Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Otterbein Sunset House during CMS and state inspections, most recent first.
The facility did not have an RN on duty for two consecutive days, with the DON only on call and not present in the building. This lack of RN coverage affected all residents in the facility.
The facility did not ensure its Legionnaire's risk assessment was properly completed, as the document was undated, unsigned, and lacked the facility's name. Both the Administrator and Environmental Services Director were unable to confirm when or by whom the assessment was done, despite policy requiring a thorough risk assessment to identify potential Legionella growth. This had the potential to affect all residents.
The facility did not conduct required fire drills on all shifts during a twelve-month period, missing drills on the first and third shifts in one quarter and on the third shift in another quarter, as confirmed by staff interviews and documentation review. This failure was identified by the state fire marshal and had the potential to affect all residents.
A resident requiring substantial assistance with daily living was found to have a private restroom in unsanitary condition, including a soiled bedpan on the toilet, brown particles in the toilet bowl, and a brown substance on the floor. Housekeeping staff confirmed that such conditions are often found after weekends.
Two residents with complex medical conditions did not have required monthly pharmacist medication regimen reviews documented in their medical records. Although the pharmacist indicated reviews were completed and reports provided to the DON and prescriber, no such documentation was available, contrary to facility policy requiring these records to be accessible to the care team.
A resident with severe cognitive impairment and major depression continued to receive Venlafaxine ER without evidence that a pharmacy consultant's recommendation for a gradual dose reduction, and the physician's directive to involve psych, were implemented. The DON confirmed that the physician's response was not carried out, resulting in a failure to ensure the resident's drug regimen was free from unnecessary drugs.
A resident with multiple chronic conditions did not receive cilostazol as ordered due to unavailability, and a RN administered brimonidine and dorzolamide eye drops consecutively without the required pause, resulting in a medication error rate of 8.11%, which is above the acceptable threshold.
Two residents experienced significant medication errors when prescribed medications were omitted due to unavailability and eye drops were administered without the required interval between doses. Nursing staff confirmed the omissions and improper administration, and facility policy regarding medication timing and administration was not followed.
A facility failed to prevent staff-to-resident physical abuse when a resident, who was highly impaired visually and had severe cognitive impairment, was subjected to rough care by an STNA. The incident was reported by a family member, and video footage confirmed the STNA's improper care and disrespectful communication. The facility's policy on abuse and restraints was not followed, leading to the deficiency.
The facility failed to seal and date opened food items in the kitchen's freezer, potentially affecting all 19 residents. Observations revealed unsealed and undated bags of Alaskan pollock, turkey sausage, and seasoned beef patties. The facility's policy requires proper labeling and dating to prevent foodborne illness.
The facility failed to ensure timely provision and signing of admission agreements for three residents, all of whom had significant medical conditions. Admission agreements were signed seven to nine days after admission, contrary to the facility's policy.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present on duty for at least 8 hours each day, as required. Review of the nursing schedules and staffing documentation for the week in question showed that there was no RN scheduled or present in the facility on two consecutive days. The Director of Nursing (DON) was on call during these days but did not report to the facility. Interviews with the Administrator and DON confirmed that no RN was working in the facility on those dates. This deficiency affected all residents in the facility, which had a census of 14 at the time.
Incomplete Water Management Risk Assessment for Legionella
Penalty
Summary
The facility failed to maintain a sufficient water management program based on an accurate risk assessment, as required for infection prevention and control. Review of the Legionnaire's Risk Assessment document revealed it was undated, unsigned, and did not include the facility's name. During an interview, both the Administrator and the Environmental Services Director confirmed that the risk assessment lacked a date, signature, and facility identification, and neither could verify when the assessment was completed or by whom. Additionally, the facility's policy required a risk assessment to identify areas where Legionella and other waterborne pathogens could grow and spread, but the documentation did not meet these requirements. The census at the time was 14 residents, and this deficiency had the potential to affect all residents.
