Sycamore Trails Post Acute

In the surveyor’s words

From the most serious findings on record at Sycamore Trails Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 27, 2024

  Based 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. Findings include: Review of the medical record for Resident #70 revealed an admitted [DATE]. […]

• Actual harm, isolatedF684Aug 25, 2022

  Based 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 [CONDITION(S)]. 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF803May 16, 2024

  Based 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. Findings include: Review of the May 2024 Menu revealed the posted breakfast for 05/13/24 was cold cereal, hard boiled egg, bagel, fruit cup and two percent milk. Observation on 05/13/24 from 9:06 A.M. to 9:28 A.M. of three residents (#33, #55 and #70) breakfast trays revealed their tickets did not match what was served. […]

• No harm, potential for more than minimal, patternF755Dec 30, 2024

  Based 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. Findings include: 1. Review of the medical record for Resident #29 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, Chronic Obstructive Pulmonary Disease (COPD), and DM II. Review of the admission MDS assessment dated [DATE] revealed Resident #29 had intact cognition as evidenced by a BIMS score of 13. […]

• No harm, potential for more than minimal, patternF689May 16, 2024

  Based 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. Findings include: 1. Review of medical record for Resident #54 revealed admitted [DATE] admitted to hospice on 11/22/23. […]