Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brickyard Healthcare -sycamore Village Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, morbid obesity, and total dependence for transfers experienced repeated accidents during care and mechanical lift transfers. During incontinence care, the resident was positioned near the edge of a smaller bed while using an overhead trapeze and fell to the floor, later describing that the bed was too small and she was too close to the edge. On another occasion, three CNAs used a mechanical lift when the sling strap stitching failed, causing the resident to fall from just above the bed and strike her back and shoulder on the lift legs, with staff unable to confirm that the sling used was the correct size or weight capacity. Observations showed staff using large blue slings without clear weight-limit tags, a unit manager unable to explain missing labeling, and no facility policy for mechanical lift use despite manufacturer guidance on proper sling selection and application. In a further incident, the mechanical lift struck the resident’s overhead trapeze, knocking it down so it hit the back of the resident’s head, demonstrating unsafe coordination of equipment around the bed and inadequate hazard control during transfers.
The facility failed to ensure compromised controlled substance medications were not stored in medication carts. Observations revealed compromised cards with slits or tape on the North and South carts. Residents with insomnia, anxiety, and pain had medications like quviviq, oxycodone, alprazolam, Norco, tramadol, and Clonazepam improperly stored. LPNs acknowledged the issue, and the DON confirmed the need for proper destruction of such medications.
The facility failed to ensure SNF-ABN forms were accurately completed for two residents discharged from Medicare services. One resident's form lacked a selection for therapy continuation, while another's form was missing a choice about remaining in the facility. The Social Service department was responsible for assisting with form completion, but the forms were left blank, contrary to facility policy.
The facility failed to update PASARR evaluations for two residents, resulting in incomplete documentation of their mental health conditions and medications. One resident's PASARR did not include anxiety disorder, PTSD, or insomnia, despite being prescribed medications for these conditions. Another resident's PASARR omitted antianxiety and hypnotic medications. The Social Service Director confirmed the omissions, which were contrary to the facility's policy requiring updated reviews for new mental health conditions.
The facility failed to obtain admission weights for two residents, one with type 2 diabetes and chronic heart failure, and another with essential hypertension and morbid obesity. Both residents were weighed several days after admission, contrary to staff interviews indicating weights should be taken on the admission day. The facility lacked a policy on admission weights.
A facility failed to follow its protocol for administering medication through a g-tube for a resident with dysphagia. An RN did not verify the g-tube placement or use the prescribed water flush before and after medication administration, instead using normal saline, contrary to the facility's policy. The DON confirmed the correct procedure was not followed, leading to the deficiency.
A facility failed to obtain a physician's order, informed consent, and assessment before using bed rails for a resident. The resident was observed with bilateral side rails, which were already attached when he moved in. The care plan did not include the use of side rails, and the Director of Nursing acknowledged the oversight. The facility's policy requires a person-centered approach and proper procedures for bed rail use, which were not followed in this case.
The facility failed to ensure proper PPE use and correct signage for two residents under transmission-based precautions. A nurse entered a resident's room without a gown, despite orders for enhanced barrier precautions. Another resident's room had inconsistent signage for precautions, leading to staff confusion. Interviews confirmed the need for proper PPE and signage as per physician orders.
A facility failed to follow physician-ordered parameters for administering blood pressure medications to a resident with hypertension and other conditions. Despite orders to hold medication if systolic blood pressure was below 120, records showed diltiazem was given multiple times when the resident's blood pressure was below this threshold. Interviews confirmed that medications should have been held, as per facility policy.
A resident with Multiple Sclerosis did not receive timely pharmaceutical services, missing 19 days of Buprenorphine due to the facility's failure to obtain the medication. Despite having a physician's order, the facility was unable to administer the medication, and the resident was discharged without it. The Director of Nursing was unaware of the medication's purpose, and the Executive Director had no further information on the issue.
