Inspection Reports for
Sycamore Heights Health and Rehabilitation
2141 SYCAMORE AVENUE, LOUISVILLE, KY, 40206
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 20, 2025
Visit Reason
An Abbreviated Survey was initiated on 02/18/2025 investigating complaints KY00045053, KY00045054, KY00044990, and KY00043864 and concluded on 02/20/2025.
Findings
There was no deficient practice identified during the abbreviated survey.
Inspection Report
Routine
Deficiencies: 4
Date: Sep 20, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, activities of daily living, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure residents received mail on Saturdays, failure to implement comprehensive care plans for residents related to oxygen therapy, smoking safety, and toileting/incontinence care. Additionally, infection prevention and control practices were inadequate, including improper use of PPE and failure to sanitize equipment between residents.
Deficiencies (4)
Failed to ensure residents had reasonable access to and privacy in their use of communication methods, specifically mail delivery on Saturdays.
Failed to develop and implement a complete care plan that meets all the resident's needs, including oxygen therapy settings, smoking apron use, and toileting assistance for three sampled residents.
Failed to provide care and assistance to perform activities of daily living for a resident unable to do so, specifically related to toileting and incontinence care.
Failed to provide and implement an infection prevention and control program, including improper PPE use and failure to sanitize equipment between residents.
Report Facts
Sampled residents: 25
Residents affected: 3
Residents affected: 1
Residents affected: 5
Oxygen liters per minute: 2
BIMS score: 15
BIMS score: 14
BIMS score: 10
Observation duration: 120
Smoking opportunities: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| R83 | Resident | Named in smoking apron care plan deficiency |
| R52 | Resident | Named in toileting and incontinence care deficiency |
| R45 | Resident | Named in oxygen therapy care plan deficiency |
| R25 | Resident | Named in mail delivery deficiency |
| R70 | Resident | Named in mail delivery deficiency |
| Director of Nursing | Director of Nursing | Interviewed regarding mail delivery and care plan implementation |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding mail delivery and toileting care |
| Unit Manager 2 | Unit Manager | Interviewed regarding mail delivery and toileting care |
| Activities Director | Activities Director | Interviewed regarding mail delivery and smoking apron use |
| Administrator | Administrator | Interviewed regarding mail delivery, care plan compliance, and infection control |
| Registered Nurse 1 | Registered Nurse | Interviewed regarding care plan implementation |
| Registered Nurse 2 | Registered Nurse | Observed and interviewed regarding infection control and resident care |
| Registered Nurse 3 | Registered Nurse | Observed regarding infection control practices |
| Certified Medication Technician 3 | Certified Medication Technician | Observed administering medication improperly |
| State Registered Nurse Aide 4 | State Registered Nurse Aide | Interviewed regarding care for Resident 52 |
| State Registered Nurse Aide 9 | State Registered Nurse Aide | Interviewed and observed regarding care for Resident 52 |
| Social Services Director | Social Services Director | Interviewed regarding smoking apron care |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed regarding smoking apron care plan |
Inspection Report
Routine
Deficiencies: 6
Date: Sep 20, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, medication administration, infection control, and safety in a nursing home facility.
Findings
The facility was found deficient in multiple areas including failure to ensure residents received mail on Saturdays, incomplete advance directives for a resident under guardianship, failure to implement comprehensive care plans for residents related to oxygen therapy, smoking safety, and incontinence care, improper medication storage and administration practices, inadequate infection prevention and control measures, and failure to provide oxygen therapy as ordered.
Deficiencies (6)
Failed to ensure residents received mail on Saturdays, affecting all residents.
Failed to ensure Advanced Directives were completed by the Legal Guardian for one resident under guardianship.
Failed to implement comprehensive care plans related to oxygen therapy, smoking safety, and incontinence care for three residents.
Failed to ensure drugs were stored under proper temperature controls and labeled according to professional principles.
Failed to establish and maintain an infection prevention and control program, including failure to use PPE and sanitize equipment properly.
Failed to provide oxygen as ordered for one resident, with oxygen set higher than prescribed.
