Below 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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Otterbein Sunset Village during CMS and state inspections, most recent first.
Surveyors identified that nursing staff did not follow physician orders and facility policy for medication administration, resulting in a medication error rate above 5%. One resident with hypertension and chronic kidney disease received metoprolol succinate ER without required pre-dose vital signs to determine if hold parameters were met. Another resident receiving cephalexin 500 mg QID for cellulitis was given a dose outside the prescribed and policy-defined time window for equally spaced antibiotic dosing. These two observed errors out of 28 opportunities resulted in a calculated medication error rate of 7.14%.
The facility failed to ensure medications were administered according to physician orders and facility policy, resulting in significant medication errors affecting three residents. A resident with multiple chronic conditions and an active PRN morphine order, but no Dilaudid order, received Dilaudid in error instead of morphine, with documentation noting that medication was not given according to the six rights and lacking clear details of the drug and dose administered. Another resident with an order for metoprolol succinate ER, to be held for low BP or HR, received the medication without the RN obtaining vital signs beforehand. A third resident with an order for cephalexin 500 mg QID at evenly spaced times received the antibiotic outside the prescribed timeframe, contrary to the facility’s liberal med administration policy requiring time-sensitive antibiotics to be given at scheduled hours.
A resident with multiple chronic conditions, including cerebrovascular disease, diabetes, epilepsy, and cortical blindness, had an order for PRN morphine sulfate but no active order for Dilaudid. On one occasion, the resident reported pain while sitting in a recliner, and documentation noted that medication was not administered according to the six rights of medication administration, with low O2 saturation that improved after PRN oxygen and the resident later drowsy but resting in bed. However, the medical record did not specify which medication or dose was given, lacked detailed description of the medication error, and contained no ongoing assessment or physician instructions related to the event. In interviews, the DON reported that an LPN had administered Dilaudid instead of the ordered morphine but could not identify for whom the Dilaudid was prescribed and had not verified the amount in the bottle, and the Administrator acknowledged there was no documented procedure to ensure accurate documentation of such incidents.
A resident with diabetes, hemiplegia, and severe cognitive impairment was not properly monitored for a diabetic foot ulcer. Required interventions, such as applying protective boots and floating legs, were not consistently implemented, and weekly wound assessments lacked necessary measurements and descriptions. Staff interviews and observations confirmed lapses in following the care plan and facility policy for wound care documentation and intervention.
A resident with severe cognitive impairment and a diabetic foot ulcer did not have protective boots applied as ordered by the physician, despite documentation in the MAR indicating they were in place. Both an LPN and a CNA confirmed the boots were not applied during observation, revealing inaccurate medical records and a failure to follow prescribed care interventions.
A facility failed to maintain accurate medical records for a resident with complex medical conditions, as a dressing change was documented but not performed by an LPN. The resident's daughter and a hospice RN confirmed the discrepancy, revealing non-compliance with the facility's skin care management policy.
The facility failed to ensure proper linen handling and lacked an effective Legionella water management program. An STNA was observed transporting linens uncovered and pressed against her body, and gowns were not worn by a Laundry Aide when handling soiled linens. The Legionella Risk Assessment indicated high risk, but the Administrator and DES were unfamiliar with the plan's elements, and there was no regular monitoring of water temperatures or flushing of faucets in empty rooms.
The facility's memory care unit kitchen was found to be unsanitary, with sticky floors and food debris on surfaces, potentially affecting 18 residents. Dietary staff confirmed the lack of regular cleaning and could not recall the last cleaning. Despite some cleaning efforts, dried food remained on various surfaces.
The facility failed to maintain cleanliness and sanitation, as evidenced by a resident's soiled wheelchair and another resident's persistently malodorous room. Despite protocols, the wheelchair remained dirty, and staff confirmed the odor issue. Additionally, food debris from the previous night was found in the dining room, indicating broader sanitation lapses.
A resident with dementia and aphasia was left with food spilled on their clothing and body after a meal, despite multiple staff members, including STNAs and nursing students, passing by without providing assistance. The resident remained in this state for an extended period, which was verified by an LPN, indicating a failure to uphold the facility's policy on resident dignity.