Failure to Ensure Safe Bed Care and Mechanical Lift Transfers for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision and safe equipment use during care and transfers for a dependent resident. Resident C had multiple medical diagnoses including COPD, CHF, hypertension, morbid obesity, and bilateral knee osteoarthritis, and was documented on the MDS as dependent on staff for transfers and substantially/fully dependent for bed mobility and toileting. Care plans identified self-care deficits and fall risk, with interventions such as use of a trapeze bar, assistance with transfers, non-skid footwear, and maintaining a safe environment. Despite these identified needs, the resident experienced several incidents during incontinence care and mechanical lift transfers. In one incident, during incontinence care, the resident was turned toward the window while holding the overhead trapeze and fell from the bed. Documentation indicated the resident turned to her left side, her hand slipped from the trapeze, and she fell from the bed, sustaining a scratch to the right lower leg. The resident and her daughter reported that the bed was too small and that the resident was too close to the edge of the bed during care, leading to her rolling or sliding off. A CNA described the resident sliding off the bed into a split position between the bed and the window while the CNA was providing peri care. This occurred even though the resident had been care planned as at risk for falls and dependent for transfers and bed mobility. In a separate incident, the resident was being transferred with a mechanical (Hoyer) lift when the sling strap broke and the resident fell to the floor. Three CNAs were involved in the transfer; one CNA reported the resident was lifted slightly off the bed when the stitching on the strap came loose, causing the resident to fall and hit her back and shoulder on the lift legs, with subsequent complaints of lumbar and back pain. Staff interviews revealed uncertainty about which sling pad was used and whether it was the correct weight limit for the resident. Observations showed staff using a large blue lift pad and declining the resident’s request to cross the leg straps, while the resident reported that staff had crossed the straps on multiple prior occasions and that she felt like she would slide out when the larger pad was used. A unit manager pulled a sling from storage that lacked a visible weight limit on the tag and stated she did not know why it was not labeled, and the facility had no policy on mechanical lift use, despite manufacturer guidance that correct sling size and application are critical to prevent accidents. In an additional incident, during another mechanical lift transfer, the lift contacted the resident’s overhead trapeze bar, knocking it down so that it struck the back of the resident’s head and caused a bump. The resident reported soreness at the back of her head, and the Executive Director confirmed that the trapeze bar dropped and hit the resident’s head. Across these events, the facility did not ensure that the environment around the bed and trapeze was arranged to prevent contact with the lift, did not consistently ensure appropriate sling selection and labeling based on resident weight, and did not have a facility policy governing mechanical lift use, all contributing to repeated accidents during care and transfers for this resident. The facility’s own "Accidents and Supervision" policy stated that residents’ environments would remain as free of accident hazards as possible and that each resident would receive adequate supervision and assistive devices to prevent accidents, with all staff involved in observing and identifying potential hazards. However, the repeated falls from the bed during peri care, the fall from the mechanical lift due to a broken sling strap, and the incident in which the lift knocked down the trapeze bar onto the resident’s head demonstrate that the facility did not adhere to these expectations for this resident. The survey findings are tied to Intake 2680656 and cite regulatory provisions 3.1-45(a)(1) and 3.1-45(a)(2).
Compromised Controlled Substance Storage in Medication Carts
Penalty
Summary
The facility failed to ensure that compromised controlled substance medications were not stored in the medication carts, as observed in two of the four medication carts inspected. On the North medication cart, five compromised controlled substance cards were found. For Resident 14, a card of quviviq for insomnia had clear tape covering the back of the number 6 slot. Resident 42 had a card of oxycodone with a slit on the back of the card in the number 22 slot and a card of alprazolam with a slit in the number 23 slot. Resident 51 had a card of Norco with a slit on the back of the card in the number 8 slot, and Resident 23 had a card of tramadol with a slit in the number 30 slot. LPN 13 acknowledged that there should not be tape or slits on the back of the cards and admitted to not checking the backs when counting narcotics. On the South medication cart, one compromised controlled substance card was found. A card of Clonazepam for Resident 75 had a slit on the back of the card in the number 29 slot. LPN 12 confirmed that the pills should not be taped or opened on the back of the cards and should be destroyed by two nurses. The Director of Nursing also indicated that staff should not tape the backs of narcotics cards and that the pills needed to be destroyed. The facility's policy on Controlled Substance Administration & Accountability requires that two licensed staff witness any disposal or destruction of a controlled substance and document it accordingly.
