Sycamore Run Nursing: Bare-Hand Insulin Injection - OH
The resident, identified in inspection records only as Resident 42, was admitted to the facility on April 14. She had type two diabetes, vascular dementia, and congestive heart failure. Her dementia was severe enough that she scored a four out of 15 on a standard cognitive assessment, meaning she needed staff assistance for basic daily tasks and could not reliably advocate for herself.
Her physician had ordered two medications relevant to what inspectors observed that morning. One was Humalog insulin, to be injected under the skin at mealtimes and adjusted based on her blood sugar readings. The other was Ativan, an anti-anxiety medication prescribed two days earlier, on April 28, to manage severe agitation from her dementia, to be given every four hours while she was awake.
At 7:55 a.m., inspectors watched Licensed Practical Nurse 363 prepare both medications. The nurse removed the Ativan tablet from its medication card and dropped it into a pill cutter. Then, with no gloves on, she used her fingers to reposition the tablet in the center of the cutter before slicing it in half.
She then checked Resident 42's blood sugar. The reading came back at 240, which put the resident in the range requiring five units of insulin under her sliding scale orders. The nurse sanitized her hands and swabbed the resident's lower right abdomen with an alcohol pad. Then she administered the injection. Still no gloves.
Five minutes later, at 8:00 a.m., an inspector asked the nurse about what had just happened. The nurse confirmed both lapses without dispute. She touched the Ativan tablet with an ungloved hand. She gave the insulin injection with ungloved hands. She told the inspector that gloves should have been worn during medication preparation and during the injection, but that she hadn't put them on.
The facility's own policy on injectable medications, in place since June 2017, lists as a required step: apply gloves prior to injecting medication.
The inspection was a complaint survey. Of 10 residents reviewed for medication administration, Resident 42 was the only one whose care produced a documented violation. The facility's total census at the time was 90 residents.
Federal inspectors rated the violation at the lowest level of harm on their scale, meaning minimal harm or potential for actual harm rather than documented injury. That rating reflects the framework inspectors use to categorize findings, not a conclusion that the resident was unaffected. Resident 42 had an open injection site on her abdomen. She had diabetes, which compromises the body's ability to fight infection. She had dementia severe enough that she could not have flagged a developing problem at the site or communicated discomfort to staff. Whether anything developed from that morning's injection, the inspection report does not say.
What the report does say is that the nurse knew the requirement, acknowledged the failure immediately when asked, and had no explanation for why she hadn't followed it. Not that she was unaware of the policy. Not that she misread the order. She simply didn't put the gloves on.
Resident 42 had been at Sycamore Run for 16 days when inspectors watched her nurse administer an injection with bare hands into her abdomen. She was still in the first weeks of what the records suggest was a complicated admission, managing three serious diagnoses, reliant on staff for everything, and unable to speak for herself about what happened to her body during morning medication rounds.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sycamore Run Nursing and Rehab Ctr from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
SYCAMORE RUN NURSING AND REHAB CTR in MILLERSBURG, OH was cited for violations during a health inspection on April 30, 2026.
The resident, identified in inspection records only as Resident 42, was admitted to the facility on April 14.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.