resident 1)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision and a secured environment was in place to prevent a resident with dementia from exiting the facility and leaving the property. On 4/10/24, after being last seen by facility staff around 8:00 P.M., a resident exited the facility and was not realized to be missing until 8:45 P.M. when the resident was noticed to not be in her room. The resident was located by local law enforcement at 9:11 P.M. approximately 2.4 miles away at a residential residence along US Highway 50. (Resident C) This Immediate Jeopardy began on 4/10/24 when the facility failed to ensure Resident C did not exit the facility through a window in the front of the building, located in the dining room, and walked approximately 2.4 miles to a residential residence. Local law enforcement located the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 12 residents reviewed in the sample. Care plans were not developed for a resident doing household chores and residents with weight loss/nutrition, dementia, and behaviors. (Resident 24, Resident 1, Resident 4, Resident 26)

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS) Assessment was completed for 3 of 5 residents reviewed for unnecessary medications. The MDS Assessment indicated one resident received a diuretic and one resident received an opioid during the lookback period when they didn't. The MDS Assessment indicated one resident was not on an antibiotic but they were. (Resident 15, Resident 27, Resident 4)

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the care plans for 3 of 7 residents reviewed for pressure ulcers and accidents. One resident had a change in condition, two residents had a change in mobility, and their care plans were not revised. (Resident 29, Resident 12, Resident 24)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was transferred by qualified personal. An unlicensed staff member transferred a resident that resulted in a fall for 1 of 4 residents reviewed for falls. (Resident 12)

Inspectors wroteBased on interview and record review, the facility failed to provide Registered Nurse (RN) coverage of at least 8 hours daily. No RN coverage was available on 3 of 12 days (nine shifts) during the review period.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were assisted in gaining access to vision services by making appointments. A resident with complaints of a recent change in vision was not assisted in making an appointment with an eye doctor for 1 of 2 residents reviewed for ancillary services. (Resident 16)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications. A resident's as needed anti-anxiety medication was ordered for greater than 14 days. (Resident 17)

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices were followed. A glucometer (blood glucose machine) was not cleaned with an appropriate cleaning agent for 1 of 4 residents reviewed for medication administration. (Resident 11)