Incomplete SNF-ABN Forms for Two Residents
Penalty
Summary
The facility failed to ensure that the Skilled Nursing Facility-Advanced Beneficiary Notice (SNF-ABN) forms were accurately completed for two residents who were discharged from Medicare services but remained in the facility. For Resident 45, the ABN form provided on October 8, 2024, indicated that their coverage was ending on October 10, 2024. However, the section of the form where the resident was supposed to choose an option regarding the continuation of physical and occupational therapy was left blank. Similarly, for Resident 91, the ABN form provided on December 4, 2024, indicated that their coverage had ended on December 2, 2024, but the section for choosing an option about remaining in the facility was also left blank. Interviews with the Business Office Manager and the Social Service Director revealed that the Social Service department was responsible for assisting residents in completing these forms, and the Business Office would only assist if Social Services was unavailable. The Business Office Manager assumed that if one form had an option chosen, all forms would have an option chosen, which was not the case. The Social Service Director confirmed that one of the three options for coverage should have been selected and that the forms should not have been left blank. The facility's policy on Advance Beneficiary Notices, dated 2024, stated that the Business Office Manager or designee is responsible for issuing notices and ensuring that documentation complies with form instructions, which was not adhered to in these instances.
Failure to Update PASARR Evaluations for Residents
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASARR) evaluations were updated and accurate for two residents. For Resident 95, the PASARR notice indicated that a Level II screen was not required, as there was no evidence of a serious mental health condition. However, the PASARR did not include diagnoses of anxiety disorder, post-traumatic stress disorder, or insomnia, despite the resident being prescribed medications for these conditions. The Social Service Director confirmed that the PASARR was missing these diagnoses and medications. Similarly, for Resident 52, the PASARR indicated no Level II was required and no mental illness was suspected. However, the resident was prescribed antianxiety and hypnotic medications that were not included in the PASARR mental health medication section. The Social Service Director acknowledged that another PASARR should have been completed when new psychotropic medications were added, but this was not done. The facility's policy requires that any resident exhibiting a newly evident or possible serious mental disorder be referred for a Level II resident review, which was not adhered to in these cases.
Failure to Obtain Admission Weights for Residents
Penalty
Summary
The facility failed to ensure that admission weights were obtained for two residents, Resident D and Resident H, upon their admission. Resident D, who had diagnoses including type 2 diabetes mellitus, muscle wasting and atrophy, and chronic heart failure, was admitted and not weighed until five days later, with the first recorded weight being 284 pounds. Similarly, Resident H, with diagnoses including muscle wasting and atrophy, essential hypertension, and morbid obesity, was admitted and not weighed until six days later, with the first recorded weight being 306 pounds. The facility's clinical admission assessments for both residents had sections for entering weights, but these were left blank. Interviews with LPNs and a Regional Dietician confirmed that admission weights should be obtained on the day of admission, especially for residents with a history of heart failure. However, the facility lacked a policy addressing the requirement for obtaining admission weights.
Failure to Follow G-Tube Medication Administration Protocol
Penalty
Summary
The facility failed to adhere to its policy and procedures for administering medications through a gastrostomy tube (g-tube) for a resident diagnosed with dysphagia and requiring a g-tube. During an observation, a Registered Nurse (RN) was seen administering medication to the resident without verifying the placement of the g-tube or flushing it with the prescribed amount of water before and after medication administration. Instead, the RN used a prefilled normal saline syringe, which is against the facility's policy that mandates the use of water for flushing the g-tube. The resident's clinical record indicated a physician's order to check the g-tube placement and flush it with 30 ml of water before and after administering medication. However, the RN admitted to not checking the placement or residual before administering the medication. The Director of Nursing confirmed that normal saline should not be used for flushing a g-tube, and the facility's policy requires verification of tube placement and flushing with water. This oversight in following the established procedures led to the deficiency noted in the report.
