Statement of Deficiencies and Plan of Correction - Form CMS-2567(02-99)

Sep 14, 2026

Uploaded by Mia

Statement of Deficiencies and Plan of Correction documents a Medicare/Medicaid survey conducted for recertification and state licensure at Sycamore Care Strategies. The form records provider identification details, survey completion date, and applicable regulatory citation 483.20(g) Accuracy of Assessments. It summarizes findings from interviews and record review, including failures to complete an accurate Minimum Data Set (MDS) assessment for specific residents and medication-related inconsistencies. The document also includes the facility’s plan of correction approach, requests for compliance handling, and signature/date sections.

LanguageEnglish

CategoryForms

FormatPDF

Pages25

Reading Time9 min

AccessFree to download

Statement of Deficiencies and Plan of Correction

Provider and Survey Information

Regulatory Citation and Accuracy of Assessments (483.20(g))

Findings and Resident Medication/MDS Issues

Plan of Correction and Completion Date

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 03/18/2024 FORM APPROVED OMB NO. 0938-039 | STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | | (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER 155263 | (X2) MULTIPLE CONSTRUCTION
A. BUILDING 00
B. WING
| | | (X3) DATE SURVEY
COMPLETED
02/26/2024 | | | --- | --- | --- | --- | --- | --- | --- | --- | | NAME OF PROVIDER OR SUPPLIER
SYCAMORE CARE STRATEGIES | | | | STREET ADDRESS, CITY, STATE, ZIP COD
12802 EAST US HWY 50
LOOGOOTEE, IN 47553 | | | | | (X4) ID
PREFIX
TAG | SUMMARY STATEMENT OF DEFICIENCIE (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION | | ID
PREFIX
TAG | | PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY) | | (X5) COMPLETION
DATE | | F 0000 Bldg. 00
F 0641 SS=D
Bldg. 00 | This visit was for a Recertification and State Licensure Survey. This visit included the Investigation of Complaint IN00427694 .
This visit was in conjunction with the Investigation of Complaint IN00428904 .
Complaint IN00427694-No deficiencies related to the allegations are cited.
Survey dates: February 19, 20, 21, 22, 23, 26, 2024
Facility number: 000164
Provider number: 155263
AIM number: 100289550
Census Bed Type: SNF/NF: 31
Total: 31
Census Payor Type: Medicare: 3
Medicaid: 19
Other: 9
Total: 31
These deficiencies reflect State Findings cited in accordance with 410 IAC 16.2-3.1.
Quality review completed on March 1, 2024.
483.20(g)
Accuracy of Assessments
§483 .20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.
Based on interview and record review, the facility | | F 0000
F 0641 | | By submitting the following material, we are not admitting the truth or accuracy of any specific findings or allegations. Wereserve the right to contest the findings or allegations as part of any proceedings and submit these responses to regulatory obligations. The facility requests plan of correction be considered our allegation of compliance effective 3/26/2024 to the state findings of the Recertification and State Licensure Survey. We respectfully request paper compliance in leu of a post survey review. Please contact the facility if additional information is needed for a desk review.
F641 | | 03/26/2024 | LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Brandi Gladish HFA 03/14/2024 Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclo days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 73UO11 Facility ID: 000164 If continuation sheet Page 1 of 25 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 03/18/2024 FORM APPROVED OMB NO. 0938-039 | STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | | (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER 155263 | (X2) MULTIPLE CONSTRUCTION
A. BUILDING 00
B. WING
| | | (X3) DATE SURVEY
COMPLETED
02/26/2024 | | | --- | --- | --- | --- | --- | --- | --- | --- | | NAME OF PROVIDER OR SUPPLIER
SYCAMORE CARE STRATEGIES | | | | STREET ADDRESS, CITY, STATE, ZIP COD
12802 EAST US HWY 50
LOOGOOTEE, IN 47553 | | | | | (X4) ID
PREFIX
TAG | SUMMARY S

FAQs

What is the purpose of this Statement of Deficiencies and Plan of Correction form?

It documents survey deficiencies and the provider’s plan of correction in response to findings related to regulatory requirements for resident care and assessment accuracy.

Which regulatory requirement is cited in the document?

The document cites 483.20(g) Accuracy of Assessments, requiring that assessments accurately reflect each resident’s status.

What assessment problem does the facility address in the findings?

The findings state the facility failed to ensure an accurate Minimum Data Set (MDS) assessment was completed, including medication-related discrepancies for reviewed residents.

Sep 14, 2026

Uploaded by Mia