Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Heights Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to ensure residents received mail on Saturdays, affecting all residents. Two residents reported not receiving mail on Saturdays, and it was confirmed that mail was locked in the Activities Director's office until Monday. Interviews with staff revealed confusion about the mail delivery process, leading to a deficiency in residents' rights to timely mail access.
The facility failed to maintain proper infection control practices, as staff repeatedly neglected to use PPE and sanitize equipment between residents. A nurse entered a resident's room under enhanced barrier precautions without PPE and did not sanitize a blood pressure machine after use. Additionally, a medication technician mishandled a dropped pill, and other staff provided direct care without PPE, despite clear signage. Interviews confirmed these actions violated infection control policies.
The facility failed to properly store and label medications. A nurse placed a cup of pills with a resident's name in a medication cart drawer after the resident went to therapy, contrary to the facility's policy of disposing of such medications. Additionally, eye drops and suppositories were improperly stored in a refrigerator door, risking temperature fluctuations. These actions violated the facility's medication storage and administration policies.
The facility failed to adhere to food service safety standards by storing ice packs in resident nourishment refrigerators, risking cross-contamination. Observations revealed ice packs stored with food items in three unit refrigerators. Interviews with unit managers and the administrator confirmed that ice packs should be stored in medication refrigerators.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in meeting their medical and nursing needs. One resident received incorrect oxygen therapy settings, another was not provided a smoking apron as required, and a third did not receive timely incontinence care. Staff interviews and observations highlighted ongoing issues with adherence to care plans, with short staffing cited as a contributing factor.
A facility failed to ensure the correct advance directives for a resident under state guardianship. Despite a court order appointing the state as the legal guardian, the facility accepted a DNR order signed by a family member, which was unauthorized. Staff interviews revealed confusion and lack of verification regarding the resident's code status, leading to the resident being incorrectly documented as DNR without proper authorization.
A resident admitted to a smoke-free LTC facility was observed smoking on the premises without a smoking apron, despite it being a care plan intervention. The facility failed to conduct a Safe Smoking Evaluation and did not communicate the resident's smoking status and safety requirements to supervising staff. The resident was not listed among those who smoked, and staff were unaware of the need for a smoking apron, leading to potential safety risks.
A resident with acute pulmonary edema was observed receiving oxygen at three liters per minute, contrary to the physician's order of two liters per minute. Despite the care plan and staff acknowledgment of the correct procedure, the facility failed to ensure the oxygen concentrator settings matched the physician's orders, potentially risking the resident's health.
A resident with dementia and moderate cognitive impairment did not receive necessary toileting and incontinence care as per their care plan. Despite directives to check for incontinence every two hours, staff frequently left the resident in soiled conditions. Family members reported ongoing issues, and staff interviews revealed inconsistencies in following the care plan, with management citing staffing shortages as a contributing factor.
A facility did not effectively develop and implement a care plan for a resident diagnosed with paranoid schizophrenia and impulse disorder. Despite recognizing the resident's behavior of manipulating objects into protective items due to hallucinations, the facility lacked continuous monitoring and removal of potentially harmful objects. This oversight led to an incident where the resident injured a roommate with a plastic fork, necessitating hospital transfer for the injured party. The care plan included interventions like using plastic utensils and room monitoring, but staff inconsistently followed these measures. Interviews with RNs and the Dietary Manager revealed inconsistencies in care plan implementation and documentation, contributing to an unsafe environment.
A deficiency report highlights a serious incident involving two residents with severe cognitive impairments. One resident, diagnosed with dementia and other conditions, sustained a laceration to the eye inflicted by another resident with dementia, paranoid schizophrenia, and impulse disorder. The incident occurred due to insufficient supervision and monitoring, despite the known risks associated with the aggressive resident's history of hallucinations and delusions. Staff hesitated to intervene physically, contributing to the injury. The facility's policies and care plans were not effectively implemented to prevent the accident.
Failure to Ensure Timely Mail Delivery to Residents
Penalty
Summary
The facility failed to ensure residents had the right to send and receive mail, affecting all residents. During a group interview conducted by the State Survey Agency, two residents complained about not receiving mail on Saturdays. The facility's policy stated that residents had the right to receive mail and other materials delivered to the facility. However, it was revealed that mail delivered on Saturdays was locked in the Activities Director's office until Monday morning, delaying residents' access to their mail. Interviews with various staff members, including the Director of Nursing, Unit Manager, Activities Director, Assistant Director of Nursing, and the Administrator, showed a lack of clarity and communication regarding the mail delivery process on Saturdays. The Activities Director confirmed that the mail was held until the Business Office Manager could sort it on Monday, contradicting the Administrator's expectation that the Manager on Duty would distribute mail on Saturdays. This miscommunication and procedural gap led to the deficiency in ensuring residents' rights to timely mail access.
