Brickyard Healthcare -Sycamore Village Care Center

In the surveyor’s words

From the most serious findings on record at Brickyard Healthcare -Sycamore Village Care Center, in the surveyor’s own words.

• Actual harm, isolatedF742Feb 10, 2021

  Based on interview and record review, the facility failed to provide mental health services to a resident with a [DIAGNOSES REDACTED]. (Resident C) This resulted in harm when Resident C received a self-inflicted wound and was admitted to a psychiatric hospital. Finding includes: The record for Resident C was reviewed on 2/8/2021 at 2:13 p.m. [DIAGNOSES REDACTED]. An admission Election of Ancillary Services, not dated, indicated the resident agreed to behavioral health services. A physician's orders [REDACTED]. A Minimum Data Set (MDS) assessment, dated 11/6/2020, indicated the residents PHQ 9 (patient health questionnaire) was 10. The score of 10 indicated the resident was exhibiting moderate symptoms of depression. […]

• No harm, potential for more than minimal, widespreadF812Jan 9, 2026

  Based 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.Findings include:During the kitchen observation, on 1/4/26 at 10:58 a.m., with the Dietary Manager (DM), the following were observed:a. The walk-in refrigerator contained two 16-ounce cans of Pepsi open, two cans of Pepsi not open, one 16-ounce bottle of water opened, a thirty-two-ounce bottle of Coffee Mate French Vanilla liquid creamer with no sugar and a Gordons choice whipped topping. All without a date or label.b. Four empty cardboard boxes were not broken down and stacked on the floor by the back exit door. c. […]

• No harm, potential for more than minimal, patternF761Dec 19, 2024

  Based 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) Findings include: 1. During an observation, on 12/18/24 at 10:45 a.m., the North medication cart had five compromised controlled substance cards. a. The clinical record for Resident 14 was reviewed on 12/18/24 at 11:35 a.m. The diagnoses included, but were not limited to, insomnia and anxiety disorder A card of quviviq (for insomnia) 25 milligram (mg) tablet for Resident 14 had clear tape covering the back of the number 6 slot. b. The clinical record for Resident 42 was reviewed on 12/18/24 at 11:40 a.m. […]

• No harm, potential for more than minimal, patternF567Oct 3, 2023

  Based 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) Findings include: A facility incident report, dated 9/12/23, indicated Unit Manager 10 was utilizing Kohl's cash which was rewarded when purchasing resident items to assist them in spending down their resident accounts. During the investigation, it was discovered Unit Manager 10 had purchased items for 4 residents between 2022-2023 and had received Kohl's cash during the purchases and it was not returned to the residents. 1. The record for Resident B was reviewed on 9/27/23 at 5:02 p.m. […]

• No harm, potential for more than minimal, patternF602Oct 3, 2023

  Based on interview and record review, the facility failed to ensure residents' personal property was not used by staff for 4 of 4 residents reviewed for misappropriation of property. (Residents B, E, F and D) Findings include: A facility incident report, dated 9/12/23, indicated Unit Manager 10 was utilizing Kohl's cash which was rewarded when purchasing resident items to assist them in spending down their resident accounts. During the investigation, it was discovered Unit Manager 10 had purchased items for 4 residents between 2022-2023 and had received Kohl's cash during the purchases and it was not returned to the residents. 1. The record for Resident B was reviewed on 9/27/23 at 5:02 p.m. […]