Sycamore Heights Health and Rehabilitation

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure the resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility. This affected all residents in the facility. During a Group Interview conducted on 09/18/2024 by the State Survey Agency (SSA), Resident (R) 25 and R70 both complained they did not receive mail on Saturdays. In an interview with the Activitie's Director on 09/20/2024, it was confirmed, mail delivered on Saturday was locked in her office until Monday morning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and helped prevent the development and transmission of communicable diseases and infections for five (5) of seven (7) sampled residents reviewed for infection control out of a total sample of 25 residents, Resident (R)2, R51, R78, R83, R340. Observation on 09/19/2024 at 8:45 AM, revealed Registered Nurse (RN)2 entered R2's room without donning proper Personal Protective Equipment (PPE) while the resident was in enhanced barrier precautions (EBP). RN2 provided direct contact resident care by obtaining R2's vital signs. RN2 then exited R2's room with the blood pressure machine, and failed to sanitize the machine. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policies, the facility failed to implement the comprehensive person-centered care plan in order to meet the resident's medical, and nursing needs for three (3) of 25 sampled residents, Resident (R)45, R52, and R83. Observation on 09/17/2024 and 09/18/2024, revealed R45's Comprehensive Care Plan (CCP) was not implemented related to oxygen settings. Furthermore, observation on 09/17/2024, revealed R83's CCP was not implemented related to wearing a smoking apron while smoking. Moreover, continuous observation on 09/19/2024 from 8:15 AM to 10:15 AM, revealed staff had not checked R52's brief or taken him to the bathroom, as per the CCP.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure drugs were stored under proper temperature controls; and were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions. Observation on 09/18/2024, revealed the top drawer of the medication cart for Hallway A, had a cup of pills with a resident's first name handwritten on the cup. Additionally, observation revealed eye drops and suppositories were stored in the door of the refrigerator in the hallway B medication room.

Inspectors wroteBased on observation, and interview, the facility failed to store food in accordance with professional standards for food service safety for three (3) of four (4) unit refrigerators used to store food for residents. Observation on 09/18/2024 of the resident nourishment refrigerators for the A-D, E, and F units, revealed ice packs stored in the freezer compartments.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure Advanced Directives were completed by the Legal Guardian for one (1) of 25 sampled residents, Resident (R)43. Although a Judge signed a court order to appoint the Cabinet for Health and Family Services (CHFS) Guardianship for R43, effective [DATE]; the facility did not verify the resident's code status, and accepted a Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) Order form, dated [DATE], signed by R43's family member.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to ensure residents who were unable to carry out Activities of Daily Living (ADLs) received the necessary services related to toileting and incontinence care for one (1) of 25 sampled residents, Resident (R)52.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (1) of nine (9) residents who smoked out of a total sample of 25 residents, Resident (R)83. The facility was a smoke free facility and only those residents who were grandfathered in could smoke on facility grounds. However, R83 was admitted after the facility went smoke free and was observed on 09/17/2024 smoking on facility grounds, without wearing a smoke apron. Furthermore, there was no documented evidence a smoking evaluation was completed for this resident to ensure the resident could safely smoke.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to provide oxygen as ordered for one (1) of 25 sampled residents, Resident (R)45. Although R45's Active Physician's orders revealed orders to administer oxygen at two (2) liters per minute via nasal cannula, observation on 09/17/2024 and 09/18/2024, revealed the resident was receiving oxygen at three (3) liters per minute.

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to have an effective system to develop and implement the comprehensive care plan with effective interventions to protect residents from accidents and hazards for one (1) of fifteen (15) sampled residents (Resident #7). The facility admitted Resident #7 (R7) with diagnoses of paranoid schizophrenia and impulse disorder. The facility care planned the resident on 11/01/2023, for attempting to manipulate objects such as forks and coat hangers into protective objects, as he was seeing hallucinations in his room. However, the facility failed to develop interventions for staff to continuously monitor and document the findings to ensure objects he could manipulate into weapons were removed from his room. [...]

Inspectors wroteBased on observation, interview, record review, facility document and policy review, the facility failed to provide an effective system to monitor and supervise residents to prevent accidents hazards for one (1) of fifteen (15) sampled residents (Resident #6). On 03/11/2024 at approximately 3:40 AM, Resident #6 (R6) and Resident #7 (R7), who were roommates, were in their room alone with the door opened. Staff entered the residents' room and observed R7 sitting in a chair next to R6's bed, with a plastic fork in one hand and both hands covered with blood. R6 was lying on his bed with blood on his face and a laceration to his left eye. When staff asked R7 about the incident the resident stated he did it because he believed R6 was trying to harm him. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to implement or develop the care plan for two (2) of twenty-one (21) sampled residents, Resident #8 and #36. The facility care planned for Resident #36 to have on non-skid footwear for ambulating/transfers; however, staff failed to implement Resident #36's care plan to prevent a fall and the resident fell and sustained a fractured hip. In addition, the facility failed to develop a care plan related to Resident #8's dental problems.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received timely treatment and care to manage pain for one (1) of twenty-one (21) sampled residents, Resident #36. Resident #36 fell on [DATE] at approximately 1:00 PM. The resident complained of hip pain at approximately 3:30 PM; however, was not sent out to the hospital for evaluation and treatment until approximately 8:00 PM, four (4) and a half hours later.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure residents received their personal clothing items back from laundry in a timely manner for eight (8) of eight (8) sampled residents, Resident #5, #22, #26, #29, #32, #47, #50, and #71.

Inspectors wroteBased on interview, facility policy review, and review of Resident Council Concern Forms, it was determined the facility failed to act upon and effectively resolve grievances from Resident Council related to missing clothing.

Inspectors wroteBased on observation and interview, it was determined the facility failed to provide a clean and sanitary environment in one (1) of two (2) shower rooms, which effected residents on three (3) of six (6) hallways, Halls A, B, and C. Observations of the C Hall Shower Room revealed black matter on the bottom of the walls, cracked tiles, a soiled brief, and other soiled items.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to obtain wound care orders upon readmission to the facility for one (1) of twenty-one (21) sampled residents, Resident #36.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to provide effective supervision to prevent accidents for one (1) of two (2) sampled residents, Resident #36. Per interview, on 03/07/19, Resident #36 resident fell and sustained a hip fracture when he/she transferred without assistance in the bathroom. Per interview and record review, the resident was not wearing non-skid footwear, which was an intervention the facility had put in place for the resident to prevent falls.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of one (1) residents received oxygen therapy in accordance with professional standards of practice and physician's order, Resident #16. Resident #16 had a physician order to administer oxygen at two (2) liters per minute (LPM) to maintain oxygen saturation levels greater than 90%, and check every shift. However, observation revealed the resident's oxygen was set at three (3) LPM, and record review revealed the saturation levels were not checked every shift as ordered.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure medications were stored securely in two (2) of five (5) medication carts, carts A and B.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to obtain emergency dental services for one (1) of two (2) sampled residents, Resident #8.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to ensure controlled medications were accurately documented for one (1) of twenty-one (21) sampled residents, Resident #36. Record review revealed nurses signed out controlled medication on the Controlled Drug Record; however, the medication was not documented on the Medication Administration Record (MAR) as administered.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain infection control during wound care for one (1) of three (3) sampled residents, Resident #37.