Infection Control Lapses in PPE Use and Equipment Sanitization
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper protocols. A registered nurse entered a resident's room, who was under enhanced barrier precautions due to a suprapubic catheter, without donning the required personal protective equipment (PPE) and failed to sanitize the blood pressure machine after use. This same nurse repeated the failure to sanitize the equipment between different residents, potentially facilitating the transmission of infections. Further observations revealed that the Minimum Data Set/Infection Prevention Nurse and the Admission Coordinator also entered the same resident's room without the necessary PPE, despite the presence of clear signage indicating the need for enhanced barrier precautions. They provided direct care, including repositioning the resident and handling the catheter, without the protective measures required to prevent infection spread. Additionally, a Certified Medication Technician was observed mishandling medication by picking up a dropped pill with an ungloved hand and administering it to a resident. Interviews with various staff members, including the Director of Nursing and the Assistant Director of Nursing, confirmed that these actions were against the facility's infection control policies, which require discarding dropped medications and using PPE when providing direct care to residents under enhanced precautions.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. In one instance, a Registered Nurse (RN) placed a cup of pills with a resident's first name handwritten on it in the top drawer of a medication cart after realizing the resident was unavailable due to therapy. The RN was unsure of the potential issues with this practice, while the Unit Manager, Assistant Director of Nursing, Director of Nursing, and Administrator all stated that medications should be disposed of if the resident is not available, rather than being stored for later use. This practice could lead to medications being forgotten, lost, or potentially administered to the wrong resident. Additionally, the facility failed to store medications under proper temperature controls. Eye drops and suppositories were found stored in the door of a medication refrigerator, which had a thermometer reading 43 degrees Fahrenheit. RN4 acknowledged that medications should not be stored in the refrigerator door due to potential temperature fluctuations that could affect their potency. These observations indicate a failure to adhere to the facility's policies on medication storage and administration, which require medications to be stored according to the manufacturer's recommendations and under appropriate conditions to ensure their efficacy and safety.
Improper Storage of Ice Packs in Resident Refrigerators
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety in three out of four unit refrigerators used for resident nourishment. During observations on September 18, 2024, ice packs were found stored in the freezer compartments of the nourishment refrigerators for the A-D, E, and F units. Specifically, the E unit refrigerator contained five ice packs along with a mesh bag of popsicles, a box of popsicles, and a frozen sweet and sour chicken dinner. The F unit refrigerator had eight ice packs, and the A-D unit refrigerator had three ice packs stored with a popsicle. Interviews conducted on September 20, 2024, revealed that the unit managers for the A-D, B, E, and F units acknowledged that ice packs should not be stored in the resident nourishment refrigerators due to the risk of cross-contamination with food. They stated that the ice packs were intended to be stored in the medication refrigerators. The facility's administrator confirmed that the ice packs were used to keep items like applesauce, supplements, and pudding cold on the medication cart and should be stored in the medication room refrigerators.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement comprehensive person-centered care plans for three residents, leading to deficiencies in meeting their medical and nursing needs. For Resident R45, the care plan required oxygen therapy at two liters per minute, but observations revealed the oxygen concentrator was set at three liters per minute on multiple occasions. This discrepancy was not addressed by the nursing staff, despite the potential adverse effects of incorrect oxygen levels, as noted by the Director of Nursing. Resident R83's care plan included the use of a smoking apron to prevent injury from unsafe smoking practices. However, observations showed that the resident smoked multiple cigarettes without wearing the apron, and interviews revealed that the resident was never offered one. The facility's staff, including the Activity Director and Social Services Director, acknowledged the risk of burns or injury if the apron was not used, yet the intervention was not implemented. For Resident R52, the care plan specified checking for incontinence every two hours to prevent skin breakdown. Despite this, continuous observation showed that staff did not provide incontinence care or assist the resident to the bathroom over a two-hour period. Interviews with family members and staff indicated ongoing issues with adherence to the care plan, with staff citing short staffing as a reason for the lack of care. The resident's guardian expressed frustration over the facility's failure to follow the care plan, which was corroborated by staff interviews acknowledging the resident's resistance to care.
