Sycamore Trails Post Acute

Inspectors wroteBased on observation, medical record review, staff interviews, resident interview, and review of facility policy, the facility failed to administer medications in a timely manner. This affected four (Residents #29, #73, #10, and #44) of four residents reviewed for medication administration. The facility census was 73.

Inspectors wroteBased on review of the medical record, observations, interviews, and policy review, the facility failed to ensure medications were administered per physician orders. There were two medication errors out of 37 opportunities resulting in a 5.4 percent medication error rate. This affected one (Resident #14) of three residents observed for medication administration. The facility census was 73.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to administer medications per physician orders and further failed to ensure Controlled Drug Records (CDR) were maintained. This affected one resident (#10) of three residents reviewed for medication administration. The facility census was 74.

Inspectors wroteBased on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure appropriate hand hygiene was performed following incontinence care. This affected one resident (#20) of four residents reviewed for incontinence care. The facility census was 74.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident was free from unnecessary psychotropic medications by ensuring the resident was on the lowest ordered dose of an antipsychotic. This affected one (#4) of three residents reviewed for psychoactive medications. The census was 82.

Inspectors wroteBased on medical record review, observation, resident and staff interviews, and review of facility policy, the facility failed to ensure medications were observed taken by residents and not left at the beside. This affected one (#3) of three residents reviewed for medication administration. The census was 82.

Inspectors wroteBased on medical record review and staff and pharmacist interviews, the facility failed to ensure antibiotics were provided as physician ordered resulting in a significant medication error. This affected one (#12) of three residents reviewed for medication administration.

Inspectors wroteBased on medical record review, review of hospital documentation, review of written statements, staff interviews, and policy review, the facility failed to provide adequate staff assistance during a bed bath resulting in an avoidable fall. This resulted in Actual Harm on 05/31/24 when State Tested Nursing Assistant (STNA) #275 rolled Resident #70 away from her during a bed bath and the resident rolled out of bed onto the floor. Subsequently, Resident #70 was transferred to the Emergency Department (ED) for evaluation and treatment and required a suture to close a forehead laceration. This affected one (#70) of three residents reviewed for falls. The facility census was 79.

Inspectors wroteBased on medical record review, observations, staff and resident interviews, and policy review, the facility failed to ensure staff observed resident consume medications. This affected one (#20) out of four residents reviewed for medication administration. The facility census was 79.

Inspectors wroteBased on personnel record review and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all 79 residents residing in the facility. The facility census was 79.

Inspectors wroteBased on record review, observations and staff and resident interviews, the facility failed to provide meals per resident choice and per the facility planned menu. This affected three (#33, #55 and #70) out of three residents reviewed for meals and had the potential to affected 78 residents residing in the facility who receive their meals from the facility, the facility identified two residents (#47, #65) who receive nothing by mouth (NPO). Facility census was 80.

Inspectors wroteBased on medical record review, observations and resident and staff interviews, the facility failed to provide adequate intervention and/or supervision to ensure residents did not possess illegal drugs and/or drugs not prescribed to the resident. Additionally, the facility failed to implement a resident's care plan to ensure adequate supervision was provided during a meal. This affected three (#54, #47 and #74) of three residents reviewed for supervision related to illegal drug usage and one (#27) of three residents reviewed for supervision with meals. The facility census was 80.

Inspectors wroteBased on record review and staff interviews, the facility failed to update resident care plan to include a resident's possession and suspected use of illegal substances. This affected one (#54) of three residents reviewed for care planning. The facility census was 80.

Inspectors wroteBased on record review, observation, staff and resident interviews, the facility failed to ensure treatments orders were completed as ordered. This affected one (#55) of three residents reviewed for implementation of treatments. The facility census was 80.

Inspectors wroteBased on record review, staff, physician and pharmacy staff interviews, the facility failed to ensure medications were administered as physician ordered. This affected two (#134 and #55) of three residents reviewed for medication administration. The facility census was 80.

Inspectors wroteBased on medical record review, staff interview, medication administration time review, and policy review, the facility failed to administer physician ordered medications and ensure medications were timely order to have available for administration. This affected four #21, #41, #58 and #63 of eight residents reviewed for medication administration. The facility census was 79.

Inspectors wroteBased on record review, staff and resident interviews, review of staffing records/schedules and policy review, the facility failed to provide timely Activities of Daily Living (ADL's) assistance. This affected one (#11) out of three residents reviewed for ADL assistance and had the potential to affect 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 and top of the 100 hallway assignment. The facility census was 82.

Inspectors wroteBased on record review, staff and resident interviews, review of staffing records/schedules and policy review, the facility failed to ensure there was sufficient staffing to provide timely assistance with Activities of Daily Living (ADL's). This affected one (#11) out of three residents reviewed for ADL assistance and had the potential to affect 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 and top of the 100 hallway assignment. The facility census was 82.