Failure to Conduct Fire Drills Across All Shifts
Penalty
Summary
The facility failed to conduct fire drills across all shifts during the twelve-month review period preceding the survey. Specifically, fire drills were not conducted on the first or third shift in the first quarter of 2024, and no fire drill was conducted on the third shift in the third quarter of 2024. This was confirmed through staff interviews and review of fire drill reports, corrective action plans, and a state fire marshal report. The facility's Emergency and Disaster Plan, last reviewed in November 2024, required that fire drills be conducted monthly and rotated so that each shift participated in a drill at least once per quarter. An interview with the Administrator and Environmental Services Director confirmed the missed fire drills, and a follow-up interview revealed that the state fire marshal issued a violation for this failure. The census at the time was 14 residents, and the deficiency had the potential to affect all residents. The report does not mention any specific residents' medical history or condition at the time of the deficiency.
Unsanitary Resident Restroom and Inadequate Housekeeping
Penalty
Summary
The facility failed to maintain a resident's private restroom in a sanitary condition, as observed during a survey. A resident with multiple diagnoses, including Alzheimer's disease, dementia, chronic kidney disease, and a recent femur fracture, who required substantial to maximal assistance with activities of daily living, was found to have a soiled bedpan containing yellow liquid placed on top of the toilet. The toilet itself had brown particles clinging to the bowl, and a brown substance was also noted on the floor tile next to the toilet. The housekeeper confirmed the unsanitary condition of the restroom and stated that soiled debris is frequently found in resident restrooms following weekends. These findings demonstrate a failure to ensure a safe, clean, and comfortable environment for the resident, as required by regulations regarding environmental and housekeeping services.
Failure to Document Monthly Pharmacist Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews by a licensed pharmacist were properly conducted and documented for two of five sampled residents. For one resident with multiple complex diagnoses, including cerebral infarction, congestive heart failure, and severe cognitive impairment, the medical record showed no documentation of the pharmacist's monthly medication review or any resulting recommendations or medication adjustments, despite a progress note indicating a review had been completed. The Director of Nursing (DON) confirmed that no such documentation was available in the resident's medical record. Similarly, another resident with severe dementia, multiple comorbidities, and on hospice care had physician orders for numerous medications. Although the pharmacist's monthly progress notes stated that the medication regimen was reviewed and any irregularities were reported to the DON and prescriber, there was no evidence in the medical record of these reports or recommendations. The DON confirmed that the pharmacist's monthly review reports were not included in the resident's medical record or otherwise available. Facility policy required that consultant pharmacist recommendations be documented and made easily accessible to the care team, but this was not followed.
Failure to Implement Physician-Directed Psychoactive Medication Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to ensure that psychoactive medication recommendations were implemented as directed by the physician for a resident with multiple complex diagnoses, including major depression and severe cognitive impairment. The resident was prescribed Venlafaxine ER 37.5 mg for major depressive disorder, and the care plan included monitoring for side effects, monthly pharmacy review, and implementation of physician recommendations regarding medication management. Despite a pharmacy consultant's recommendation for the physician to consider a gradual dose reduction (GDR) of the psychoactive medication, and the physician's response to involve psychiatric consultation, there was no documentation in the medical record that this recommendation or physician response was implemented. The Director of Nursing confirmed during an interview that the physician's response had not been carried out, resulting in a failure to follow through on medication management protocols for unnecessary drugs.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician and without error, resulting in a medication error rate of 8.11%, which exceeds the acceptable threshold of 5%. Specifically, three errors were identified out of 37 medication administrations observed. One resident, who had multiple diagnoses including pneumonia, hypoxemia, diabetes, COPD, glaucoma, chronic kidney disease, and depression, was affected. This resident was assessed as having moderately impaired cognition, was dependent on staff for activities of daily living, had adequate vision with corrective lenses, and was incontinent of urine. During medication administration, a registered nurse did not administer cilostazol 100 mg as ordered because it was not available at the facility. Additionally, the nurse administered brimonidine and dorzolamide eye drops consecutively without the required pause between different eye medications, contrary to facility policy, which specifies a 3 to 5 minute interval for optimal absorption. These actions were confirmed through observation and staff interview, and were not in accordance with the facility's medication administration procedures.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the omission and improper administration of prescribed medications for two residents. For one resident with multiple chronic conditions including diabetes, glaucoma, and chronic kidney disease, the morning dose of cilostazol was not administered because the medication was unavailable. Additionally, the resident received two different ophthalmic solutions for glaucoma without the required pause between administrations, contrary to facility policy, which specifies a waiting period to ensure optimal absorption. The nurse confirmed both the omission of cilostazol and the lack of pause between eye drop medications during interviews. Another resident, admitted with diagnoses such as femur fracture, schizophrenia, diabetes, and heart failure, did not receive the prescribed antidepressant vilazodone for three consecutive days due to the medication not being available in the facility. There was no documentation indicating that the medication was administered or that the physician was notified of the omission. The Director of Nursing confirmed the missed doses and the lack of medication availability. Facility procedures require medications to be administered as ordered and within a specific time frame, which was not followed in these cases.
