Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sycamore Care Strategies during CMS and state inspections, most recent first.
A resident with Alzheimer's disease, dementia, and severely impaired cognition, who was assessed as an elopement risk and used a Wanderguard device, was taken outside for a porch activity and left unattended when an activities assistant went inside with another resident. During the unsupervised interval, the resident left the property and was later found by a community bystander about 0.8 miles away, appearing lost and asking to be taken home, before being returned without visible injury. Staff interviews showed that while nursing staff knew the resident wandered and approached exits, activities staff were not aware of the resident’s elopement risk status.
A shared shower room and a resident bathroom were found with musty odors, visible mold, discolored tiles, dust buildup, exposed sticky traps with dead insects, and debris. Uncovered urine collection hats and resident care items were improperly stored in the bathroom. Staff confirmed the presence of mold and improper storage practices, and there was no policy in place for maintaining the environment in these areas.
The facility failed to maintain resident dignity and timely meal service, as observed during dining. A resident waited 12 minutes for water, and another was fed without interaction. Understaffing led to meal delays, with only one CNA passing trays on two halls. Promised coffee was not delivered to a resident, and another was served without a clothing protector. The DON acknowledged the need for more staff during meals.
The facility failed to ensure accurate resident assessments, with side rails incorrectly marked as restraints and discrepancies in medication records. Observations showed that side rails intended for mobility were documented as restraints for several residents. Additionally, a resident was marked as taking a hypnotic, but records showed no such medication was administered. Another resident was noted to have been prescribed opioids, yet no opioids were given during the review period. The DON acknowledged these errors, citing incorrect MDS entries and reliance on the RAI manual.
The facility failed to implement comprehensive care plans for residents, leading to unmet needs. A resident with mobility issues had their call light and reaching device out of reach, despite orders for accessibility. Another resident, requiring assistance with eating, was left unattended in the dining room. Additionally, a resident on antipsychotic medication lacked a care plan for its use. These deficiencies indicate a failure to adhere to care plans and physician orders.
The facility failed to maintain proper infection control practices, including not disinfecting equipment between residents, inadequate hand hygiene during incontinence and wound care, and improper use of PPE for a resident on Enhanced Barrier Precautions. These deficiencies involved multiple residents and staff, highlighting lapses in maintaining a safe and sanitary environment.
The facility was found deficient in maintaining a safe and sanitary environment, with issues such as soiled grout and leaking fixtures in the shower room, cracked and sharp plastic on a room door, and flaking leather on resident wheelchairs. Additionally, a resident's recliner had a strong urine odor, and loose carpeting created an uneven floor surface. These deficiencies were observed over several days, indicating a lack of timely maintenance and cleaning.
A facility failed to clarify a resident's code status, resulting in a mismatch between the physician's order and the signed POST form. The resident, with severe cognitive impairment, had a physician's order for full code status, while the POST form indicated DNR. Staff interviews revealed reliance on the EHR, which showed the incorrect status, and the discrepancy was not corrected, violating the facility's Advance Directives Policy.
The facility failed to provide Advanced Beneficiary Notices (ABN) to two residents whose Medicare Part A services were terminated, leaving them unaware of potential financial liabilities for non-covered services. Staff interviews revealed a lack of awareness and policy regarding ABN issuance.
A resident with dementia, at high risk for falls, repeatedly attempted to leave her chair, triggering alarms and becoming agitated. Despite expressing needs such as wanting water and needing the bathroom, staff did not offer activities or environmental changes to address her needs. The care plan lacked details on her preferences, and facility policies on dementia care were not followed.
A resident with dementia exited a facility through an unsecured window, walking 2.4 miles before being found by law enforcement. The resident, at risk for elopement, was not adequately supervised, and the facility failed to secure windows, contributing to the incident. The resident sustained injuries from falls during the elopement.
