Sycamore Care Strategies

In the surveyor’s words

From the most serious findings on record at Sycamore Care Strategies, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 16, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689May 2, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF921Dec 5, 2025

  Based 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])Findings include:1. […]

• No harm, potential for more than minimal, patternF550Mar 19, 2025

  Based 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) Findings include: 1. During a random continuous observation on 3/12/25 at 12:34 P.M., a resident seated in the main dining room asked a staff member for water to drink and indicated they had been there for a long time waiting for their trays. […]

• No harm, potential for more than minimal, patternF641Mar 19, 2025

  Based 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) Findings include: 1. During an observation on 3/12/25 at 10:26 A.M., Resident 7's bed was observed with half size side rails. On 3/13/25 at 2:10 P.M., Resident 7's clinical record was reviewed. […]