Failure to Prevent Staff-to-Resident Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident physical abuse, affecting one resident who was highly impaired visually and had severe cognitive impairment. The resident was dependent on staff for various activities of daily living and required assistance for transfers using a lift device. The resident's medical record indicated multiple diagnoses, including dementia and hemiparesis following a cerebral vascular accident. The incident came to light when a family member reported to the Director of Nursing that a State tested Nursing Assistant (STNA) was rough while providing care during the midnight shift. The facility's investigation, which included reviewing video footage provided by the family, confirmed that the STNA provided improper care and communicated disrespectfully with the resident. The video showed the STNA crossing the resident's arms across their chest, pulling the shirt over the arms, and securing it over the shoulders, which restricted the resident's movement. Additionally, the STNA mocked the resident when they moaned during care. The facility's policy on abuse, mistreatment, neglect, exploitation, and misappropriation of resident property was reviewed, which emphasized residents' rights to be free from abuse and restraints not required for medical symptoms. The policy defined physical restraint as any method or device that restricts freedom of movement or access to one's body. The facility's failure to adhere to this policy resulted in the deficiency being cited.
Improper Food Storage in Facility Freezer
Penalty
Summary
The facility failed to properly seal and date opened food items in the kitchen's freezer, which could potentially affect all 19 residents residing in the facility. During an observation of the kitchen's freezer, it was found that there were opened, unsealed, and undated bags of Alaskan pollock, turkey sausage, and seasoned beef patties. This finding was verified by a dietary staff member. An interview with the Administrator confirmed that all residents were receiving food from the kitchen, and there were no residents on a nothing by mouth status. The facility's Food Storage Policy and Procedure, last revised in May 2013, requires that all food be stored, labeled, and dated properly to ensure stock rotation and prevent foodborne illness. This deficiency was investigated under Complaint Number OH00154237.
Failure to Provide Timely Admission Agreements
Penalty
Summary
The facility failed to ensure that admission agreements were provided and signed timely for newly admitted residents. This deficiency affected three residents, all of whom had significant medical conditions. Resident #10, diagnosed with sepsis, prostate cancer, type II diabetes, and other conditions, was admitted on [DATE] but did not sign the admission agreement until nine days later. Similarly, Resident #11, with diagnoses including a fractured clavicle and heart disease, signed the admission agreement nine days after admission and just three days before discharge. Resident #12, who had undergone joint replacement surgery and had other medical issues, signed the agreement seven days after admission and one day before discharge. The Admissions Director confirmed that admission packets are typically signed within 72 hours, although there is no defined timeframe for signature. The facility's policy requires that potential residents sign the admission agreement and receive a copy of the facility's description of services, payment options, and resident rights prior to signing. However, this policy was not followed for the three residents in question. The deficiency was investigated under Complaint Number OH00152165.
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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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How nearby facilities compare on the same public inspection record.
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| Park Terrace Rehabilitation Center | 1.5 mi | ★★★★★ | 16 | 0 |
| Divine Rehabilitation And Nursing At Toledo | 1.6 mi | — | 28 | 0 |
| Ayden Healthcare Of Toledo | 1.7 mi | ★★★★★ | 4 | 0 |
| Continuing Healthcare Of Toledo | 2.8 mi | ★★★★★ | 6 | 0 |
| Franciscan Care Ctr Sylvania | 3 mi | ★★★★★ | 30 | 1 |
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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 July 2026) and official state health department websites.