Elopement of Cognitively Impaired Resident Left Unsupervised Outdoors
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for a resident at risk for elopement, resulting in the resident leaving the facility property during an outdoor activity. The resident, who had diagnoses including Alzheimer's disease, dementia, and anxiety, had severely impaired cognition per both admission and quarterly MDS assessments and was known to wander. Her assessments identified her as at risk for elopement due to wandering behavior, including aimless wandering and a verbalized desire to go home. Her care plan documented that she was at risk for elopement related to her Alzheimer's disease, dementia, and wandering, and that a Wanderguard device had been placed on her ankle, with physician orders to check the placement and functioning of the device every shift. On the day of the incident, the resident participated in an outdoor porch activity supervised by an activities assistant. The activities assistant brought another resident inside and left the remaining residents, including this resident, unattended on the front porch for approximately five minutes. When the activities assistant returned, the resident was no longer on the porch. Staff then searched in and around the facility before determining the resident could not be located and calling 911 to report an elopement. The facility’s own documentation indicated that the activities assistant acknowledged that residents with dementia diagnoses should not be left unattended outside. Shortly after the search and notification to emergency services, a community bystander, who had encountered the resident approximately 0.8 miles from the facility, returned her to the facility. The bystander reported that the resident appeared lost, was dressed in warm clothing that seemed unusual for being outside, and had asked to be brought home when offered assistance. Upon return, the resident had no visible injuries. Interviews with staff, including an RN and activities assistants, confirmed that the resident was known to wander within the facility and attempt to access exit doors, but activities staff were not aware that she was specifically identified as an elopement risk prior to the incident.
Failure to Maintain Sanitary and Homelike Resident Bathrooms and Shower Room
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in both a shared resident bathroom and a shared shower room. Observations revealed that the shared shower room had a persistent musty odor, visible mold-like dark circular areas around ceiling vents, discolored and possibly moldy or mildewed shower tiles, missing paint on walls, a displaced shut-off valve cover exposing a sticky trap with dead insects and droppings, dust accumulation on an overhead heater, and debris behind the commode. Staff interviews confirmed the presence of mold and cleanliness issues in the shower room, and the Housekeeping Manager stated that despite daily cleaning and deep cleaning efforts, the tile discoloration persisted. Maintenance staff were identified as responsible for the overhead vents. In the shared restroom between resident rooms, two uncovered urine collection hats were stored between the handrail and wall on each side of the commode, and two packages of briefs along with a pack of wipes were left on the floor next to the commode. The Infection Preventionist confirmed that urine sample hats should be stored in a facility storage closet until use and that resident care items should not be stored on the bathroom floor. The DON indicated there was no policy related to the resident environment in shared shower rooms and bathrooms. These findings were based on direct observation, staff interviews, and record review.
Failure to Maintain Resident Dignity and Timely Meal Service
Penalty
Summary
The facility failed to treat residents with respect and dignity during dining observations over two days. On one occasion, a resident in the main dining room requested water and had to wait 12 minutes before receiving it. Another resident, Resident 29, was fed by a CNA who did not engage in conversation with her throughout the meal. The CNA was observed attending to multiple residents simultaneously, which included picking up a roll from the floor, cueing another resident to eat, and addressing other residents' needs, all while feeding Resident 29 without any interaction. Additionally, the facility was understaffed during meal service, leading to delays in serving food. CNA 15 was the only staff member passing trays on two halls, while a nurse was present at the nurse's station but did not assist. In the main dining room, there were periods when no staff were present to pass trays, and the Administrator and other staff members did not assist in serving meals. This resulted in residents waiting for extended periods before receiving their meals. Specific incidents included Resident 1 being promised coffee, which was not delivered, and Resident 8 being served pureed food without a clothing protector, only a napkin. The Director of Nursing acknowledged that there should have been at least two staff members in the dining room during meals and that the delays and lack of attention to residents' needs were not acceptable. The facility's policies on dignity and assistance with meals were not adhered to, as evidenced by the observations.
