Above 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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sycamore Run Nursing And Rehab Ctr during CMS and state inspections, most recent first.
Two residents with COPD and other comorbidities, one cognitively intact and one cognitively impaired, had physician orders for Ellipta and Breo Ellipta inhalers that included instructions to rinse the mouth with water after use, with one order specifying not to swallow the water. During observed morning medication administration, an LPN gave each resident their prescribed inhaled medication but did not prompt either resident to rinse and, for the second resident, to spit out the water as ordered. The LPN confirmed in interviews that the residents did not rinse their mouths after inhaler use, despite the documented orders and manufacturer guidelines requiring post-inhalation mouth rinsing.
A resident with type 2 DM, vascular dementia, and CHF had orders for mealtime Novolog insulin per sliding scale and bedtime Lantus insulin. During a medication pass, an LPN was observed administering the resident’s morning medications and sliding scale insulin, while a Novolog pen and a Lantus pen in the top drawer of the med cart lacked any labels with the resident’s name or insulin orders. The LPN acknowledged the pens were unlabeled and explained that the resident was the only person on the unit receiving insulin and staff knew the pens were theirs, despite facility policy requiring medications to be stored in pharmacy-dispensed containers that meet regulatory requirements.
An LPN failed to follow infection control practices while preparing and administering medications to a resident with diabetes, vascular dementia, and CHF. The LPN handled an Ativan tablet with a bare hand while using a pill cutter and then administered Humalog insulin subcutaneously after cleansing the injection site but without donning gloves, contrary to facility policy requiring glove use for injectable medications.
A resident admitted with multiple conditions, including spina bifida, wheelchair dependence, and existing chronic wounds, had physician orders for turning/repositioning and topical Mupirocin, as well as an order to evaluate a coccyx pressure area each shift. On the admission date, nursing documentation only noted that the skin was warm and dry, and no comprehensive admission skin assessment was completed by the admitting nurse. Several days later, an LPN wound nurse documented a coccyx pressure injury with drainage, a red wound bed, and macerated edges, and confirmed that the required admission skin assessment had not been done, resulting in a deficiency for failure to assess skin integrity on admission.
A facility failed to maintain a resident's dignity by not covering an indwelling urinary catheter drainage bag, which was visible from the hallway. The resident, with a history of neuromuscular dysfunction of the bladder and other medical conditions, was dependent on staff for daily activities. Observations confirmed the catheter bag was uncovered, compromising the resident's privacy.
A facility failed to obtain written authorization to manage a resident's personal funds, violating their right to manage their financial affairs. Despite the resident's severe cognitive impairment and indication that they did not wish to open a personal funds account, a deposit was made into their account without authorization. Interviews revealed the resident was unaware of their financial status, and the Business Office Manager confirmed the account was opened without a signed form.
The facility failed to implement fall interventions for two residents, leading to deficiencies in accident prevention. A resident with dementia and other conditions had a motion sensor alarm and floor mat improperly placed, while another resident's bed was not in the lowest position as required. These lapses were confirmed by staff interviews.
A facility failed to maintain an accurate medical record for a resident with a complex medical history, including vascular dementia and psychosis. The resident's medical record did not include a diagnosis of psychosis, despite psychiatric notes and physician confirmation of the condition. The resident was receiving Risperidone for delusions and psychosis, but the MDS assessment did not reflect this diagnosis, leading to a deficiency.
Failure to Ensure Mouth Rinsing After Inhaled Respiratory Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate respiratory care by not ensuring residents rinsed their mouths after administration of prescribed inhaled respiratory medications. For one resident admitted with COPD, emphysema, and heart disease, with intact cognition and needing assistance with ADLs, the physician’s order for Ellipta 62.5 mcg inhaler specifically included rinsing the mouth with water after use. During an observation of the morning medication pass, an LPN administered the Ellipta inhaler but did not prompt the resident to rinse his mouth afterward, and the LPN confirmed in interview that the resident did not rinse following administration. A second resident, admitted with COPD, high blood pressure, and anxiety, had impaired cognition with a low BIMS score and required staff assistance with ADLs. This resident had a physician’s order for Breo Ellipta 100-25 mcg inhaler with instructions to rinse the mouth with water after use and not to swallow. Review of the MAR confirmed this order. During observation, the same LPN administered the Breo Ellipta inhaler but did not prompt the resident to rinse and spit out the water into a cup, and confirmed in interview that this was not done per the physician’s order. Manufacturer guidelines for Breo Ellipta state that patients should rinse their mouth with water without swallowing after inhalation to help reduce the risk of oropharyngeal candidiasis (thrush).