Failure to Verify Advance Directives for Resident Under State Guardianship
Penalty
Summary
The facility failed to ensure that the advance directives for Resident 43 were completed by the legal guardian, as required. Despite a court order appointing the Cabinet for Health and Family Services (CHFS) as the legal guardian for Resident 43, the facility accepted a Do Not Resuscitate (DNR) order signed by a family member, which was not authorized. The resident, who was admitted with severe cognitive impairment and under state guardianship, was incorrectly documented as having a DNR status without the proper authorization from the state-appointed guardian. Interviews with staff revealed a lack of clarity and communication regarding the resident's code status. The State Guardian confirmed that once the state was appointed as the guardian, the resident's code status should have been full code, and any changes to a DNR status required a review by a state nurse. However, the facility's staff, including registered nurses and the Director of Nursing, failed to verify the correct code status upon the resident's return from the hospital, relying instead on information provided by the hospital, which was incorrect. The facility's policy required that advance directives be reviewed during care planning and upon re-admission from the hospital. However, interviews with the Unit Manager and Director of Nursing indicated that the social services department was responsible for handling advance directives, and there was no clear evidence that Resident 43's code status was reviewed during Interdisciplinary Team meetings. This oversight led to the resident being at risk of not receiving necessary life-saving interventions due to the incorrect DNR status.
Failure to Ensure Safe Smoking Practices for Resident
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who smoked, despite being a smoke-free facility. The resident, admitted after the facility went smoke-free, was observed smoking on facility grounds without wearing a smoking apron, which was an intervention noted in the resident's care plan. There was no documented evidence of a smoking evaluation being completed for this resident to ensure safe smoking practices. The facility's smoking policy indicated that residents who smoked were to be supervised and assessed using a Safe Smoking Evaluation, with all safety measures documented in the care plan. However, the resident was not listed among those who smoked, and the staff responsible for supervising smoking residents were not informed of the resident's need for a smoking apron. Interviews with various staff members revealed a lack of awareness and communication regarding the resident's smoking status and safety requirements. The resident was observed smoking multiple times without a smoking apron, despite being supervised by staff. Interviews with the resident and staff indicated that the resident was not offered a smoking apron, and there was no documentation of any refusal to wear one. The facility's administration acknowledged that the resident should not have been allowed to smoke on the premises and that a smoking evaluation was likely not conducted, leading to a potential risk of burns or fire.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide oxygen as ordered for a resident, identified as R45, who was supposed to receive oxygen at two liters per minute via nasal cannula. However, observations on two consecutive days revealed that the resident was receiving oxygen at three liters per minute. This discrepancy was noted despite the resident's active physician's orders and comprehensive care plan specifying the correct oxygen administration rate. The resident, who was admitted with diagnoses including unspecified dementia and acute pulmonary edema, had a BIMS score indicating intact cognition and was receiving oxygen therapy as part of their care plan. Interviews with facility staff, including a registered nurse, unit manager, director of nursing, and the administrator, confirmed that it was the nurse's responsibility to ensure the oxygen concentrator settings matched the physician's orders. The staff acknowledged that incorrect oxygen settings could potentially harm the resident, causing adverse effects such as slowed breathing, increased heart rate, and restlessness. Despite these acknowledgments, the facility failed to adhere to the physician's orders, resulting in the resident receiving an incorrect oxygen dosage.
Failure to Provide Adequate Incontinence Care for Resident with Dementia
Penalty
Summary
The facility failed to provide necessary services related to toileting and incontinence care for Resident 52, who was unable to carry out Activities of Daily Living (ADLs) due to moderate cognitive impairment and other medical conditions. Despite having a care plan that required checking for incontinence every two hours and using briefs at night, the resident was often found in soiled conditions. Family members reported that the resident was frequently left in a soiled bed and dirty clothing, and staff did not adhere to the care plan's requirements for regular toileting and incontinence checks. Observations and interviews revealed that staff did not consistently check on Resident 52 as required. On multiple occasions, staff entered the resident's room without providing incontinence care or assisting with toileting. Interviews with staff members, including SRNAs and RNs, indicated that while they were aware of the resident's needs and care plan, they did not always follow through with the required checks and assistance. The resident's refusal of care was noted, but staff did not consistently document these refusals or attempt alternative approaches as outlined in the care plan. Family members expressed frustration with the facility's lack of accountability and frequent staff turnover, which contributed to the inadequate care. The facility's management, including the DON and Administrator, acknowledged the issues but cited staffing shortages as a reason for the lapses in care. Despite the care plan's clear directives, the facility failed to ensure that Resident 52 received the necessary assistance with ADLs, leading to repeated instances of neglect in toileting and incontinence care.