Inaccurate Resident Assessments and Medication Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected their status, particularly concerning the use of physical restraints and unnecessary medications. Observations and record reviews revealed that side rails, intended for mobility, were incorrectly documented as physical restraints for several residents. For instance, Resident 7, who had severe cognitive impairment, was noted to use side rails daily as a physical restraint, despite assessments indicating they were for mobility enhancement. Similarly, Residents 23, 25, and 28 were observed with side rails marked as restraints, although assessments suggested they were for promoting independence and mobility. Additionally, discrepancies were found in medication administration records. Resident 23 was marked as taking a hypnotic, but the medication administration record showed no hypnotic was given during the review period. Instead, the resident was on Remeron for insomnia, which was incorrectly categorized. Resident 30 was noted to have been prescribed opioids, yet the medication administration record indicated no opioids were administered during the specified timeframe. The Director of Nursing acknowledged these errors, attributing them to incorrect entries on the MDS assessments and a lack of a specific policy for completing these assessments, relying instead on the Resident Assessment Instrument manual.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. Resident 9, who had diagnoses including chronic obstructive pulmonary disease, impaired mobility, and diabetes mellitus type II, was observed multiple times with his call light and reaching device out of reach, despite physician orders and a fall risk care plan indicating these should be accessible. Resident 9 confirmed that he had difficulty finding these items, which were essential for his safety and communication needs. Resident 1, diagnosed with dementia, hallucinations, and depression, was observed in the dining room with her meal tray untouched and without assistance, despite a care plan indicating she required help with eating due to impaired mobility. Staff did not assist her, and she was seen feeding herself very slowly without support. Additionally, Resident 30, who was on an antipsychotic medication, lacked a care plan addressing the use of this medication, contrary to the facility's policy as stated by the Director of Nursing. These observations highlight the facility's failure to adhere to care plans and physician orders, resulting in unmet needs for the residents.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, leading to the potential transmission of communicable diseases and infections. During observations, staff did not adhere to proper infection control protocols. For instance, a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) used a wrist blood pressure cuff and pulse oximeter on multiple residents without disinfecting the equipment between uses. This occurred during medication administration and vital sign checks, involving Residents 2 and 22, and during a random observation with Residents 29 and 26. Incontinence care procedures were also found lacking in infection control practices. Certified Nurse Aides (CNAs) were observed not changing gloves or sanitizing hands between dirty and clean tasks. For example, during incontinence care for Residents 1 and 25, CNAs did not change gloves or sanitize hands after handling soiled incontinence pads and before assisting with clean tasks, such as wiping the perineal area and adjusting clean incontinence pads. Additionally, staff failed to use proper Personal Protective Equipment (PPE) when interacting with a resident on Enhanced Barrier Precautions (EBP). CNA 26 entered Resident 30's room without wearing PPE, despite the presence of an EBP sign and a PPE cart outside the room. This resident had a wound on the buttock and was diagnosed with moderate dementia with behavioral disturbance. Furthermore, during wound care for Resident 30, RNs did not perform adequate hand hygiene, with handwashing lasting less than the recommended 20 seconds, and failed to sanitize hands between glove changes.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for its residents, as evidenced by multiple deficiencies observed in various areas. In the shower room, there was a missing tile at the entrance, soiled grout on the floor and walls, white buildup on the floor and handrails, and a leaking handheld shower head. Additionally, the toilet paper holder was missing, leaving the toilet paper exposed on the back of the toilet. These issues persisted over several days of observation. In resident rooms, several deficiencies were noted, including a cracked and sharp plastic cover on a room door, duct tape on a footboard, and loose carpeting causing an uneven floor surface. Resident wheelchairs and a Broda chair had flaking leather on the armrests, exposing the foam padding. A resident's recliner emitted a strong urine odor and had stained cushions. These conditions were observed repeatedly over multiple days, indicating a lack of timely maintenance and cleaning, as confirmed by the Director of Nursing during an interview.