Failure to Obtain Consent and Assessment for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper procedures were followed before the use of bed rails for a resident, identified as Resident 95. During multiple observations, Resident 95 was seen with bilateral side rails attached to his bed. The resident mentioned that the side rails were already on the bed when he moved in and believed they were to prevent him from rolling out of bed. However, the facility did not have a signed consent from the resident for the use of these side rails. Additionally, a review of the resident's clinical record revealed the absence of a physician's order, an informed consent, and an assessment for the use of the side rails. The care plan for Resident 95, which was last revised in November 2024, indicated a self-care performance deficit but did not include the current use of side rails. The Director of Nursing confirmed that an assessment and consent should have been completed before attaching side rails to the resident's bed. The facility's policy on the proper use of bed rails emphasizes a person-centered approach and requires correct installation, use, and maintenance of the rails. Despite this policy, the facility did not obtain the necessary consent and assessment for Resident 95, leading to the deficiency.
Failure to Ensure Proper PPE Use and Signage for Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and correct signage for transmission-based precautions for two residents. In the first instance, a registered nurse entered the room of a resident under enhanced barrier precautions without wearing a gown, despite a physician's order and care plan indicating the need for such precautions due to the resident's conditions, including hypoxia, cardiomegaly, and pressure ulcers. The nurse acknowledged the oversight during an interview, and another staff member confirmed the requirement for gown and gloves during high-contact care. In the second instance, the facility did not maintain appropriate signage for a resident requiring enhanced barrier precautions due to enterocolitis caused by Clostridium difficile. Observations revealed inconsistent signage, with both enhanced barrier and contact precaution signs posted, despite the contact precautions order having been completed. Interviews with staff, including the Director of Nursing, highlighted confusion regarding the correct precautions to follow, as the enhanced barrier precautions were still in effect per the physician's order.
Failure to Follow Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for administering blood pressure medications to Resident 87, who was diagnosed with essential primary hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease stage 3, and dementia. The physician's orders specified that diltiazem and later lisinopril should be held if the resident's systolic blood pressure was less than 120. However, the Medication Administration Records (MAR) indicated that diltiazem was administered on multiple occasions in October, November, and December 2024, despite the resident's systolic blood pressure being below the specified threshold. Interviews with the Dementia Unit Manager and an LPN revealed that a check mark on the MAR indicated the medication had been given, and if the blood pressure was below the ordered parameter, the medication should have been held and marked with a specific code. The facility's current medication administration policy, as provided by the Director of Nursing, also stated that medications should be held for vital signs outside the physician's prescribed parameters. This oversight in following the physician's orders led to the deficiency noted in the report.
Failure to Provide Timely Pharmaceutical Services for Resident
Penalty
Summary
The facility failed to ensure timely pharmaceutical services for a resident, identified as Resident E, who was undergoing pain management. Resident E, diagnosed with Multiple Sclerosis, anxiety disorder, and muscle spasms, was admitted to the facility with a prescription for Buprenorphine, an opioid medication. Despite having a physician's order to administer Buprenorphine three times a day, the facility did not administer the medication on several occasions, leading to a total of 19 missed days of medication. The deficiency was further compounded by the facility's inability to obtain the medication from the pharmacy. Nursing progress notes indicated that the facility was out of Buprenorphine and that a new prescription was required before the pharmacy could fill the order. Despite attempts to resolve the issue, including contacting the pharmacy and waiting for a new order from a Nurse Practitioner, the medication remained unavailable, and Resident E was discharged without it. The facility's policy on pharmaceutical services, which mandates timely and accurate medication administration, was not adhered to in this case. The Director of Nursing was unaware that Buprenorphine was prescribed for Multiple Sclerosis, and the Executive Director had no additional information regarding the medication's unavailability. The facility's failure to provide the necessary medication and ensure proper pharmaceutical services resulted in a significant lapse in Resident E's care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 141 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kokomo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Woods Village | 0.7 mi | — | 7 | 0 |
| Waterford Place Health Campus | 0.7 mi | — | 11 | 0 |
| Wellbrooke Of Kokomo | 1.9 mi | — | 11 | 0 |
| Kokomo Healthcare Center | 3 mi | — | 7 | 0 |
| Aperion Care Kokomo | 3.7 mi | — | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Brickyard Healthcare -sycamore Village Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.