Inadequate Care Plan Implementation and Supervision for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to develop and implement an effective care plan for Resident #7, who had diagnoses of paranoid schizophrenia and impulse disorder. Despite being aware of the resident's tendency to manipulate objects into protective items due to hallucinations, the facility did not have interventions in place to continuously monitor and remove objects that could be used as weapons. This lack of oversight led to a serious incident where Resident #7 injured his roommate, Resident #6, with a plastic fork, resulting in Resident #6 being transferred to the hospital for treatment. The deficiency was further highlighted by the facility's failure to adequately supervise Resident #7, who was assessed to be severely cognitively impaired. The care plan for Resident #7, developed on 11/01/2023, included interventions such as serving only plastic utensils and monitoring his room for potentially harmful objects. However, staff did not consistently follow through with these interventions, as evidenced by Resident #7 being found with a bloody fork in his hand after harming Resident #6. The lack of proper monitoring and supervision contributed to the unsafe environment that resulted in harm to a resident. Interviews with staff members, including the Registered Nurses and the Dietary Manager, revealed inconsistencies in the implementation of the care plan interventions for Resident #7. While efforts were made to provide plastic utensils and monitor the resident's room, there was a lack of formal documentation and oversight to ensure these measures were consistently enforced. The facility's failure to address Resident #7's safety concerns and adequately monitor his behaviors ultimately led to a serious incident that put residents at risk and resulted in harm.
Inadequate Supervision Leads to Resident Injury
Penalty
Summary
The deficiency identified in the report pertains to the facility's failure to provide adequate supervision and monitoring to prevent accident hazards, resulting in a serious incident involving two residents, Resident #6 and Resident #7. Resident #6, admitted with diagnoses including unspecified dementia, major depressive disorder, and insomnia, sustained a laceration to his left eye inflicted by Resident #7, who had diagnoses of unspecified dementia, paranoid schizophrenia, and impulse disorder. Both residents had severe cognitive impairment as indicated by their Brief Interview for Mental Status (BIMS) scores. Despite Resident #7's history of hallucinations and attempts to manipulate objects into protective items due to his delusions, the facility did not effectively monitor or supervise him to prevent potential harm to himself or others. The incident occurred in the early hours of the morning when staff found Resident #6 with a laceration to his left eye and blood on his face, while Resident #7 was holding a bloody fork and stated he did it because he believed Resident #6 was trying to harm him. Staff members, including nurses and CNAs, were hesitant to intervene physically due to fear of Resident #7, who had a history of hallucinations and had previously expressed intentions to use objects as defensive weapons. Despite the facility's knowledge of Resident #7's behaviors and the development of a care plan to mitigate risks, the lack of effective supervision and monitoring led to the serious injury suffered by Resident #6. The facility's policies and procedures related to preventing abuse, neglect, and accidents, as well as the specific care plan developed for Resident #7, highlighted the importance of identifying and mitigating risks to ensure resident safety. However, the failure to implement these measures effectively, including monitoring the removal of potentially harmful objects from Resident #7's room and providing adequate supervision, resulted in the incident that posed a serious risk to resident safety. The deficiencies in supervision and monitoring, coupled with the residents' cognitive impairments and history of delusions, underscore the critical need for facilities to proactively address safety concerns and provide appropriate oversight to prevent accidents and harm to residents in long-term care settings.
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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 Louisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nazareth Home Clifton | 0.2 mi | ★★★★★ | 0 | 0 |
| Clifton Heights | 0.4 mi | ★★★★★ | 11 | 1 |
| Home Of The Innocents | 1.4 mi | ★★★★★ | 37 | 0 |
| Kindred Hospital - Louisville | 1.6 mi | ★★★★★ | 3 | 0 |
| Highlands Nursing And Rehabilitation | 1.9 mi | ★★★★★ | 0 | 0 |
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