Failure to Clarify Resident's Code Status
Penalty
Summary
The facility failed to clarify the code status for a resident, leading to a discrepancy between the physician's order and the signed Indiana Physician Orders for Scope of Treatment (POST) form. The resident, who had severe cognitive impairment due to dementia, had a physician's order indicating a full code status for cardiopulmonary resuscitation (CPR), while the POST form and the code status care plan indicated a Do Not Attempt Resuscitation (DNR) status. This inconsistency was not addressed, and the electronic health record (EHR) reflected the full code status, which was not updated to match the POST form. Interviews with staff revealed that the Registered Nurse (RN) relied on the EHR for the resident's code status, which showed the incorrect full code status. The Social Services Director (SSD) indicated that during care plan conferences, the resident's advance directive was discussed, and she checked for consistency between the code status care plan and the POST form. However, the discrepancy remained uncorrected, and the facility's Advance Directives Policy required that the plan of care be consistent with the resident's documented treatment preferences, which was not adhered to in this case.
Failure to Provide Advanced Beneficiary Notices
Penalty
Summary
The facility failed to provide appropriate notice of charges for services covered and not covered under Medicare for two residents. Both residents were discharged from Medicare Part A services but remained in the facility without receiving an Advanced Beneficiary Notice (ABN) for future services. Resident 5's Medicare Part A benefits ended on January 17, 2025, and Resident 14's benefits ended on January 31, 2025. Despite this, neither resident received the required ABN notice, which is necessary to inform them of their potential financial liability for services not covered by Medicare. Interviews with facility staff revealed a lack of awareness and policy regarding the issuance of ABN notices. The Social Services Director indicated that the therapy department was responsible for completing ABN notices, but the Business Office Manager and the Senior Administrator were unaware that such notices should have been issued for the residents in question. The Senior Administrator acknowledged the absence of a policy but stated that it would be their policy to follow the regulation for beneficiary notices.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, who was at high risk for falls. The resident was observed multiple times attempting to get out of a recliner, triggering the chair alarm, and becoming agitated. Despite these repeated attempts, the staff, including an LPN, did not offer any activities or changes in environment to address the resident's needs. The resident expressed needs such as wanting a drink of water and needing to use the bathroom, but these were not promptly addressed by the staff. The resident's clinical records indicated severe cognitive impairment and dependence on staff for daily activities. The dementia care plan lacked specific details about the resident's likes and dislikes, which could have been used to engage her and prevent agitation. Interviews with staff revealed some knowledge of the resident's preferences, such as enjoying mint ice cream sandwiches and music, but these were not utilized during the observed incidents. The facility's policies on quality of life and dementia care emphasized addressing the root causes of behavior and supporting residents in daily activities, which were not followed in this case.
Resident Elopement Due to Inadequate Supervision and Unsecured Windows
Penalty
Summary
The facility failed to ensure adequate supervision and a secured environment, resulting in a resident with dementia exiting the facility and leaving the property. The resident, who was at risk for elopement and wore a WanderGuard bracelet, managed to exit through a window in the dining room. The resident was last seen by staff at 8:00 P.M. and was not noticed missing until 8:45 P.M. The resident was found by local law enforcement approximately 2.4 miles away from the facility, having sustained a facial laceration and minor head injury from multiple falls. The resident's medical history included Alzheimer's Disease, altered mental status, anorexia, insomnia, and dementia, with a risk for elopement assessment completed prior to the incident. The resident's care plan included interventions for elopement risk and intrusive wandering, but did not document adequate supervision measures to prevent elopement. The resident had shown increased exit-seeking behavior, which was noted in nurse's notes, but no additional non-pharmaceutical interventions or increased supervision were implemented. The facility's investigation revealed that the resident was able to unlock and open a window in the dining room, which was not equipped with window stops, allowing the resident to climb out. The facility's policy on wandering and elopements required strategies and interventions to maintain resident safety, but these were not effectively implemented. The facility's failure to secure windows and provide adequate supervision contributed to the resident's elopement and subsequent injuries.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Loogootee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bertha D Garten Ketcham Memorial Center | 5.3 mi | ★★★★★ | 4 | 0 |
| Poplar Care Strategies | 10.7 mi | ★★★★★ | 16 | 0 |
| Eastgate Manor Nursing And Rehabilitation | 18.3 mi | ★★★★★ | 0 | 0 |
| Hillside Manor Nursing Home | 19 mi | ★★★★★ | 31 | 1 |
| Prairie Village Nursing And Rehabilitation | 19.1 mi | ★★★★★ | 0 | 0 |
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