Inspectors wroteBased on record review, observations, staff interviews and policy review, the facility failed to ensure infection control procedures were followed during wound care. This affected one (#14) of three residents reviewed for wound care. Facility census was 82.

Inspectors wroteBased on medical record review, review of controlled substance records, staff interview, and review of facility policy, the facility failed to ensure a resident's narcotic medication administration was accurately documented in the medical record. This affected #81 of three residents reviewed. The census was 78.

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to schedule a blood transfusion as ordered for Resident #273 after critical laboratory (lab) results were received. This resulted in actual harm when Resident #273 was hospitalized due to symptoms of chest pain and shortness of breath and required blood transfusions. This affected one (Resident #273) of three residents reviewed for hospitalization. Additionally, the facility failed to ensure Resident #24's wound dressing was applied as ordered. This affected one (Resident #24) of one resident reviewed for wound care. The facility failed to ensure Resident #34 received timely antibiotic treatment for a Urinary Tract Infection (UTI). This affected one (Resident #34) of three residents reviewed for UTIs. The facility failed to ensure a resident received timely treatment following a fall. [...]

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to conduct initial and quarterly care conferences. This affected four (Residents #173, #174, #33, and #14) of six residents reviewed for care conferences. Additionally, the facility failed to update residents care plans. This affected two (Residents #24 and #34) of six residents reviewed for care planning. The facility census was 72.

Inspectors wroteBased on medical record review, observation, staff interview, resident interview, and review of facility policy, the facility failed to provide adequate grooming services for two (Residents #60 and #2) of two reviewed for grooming. Additionally, the facility failed to ensure residents received scheduled/preferred showers. This affected three (Residents #33, #14, and #46) of three residents review for bathing. The census was 72.

Inspectors wroteBased on record review, observation, interview and policy review, the facility failed to ensure a root cause analysis was completed on a resident who suffered a fall with a fracture. This affected one (Resident #62) of four residents reviewed for falls. The facility also failed to ensure water temperatures in resident rooms were below 120 degrees Fahrenheit (F). This had the potential to affect 57 (Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #14, #15, #16, #17, #18, #19, #21, #22, #23, #24, #26, #27, #29, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #43, #44, #45, #46, #47, #48, #50, #51, #52, #53, #54, #55, #56, #57, #59, #60, #61, #62, #63, #64, #65, #67 and #68) residents who resided on the 100, 200 and 300 halls. The census was 72.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure food was properly stored in the refrigerator, freezer, and dry storage areas. This affected all residents except Residents #51 #60 and #63 who do not eat food from the kitchen. The census was 72.

Inspectors wroteBased on medical record review, observation, staff interview, and resident interview, the facility failed to timely respond to a resident's request to return to bed and use the bed pan. This affected one (Resident #46) of two residents reviewed for accommodations of needs and dignity. Additionally, facility failed to ensure residents were able to eat meals in the dining room. This affected all residents accept Residents #51, #60 and #63 who did not eat food from the kitchen. The census was 72.

Inspectors wroteBased on record review, interview and policy review, the facility failed to notify a resident's representative of changes in condition that required physician intervention. This affected two (Residents #62 and #34) of two residents reviewed for notification for change in condition. The census was 72.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide ongoing re-evaluation for the need of a seatbelt/restraint and failed to initiate a care plan with interventions for the use of a seatbelt/restraint. This affected one (Resident #62) of one resident reviewed for physical restraints. The facility census was 72.

Inspectors wroteBased on interview and record review, facility failed to ensure residents received requested vision services. This affected one (Resident #55) of two residents reviewed for vision services. Facility census was 72.

Inspectors wroteBased on medical record review, observation, staff interview, review of facility policy, and review of manufacturer's guidelines, the facility failed to ensure medications were stored and labeled properly. This affected two (Residents #6 and #25) of five residents reviewed for medications. The census was 72.

Inspectors wroteBased on record review, observation and interview, the facility failed to provide adaptive equipment during meal service. This affected one (Resident #62) of one resident reviewed for adaptive equipment. The census was 72.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide written notice of transfer to residents or their representatives. This affected five (Residents #3, #31, #66, #273, and #73) of five residents reviewed for transfer to the hospital. The census was 72.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide bed hold notices to residents or their representatives. This affected five (Residents #3, #31, #66, #273, and #73) of five residents reviewed for transfer to the hospital. The census was 72.

