Sycamore Run Nursing and Rehab CTR

In the surveyor’s words

From the most serious findings on record at Sycamore Run Nursing and Rehab CTR, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF755Feb 5, 2023

  Based on record review, review of medication administration times form, review of pharmacy contract, review of pharmacy delivery invoices, review of the swing kit (emergency box) replacement forms, review of the swing kit contents, review of medication and treatment errors and omissions reports, review of 12/25/22 census sheet, review of the Quality Improvement Plan, review of MapQuest, review of policies, observation, and interviews the pharmacy failed to ensure the facility maintained an adequate plan and supply of scheduled oral prescription medications during holidays and inclement weather to prevent the interruption of routine medication administration. […]

• No harm, potential for more than minimal, isolatedF695Apr 30, 2026

  Based on medical record review, observation, interview, and medication manufacturer guideline review the facility failed to provide respiratory care following inhaled respiratory medication as administered. This deficient practice affected two residents (Resident #3 and #11) out of three residents reviewed for respiratory medication administration. The facility census was 90. 1.Review of Resident #11's medical record revealed admission date 02/27/26 with diagnoses including but not limited to Chronic Obstructive Pulmonary Disease (COPD), emphysema, and heart disease.Review of Resident #11's physician orders revealed an order dated 03/04/26 for respiratory medication Ellipta 62.5 micrograms (MCG) per actuation Aerosol Powder, breath activated 1 puff inhale orally one time a day related to… […]

• No harm, potential for more than minimal, isolatedF761Apr 30, 2026

  Based on record review, observation, interview and facility policy review the facility failed to ensure medications were labeled and stored securely. This deficient practice affected one resident (Resident #42) out of 10 residents reviewed for medication administration. The facility census was 90.Findings Include:Review of Resident #42's medical record revealed admission date 04/14/26 with diagnoses including but not limited to type two Diabetes, vascular dementia, and Congestive Heart Failure (CHF).Review of Resident #42's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #42 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of four out of possible 15 and required assistance from staff to complete Activities of Daily Living (ADL) tasks.Review of… […]

• No harm, potential for more than minimal, isolatedF880Apr 30, 2026

  Based on record review, observation, interview and facility policy review the facility failed to follow infection control procedures related to medication administration This deficient practice affected one resident (Resident #42) of 10 residents reviewed for medication administration. The facility census was 90. Findings include:Findings Include:Review of Resident #42's medical record revealed admission date 04/14/26 with diagnoses including but not limited to type two Diabetes, vascular dementia, and Congestive Heart Failure (CHF).Review of Resident #42's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #42 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of four out of possible 15 and required assistance from staff to complete Activities of… […]

• No harm, potential for more than minimal, isolatedF686Jan 21, 2026

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEYBased on record review, interview and policy review, the facility failed to ensure residents were assessed for alterations in skin integrity upon admission. This deficient practice affected one resident (Resident #89) out of two residents reviewed for alterations in skin integrity. The facility census was 88.Findings include: Review of Resident #89 ' s medical record revealed an admission dated 12/23/25 and a discharge date [DATE] against medical advice (AMA) with diagnoses including but not limited to urinary tract infection (UTI), spina bifida, asthma, dysphagia, and dependence on wheelchair for mobility.Review of Resident #89 ' s physician orders revealed an order… […]