Report Facts
Residents sampled: 25
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 5
Residents affected: 1
Oxygen liters per minute ordered: 2
Oxygen liters per minute observed: 3
Medication refrigerators with ice packs: 3
Ice packs observed: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN2 | Registered Nurse | Failed to sanitize blood pressure machine and did not don PPE for Enhanced Barrier Precautions |
| RN3 | Registered Nurse | Failed to sanitize blood pressure machine and improperly handled medication |
| RN4 | Registered Nurse | Stated responsibility to check oxygen settings and medication storage |
| Unit Manager 2 | Unit Manager | Provided expectations on medication disposal and PPE use |
| Assistant Director of Nursing | ADON | Provided expectations on medication disposal, PPE use, and resident care |
| Director of Nursing | DON | Provided expectations on medication disposal, PPE use, and resident care |
| Administrator | Administrator | Provided expectations on medication disposal, PPE use, and resident care |
| Certified Medication Technician 3 | CMT | Dropped pill and picked it up with ungloved hand |
| Family Member 5 | Reported ongoing issues with resident care and toileting | |
| Family Member 6 | Reported ongoing issues with resident care and toileting | |
| Activity Director | AD | Provided information on mail delivery and smoking interventions |
| Activities Assistant | AA | Provided information on smoking safety list |
| Minimum Data Set Coordinator | MDS Coordinator | Provided information on smoking safety and care plan interventions |
| State Guardian | SG | Provided information on resident guardianship and advance directives |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 12, 2024
Visit Reason
The inspection was conducted following a complaint and incident involving Resident #7 assaulting Resident #6 with a plastic fork, resulting in serious injury to Resident #6. The investigation focused on the facility's failure to develop and implement an effective comprehensive care plan and provide adequate supervision to prevent accidents and hazards.
Complaint Details
The complaint investigation was triggered by an incident on 03/11/2024 where Resident #7 assaulted Resident #6 with a plastic fork, causing serious injuries including facial lacerations and eye trauma. The facility was found to have failed in monitoring and supervision, and the incident was substantiated with immediate jeopardy identified on 04/01/2024 and removed on 03/15/2024.
Findings
The facility failed to develop and implement a comprehensive care plan with effective interventions to protect residents from hazards, specifically failing to monitor Resident #7 who had hallucinations and manipulated objects into weapons. This failure led to Resident #7 assaulting Resident #6, causing serious injuries. The facility also failed to provide adequate supervision to prevent accident hazards, resulting in immediate jeopardy to resident health and safety.
Deficiencies (2)
Failure to develop and implement a complete care plan that meets all the resident's needs, with measurable timetables and actions, specifically for Resident #7 who manipulated objects into weapons.
Failure to provide adequate supervision and monitoring to prevent accident hazards, resulting in Resident #6 being assaulted by Resident #7.
Report Facts
Residents sampled: 15
Residents affected: 2
BIMS score: 0
BIMS score: 1
Date of incident: Mar 11, 2024
Date of Immediate Jeopardy identification: Apr 1, 2024
Date of Immediate Jeopardy removal: Mar 15, 2024
Date of survey completion: Apr 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #3 | Registered Nurse | Documented progress notes on the incident and was assigned to care for Residents #6 and #7 on the night of the incident |
| Social Services Director #18 | Social Services Director | Developed Resident #7's care plan and had firsthand knowledge of his hallucinations and use of objects as weapons |
| Dietary Manager #21 | Dietary Manager | Managed the intervention of serving Resident #7 plastic utensils and removal of utensils after meals |
| Director of Nursing | Director of Nursing | Involved in internal investigation and provided statements about supervision and care plan changes |
| Registered Nurse #4 | Registered Nurse | Provided care for Resident #7 and gave interview about resident's hallucinations and staff monitoring |
| Certified Nurse Aide #8 | Certified Nurse Aide | Cared for Resident #7 on the evening of the incident and described utensil removal process |
| Metro Police Officer #22 | Police Officer | Responded to the incident, observed the scene, and provided statements about staff response |
| Psych Nurse Practitioner #4 | Psychiatric Nurse Practitioner | Provided psychiatric care and assessment of Resident #7 |
| Nurse Practitioner #3 | Nurse Practitioner | Provided medical progress notes on Resident #6's injuries |
| Certified Nurse Aide #3 | Certified Nurse Aide | Assigned to care for Residents #6 and #7 on the night of the incident and described staff fear and response |
Inspection Report
Routine
Deficiencies: 12
Date: Apr 5, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations, including laundry services, grievance resolution, environment cleanliness, wound care, medication administration, dental services, and infection control.
Findings
The facility was found deficient in multiple areas including failure to return residents' personal clothing in a timely manner, ineffective grievance resolution related to missing clothing, unsanitary conditions in a shower room, failure to obtain wound care orders upon readmission, incomplete care plans for residents, inadequate supervision to prevent falls, improper oxygen therapy administration, delayed pain management, unsecured medication carts, failure to provide timely emergency dental services, inaccurate documentation of controlled medications, and improper infection control during wound care.
Deficiencies (12)
Failed to ensure residents received their personal clothing items back from laundry in a timely manner for eight sampled residents.
Failed to act upon and effectively resolve grievances from Resident Council related to missing clothing.