Inspectors wroteBased on review of personal funds account balances, facility surety bond, and interview, the facility failed to ensure the surety bond was sufficient to cover account balances. This had the potential to affect 38 Residents (#2, #5, #8, #11, #16, #18, #19, #20, #22, #25, #27, #28, #30, #32, #33, #35, #36, #37, #38, #39, #43, #46, #48, #50, #57, #62, #63, #64, #66, #67, #70, #71, #73, #77, #81, #87, #90, and #92) whom had a personal funds account managed by the facility. Facility census was 104.

Inspectors wroteBased on record review and interview, the facility failed to ensure the ombudsman, residents and/or their representatives were notified of transfer or discharge in writing. This affected five (#3, #22, #68, #92 and #100) of five residents reviewed. The facility census was 104.

Inspectors wroteBased on observation, staff interview, record review, and review of Food From Outside Sources and In-Room Refrigerators Policy, the facility failed to ensure food items were properly labeled, covered, discarded and the pantry refrigerator was maintained at an acceptable temperature. This had the potential to affect 68 residents (#2, #3, #4, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #24, #25, #27, #28, #29, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #42, #43, #44, #46, #47, #48, #50, #51, #54, #56, #58, #59, #62, #64, #65, #66, #67, #68, #69, #71, #73, #74, #77, #79, #81, #82, #85, #90, #95, #96, #97, #150, #250) whom resided on the 100, 200, and 300 halls. The facility census was 104.

Inspectors wroteBased on observation, medical record review, staff and resident interview, the facility failed to ensure a resident was provided dignity when staff placed her name on the front of her shirt. This affected one (#33) of one resident reviewed for dignity. The census was 104.

Inspectors wroteBased on record review and interview, the facility failed to complete a Pre admission Screen and Record Review (PASARR) when a resident was diagnosed with a mental illness. This affected one (#2) of one resident reviewed for PASARR. The facility census was 104.

Inspectors wroteBased on medical record review and staff interview, the facility failed to timely provide baseline care plans to resident's and/or their responsible party. This affected one (#43) of 13 residents reviewed for baseline care plans. The total facility census was 104.

Inspectors wroteBased on medical record review and staff interview, the facility failed to timely review and revise a resident's comprehensive care plans to ensure the care plan accurately reflected the residents status and care needs. This affected one (#12) of 28 resident care plans reviewed during the survey. The total facility census was 104.

Inspectors wroteBased on medical record review, observation and staff and resident interview the facility failed to ensure water that was accessible to residents was at an acceptable temperature. This affected one (#11) of one resident reviewed for accidents. The total facility census was 104.

Inspectors wroteBased on observations, medical record review, staff and resident interview and policy review, the facility failed to properly manage Resident #41's pain while providing tracheostomy care. This affected one (#41) of four residents reviewed for pain management program. The facility identified 74 residents who were on a pain management program. Facility census was 104.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a residents narcotic pain medication was reordered timely. This affected one (#54) of four residents reviewed for pain management program. The facility identified 74 residents who were on a pain management program. Facility census was 104.

Inspectors wroteBased on record review, and facility staff interview the facility failed to timely respond to pharmacy recommendations, this affected one (#2) of five residents reviewed for unnecessary medications. The total facility census was 104. Findings Include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of weakness, shortness of breath, dyspnea, idiopathic peripheral autonomic neuropathy, hypertension, osteoarthritis, depression, constipation, chronic obstructive pulmonary disease, glaucoma repeated falls and hyperlipidemia. Review of the most recent quarterly Minimum Data Set revealed the resident was cognitively impaired, had hallucinations, but no other behaviors. The resident required extensive assist for bed mobility, transfers, dressing, toileting and was supervision for eating. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to store medications as per manufacturer recommendation for Resident #32. This affected one of four medication carts observed. The facility has seven medication carts. Findings Include: Observation of 200-1 medication cart with Licensed Practical Nurse (LPN) #79 on 07/12/19 at 1:41 P.M. revealed Latanoprost 125 micrograms (mcg.)/25 milliliters (ml.) ophthalmic solution was undated. LPN #79 confirmed there was no date on the bottle and the resident was ordered to have the medication at bedtime with the dose for administration being one drop to each eye. LPN #79 confirmed the medication was initially ordered in April 2019 and the facility re-ordered the medication in May 2019 and no medication had been ordered since May 2019. [...]

Inspectors wroteBased on observation, record review and interview, the facility to ensure a resident with missing dentures was referred to a dentist for treatment. This affected one (Resident #41) of three reviewed for personal property. The census was 104.

Inspectors wroteBased on medical record review, observation, staff interview and policy review, the facility failed to ensure staff washed their hands after providing care to a resident who was in isolation for Clostridium difficile (C-diff). This affected one (#41) of one resident reviewed for handwashing in C-diff isolation. The facility identified only one resident (#41) in C-diff isolation.