Sycamore Heights Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Sycamore Heights Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Apr 12, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689Apr 12, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF576Sep 20, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Sep 20, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF656Sep 20, 2024

  Based 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. […]