Failed to provide a clean and sanitary environment in one of two shower rooms, with observations of black matter, cracked tiles, soiled briefs, and other soiled items.
Failed to obtain wound care orders upon readmission for one resident with a surgical wound.
Failed to implement or develop the care plan for two residents, including failure to prevent a fall and failure to develop a care plan related to dental problems.
Failed to provide effective supervision to prevent accidents for one resident who fell and sustained a hip fracture while transferring without assistance and not wearing non-skid footwear.
Failed to ensure oxygen therapy was administered according to physician's order and failed to check oxygen saturation levels every shift for one resident.
Failed to ensure timely treatment and care to manage pain for one resident who fell and sustained a hip fracture, with delayed hospital transfer and inadequate pain assessment and documentation.
Failed to ensure medications were stored securely in two of five medication carts.
Failed to obtain emergency dental services for one resident, resulting in delayed dental evaluation and treatment.
Failed to ensure controlled medications were accurately documented, with discrepancies between Controlled Drug Record and Medication Administration Record for one resident.
Failed to maintain infection control during wound care for one resident, including improper glove use and hand hygiene.
Report Facts
Residents affected: 8
Residents affected: 8
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication carts unsecured: 2
Residents affected: 1
Controlled medication doses not documented: 63
Controlled medication doses not documented: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Named in pain management, wound care, and medication documentation deficiencies |
| LPN #6 | Licensed Practical Nurse | Named in pain management and medication documentation deficiencies |
| CNA #1 | Certified Nursing Assistant | Named in laundry and grievance deficiencies |
| CNA #2 | Certified Nursing Assistant | Named in laundry and grievance deficiencies |
| CNA #3 | Certified Nursing Assistant | Named in laundry, grievance, and fall supervision deficiencies |
| CNA #4 | Certified Nursing Assistant | Named in laundry and shower room cleanliness deficiencies |
| CNA #5 | Certified Nursing Assistant | Named in fall supervision deficiency |
| LPN #3 | Licensed Practical Nurse | Named in medication cart security deficiency |
| LPN #4 | Licensed Practical Nurse | Named in medication cart security deficiency |
| Housekeeping Supervisor | Named in shower room cleanliness deficiency | |
| Housekeeper | Named in shower room cleanliness deficiency | |
| Maintenance Director | Named in shower room cleanliness deficiency | |
| Director of Nursing | Named in multiple deficiencies oversight | |
| Assistant Director of Nursing | Named in multiple deficiencies oversight | |
| Unit Manager | Named in medication cart security and dental services deficiencies | |
| Social Services Director | Named in grievance and dental services deficiencies | |
| Administrator | Named in multiple deficiencies oversight |
Inspection Report
Routine
Deficiencies: 6
Date: Jan 19, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, wound care, environmental safety, infection control, and food safety in the nursing home.
Findings
The facility failed to ensure proper medication self-administration assessment and monitoring, adequate wound care and care plan revisions for pressure ulcers, safe medication storage and administration practices, maintenance of a pest-free kitchen environment, and implementation of infection control practices including proper handling of treatment supplies and equipment sanitation.
Deficiencies (6)
Failure to ensure Resident #45 was assessed and authorized to self-administer medications safely, with medications found unsecured and expired inhaler present.
Failure to revise Resident #12's care plan with necessary interventions to promote wound healing and prevent pressure ulcers, including elevating heels and proper wound care communication.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for Resident #12, with inadequate wound monitoring and communication among staff.
Failure to maintain a safe environment free from hazards, with unattended pills found at Resident #44's bedside and medication found on the floor.
Failure to ensure a clean and sanitary kitchen environment, with live and dead bugs observed and inadequate pest control measures.
Failure to implement infection control practices, including improper handling of treatment supplies by nursing staff and failure to date and properly store oxygen and nebulizer equipment for Resident #45.
Report Facts
Sampled residents: 15
Unused vials of medication: 3
Blister size: 4.5
Blister depth: 0.1
Medication doses: 1
Medication doses: 2
Pest sightings: 8
Oxygen liters: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding medication self-administration, wound care, medication safety, and infection control |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding medication self-administration and infection control practices |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding wound care and communication failures |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding medication safety concerns |
| Registered Nurse | Registered Nurse | Observed and interviewed regarding improper handling of treatment supplies |
| Dietary Manager | Dietary Manager | Interviewed regarding pest control issues in kitchen |
| Maintenance Technician | Maintenance Technician | Interviewed regarding pest control and bug sightings |
| Dietary Aide | Dietary Aide | Interviewed regarding increase in bugs in kitchen |
| Administrator | Administrator | Interviewed regarding medication safety, pest control, infection control, and facility oversight |
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