Unlabeled Insulin Pens Found in Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were labeled and stored in accordance with professional standards and facility policy. A resident admitted with diagnoses including type 2 diabetes, vascular dementia, and congestive heart failure had physician orders for Humalog (therapeutic interchange for Novolog) insulin to be administered subcutaneously with meals per a specified sliding scale, and Lantus insulin to be administered daily at bedtime. The resident’s admission MDS showed impaired cognition with a BIMS score of 4/15 and a need for staff assistance with ADLs. During a medication pass observation, an LPN administered the resident’s morning medications and sliding scale insulin. In the top drawer of the medication cart, surveyors observed a Novolog insulin pen and a Lantus insulin pen with no labels indicating the resident’s name or insulin orders. In interview, the LPN confirmed that the insulin pens were not labeled with the resident’s name or orders and stated that the resident was the only person on the unit requiring insulin and that staff knew the pens belonged to that resident. Review of the facility’s Medication Storage policy indicated that medications are to be kept and stored in the packaging/containers dispensed by pharmacy that meet regulatory requirements, which was not followed in this instance.
Failure to Follow Infection Control Practices During Medication and Insulin Administration
Penalty
Summary
The deficiency involves failure to follow infection prevention and control procedures during medication administration for one resident. The resident was admitted with diagnoses including type 2 diabetes, vascular dementia, and congestive heart failure, and had impaired cognition with a BIMS score of 4/15, requiring staff assistance with ADLs. Physician orders included Humalog insulin via sliding scale with meals for diabetes and Ativan 0.5 mg by mouth every 4 hours while awake for severe agitation related to vascular dementia. During a medication pass observation, an LPN removed an Ativan tablet from the medication card, placed it into a medication cup, then poured it into a pill cutter and used an ungloved hand to reposition the tablet in the center of the pill cutter before cutting it and placing half the tablet into the medication cup. The same observation showed the LPN then prepared and administered the resident’s Humalog insulin based on a blood sugar reading of 240, which required 5 units per the sliding scale order. The LPN sanitized her hands, cleansed the resident’s right lower abdomen with an alcohol pad, injected the insulin, and wiped the area with another alcohol pad, but did not don gloves at any time during the insulin administration. In a subsequent interview, the LPN confirmed that she had repositioned the Ativan tablet with an ungloved hand and had not worn gloves while administering the insulin, and acknowledged that gloves should have been worn during medication preparation and insulin administration. Review of the facility’s “Injectable Medications” policy dated 06/21/17 showed a requirement to apply gloves prior to injecting medication, which was not followed in this instance.
Failure to Complete Admission Skin Assessment for Resident With Existing Wound
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a newly admitted resident received a complete admission skin assessment as required by facility policy. The resident was admitted with multiple diagnoses, including urinary tract infection, spina bifida, asthma, dysphagia, and dependence on a wheelchair for mobility. Physician orders at admission included instructions to encourage and assist with turning and repositioning every shift, to apply Mupirocin 2% ointment to chronic wounds every shift, and later to evaluate and assess a pressure area with a dressing at the coccyx every shift. Despite these orders and the resident’s conditions, the only documentation on the admission date regarding skin was a general notation that the skin was warm and dry, with no further detailed skin assessment completed at that time. A subsequent skin assessment performed several days later by the wound nurse (an LPN) documented a pressure area on the coccyx measuring 1.5 cm by 1.0 cm by 0.2 cm, with a small amount of serosanguineous drainage, a red wound bed, and maceration of the wound edges. The resident’s MDS indicated intact cognition with a BIMS score of 15, bilateral extremity impairment, and an unhealed pressure area to the coccyx. In interview, the wound nurse confirmed that an admission skin assessment had not been completed on the admission date and stated that the admitting nurse is responsible for the initial admission skin assessment, with the wound nurse to complete a second assessment and review admission treatment orders. This lack of an initial admission skin assessment constituted the cited noncompliance.
Failure to Maintain Resident Dignity by Covering Catheter Bag
Penalty
Summary
The facility failed to maintain resident dignity by not covering an indwelling urinary catheter drainage bag for a resident. This deficiency was observed during two separate occasions where the catheter drainage bag was left uncovered and visible from the hallway. The resident involved had a history of neuromuscular dysfunction of the bladder, paraplegia, and other medical conditions, and was dependent on staff for various activities of daily living. The resident's medical record indicated the use of a 16 French foley catheter with continuous drainage due to their condition. During observations, the resident was found lying in bed with the catheter drainage bag hanging on the bed frame, exposing the collected urine to view from the hallway. A certified nursing assistant confirmed the visibility of the uncovered catheter bag. The facility's failure to cover the catheter drainage bag compromised the resident's right to dignity and privacy, as the collected urine was visible to anyone passing by the hallway.
Failure to Obtain Written Authorization for Managing Resident's Funds
Penalty
Summary
The facility failed to obtain written authorization to manage a resident's personal funds, which is a violation of the resident's right to manage their financial affairs. The resident, who was admitted with diagnoses including vascular dementia, peripheral vascular disease, type II diabetes, and major depressive disorder, had indicated on a Management of Personal Funds form that they did not wish to open a personal funds account and would manage their own funds or have another person or entity do so. Despite this, a deposit was made into the resident's account without the necessary written authorization. Interviews revealed that the resident was unaware of their financial status, as they expressed a desire for a haircut but did not know if they had the funds to pay for it. The Business Office Manager confirmed that the resident had money in an account for a haircut and acknowledged that a personal funds account had been opened without a signed Management of Personal Funds form. This oversight affected the resident's ability to exercise their right to manage their financial affairs, as outlined in the facility's policy.
Failure to Implement Fall Interventions for Residents
Penalty
Summary
The facility failed to implement fall interventions for two residents, leading to deficiencies in accident prevention. Resident #34, who has dementia, COPD, CHF, and pre-diabetes, was identified as at risk for falls. Her care plan included the use of an alarming floor mat and a motion sensor to alert staff of unassisted ambulation attempts. However, observations revealed that the motion sensor alarm was not in place and was found lying on the dresser or bed in the off position. Additionally, the floor mat was not properly positioned or taped down with brightly colored tape as required. These observations were confirmed by interviews with LPNs. Resident #10, who has COPD, heart disease, and other conditions, was also at risk for falls. The care plan required the bed to be in the lowest position, locked, and the call light within reach. However, observations showed that the bed was not in the lowest position during multiple checks. This was verified by a CNA. The facility's Fall Management policy emphasizes the need for ongoing assessment and intervention to prevent falls, but these measures were not effectively implemented for the residents in question.
Inaccurate Medical Record for Resident with Psychosis
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident, identified as Resident #47, which led to a deficiency. The medical record for this resident did not include a diagnosis of psychosis, despite psychiatric notes indicating that the resident was receiving psychiatric services for psychosis secondary to a general medical condition. The resident's comprehensive list of diagnoses in the electronic medical record did not reflect this condition, which was confirmed during interviews with the Director of Nursing and the psychiatric physician. The resident had a complex medical history, including conditions such as vascular dementia, type two diabetes mellitus, and chronic kidney disease, among others. The resident was receiving Risperidone to treat delusions and psychosis not related to dementia behaviors, as per the physician's orders. However, the quarterly Minimum Data Set (MDS) assessment did not indicate any cognitive impairment or a diagnosis of psychosis, which was inconsistent with the psychiatric physician's confirmation of the resident's condition. This discrepancy in the medical records highlights the facility's failure to maintain accurate and complete documentation for the resident.
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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 Millersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majora Lane Ctr For Rehab & Nsg Care Inc | 2.8 mi | ★★★★★ | 18 | 0 |
| Scenic Pointe Nursing And Rehab Ctr | 3.5 mi | ★★★★★ | 0 | 0 |
| Walnut Hills Nursing Home | 10.8 mi | ★★★★★ | 0 | 0 |
| Wayne County Care Center | 14.1 mi | ★★★★★ | 0 | 0 |
| Oak Pointe Nursing & Rehabilitation | 14.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.