A resident with a history of bipolar disorder, panic disorder, anxiety, and epilepsy was found with a call light out of reach, despite a care plan intervention to keep it accessible due to fall risk and need for assistance with ADLs. An STNA confirmed the call light's location, and the facility lacked a policy on call lights.
A resident with multiple health conditions refused several doses of critical medications, including insulin and anticoagulants, on multiple occasions. An LPN documented the refusals due to nausea or vomiting but failed to notify the physician or the resident's family, as required by the facility's policy.
A facility failed to implement fall interventions for a resident at risk for falls. Despite the care plan requiring a fall mat next to the bed, observations showed the mat was not in place, but leaning against the wall. An LPN confirmed the mat should have been positioned correctly, indicating non-compliance with the care plan.
The facility failed to serve meals at an appetizing temperature, affecting two residents who received food from the memory care unit. Meals were consistently cold when served in rooms, with observations confirming inadequate temperature maintenance due to unheated plates and insufficient covers. A test tray showed significantly cooled food, and Resident Council Meeting Minutes documented ongoing concerns about food temperatures.
The facility failed to ensure pneumococcal vaccinations were offered or administered per CDC recommendations, affecting two residents. One resident, cognitively intact, had not received an updated vaccine since 2017 and was not educated on CDC guidelines until the survey. Another resident, moderately cognitively impaired, had no record of being offered the vaccine, and their representative's consent form was incomplete. The facility's policy to offer and educate residents on pneumococcal immunizations upon admission was not followed.
A facility failed to administer medications as ordered by a physician, resulting in a 25% medication error rate. An LPN crushed medications for a resident without a physician's order, contrary to the facility's procedures. The medications included Amlodipine, Cholecalciferol, Citalopram, and others. The facility's procedure requires medications to be administered according to physician orders, with crushing only allowed if indicated in the resident's orders and MAR.
Medication Administration Errors Resulting in Error Rate Above 5%
Penalty
Summary
The deficiency involves failure to ensure medications were administered in accordance with physician orders, resulting in a medication error rate of 7.14% (2 errors out of 28 opportunities), which exceeded the 5% threshold. For one resident with hypertension related to hypertensive chronic kidney disease, a physician order dated 09/11/25 directed administration of metoprolol succinate ER 25 mg by mouth once daily, with instructions to hold the dose if systolic blood pressure was less than 100 mmHg or heart rate was less than 60 beats per minute. On 02/18/26, an RN prepared and administered this medication whole with water without obtaining the resident’s vital signs beforehand, as confirmed by the RN during interview, meaning the medication was given without verifying the hold parameters specified in the order. The second error involved an antibiotic order for cephalexin 500 mg by mouth four times daily for cellulitis for 10 days, with prescribed administration times of 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. Facility policy required medications to be administered within one hour before or after the scheduled time, and a liberal medication administration policy specified that time-sensitive medications requiring equally spaced dosing, such as antibiotics given four times daily, must follow those scheduled times. On 02/18/26, an RN prepared the cephalexin capsule with other medications in applesauce and administered it at approximately 9:19 A.M., which was outside the physician-prescribed timeframe for that dose, as verified by the RN. These two observed errors, confirmed through observation, record review, and staff interview, led to a medication error rate above the acceptable limit.
Significant Medication Errors and Failure to Follow Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with physician orders, resulting in significant medication errors for multiple residents. One resident with extensive medical conditions including cerebrovascular disease, type II diabetes, epilepsy, hypertension, chronic pain, cortical blindness, and morbid obesity had an active order for morphine sulfate oral solution 20 mg/mL, 0.5 mL by mouth every two hours as needed for pain or shortness of breath, and no active order for Dilaudid. Event documentation for this resident noted an incident in which the resident was sitting in a recliner, reported pain, and was found to have oxygen saturation below 90%, requiring application of as-needed oxygen to return saturation above 90% on 2.5 L via nasal cannula. The documentation referenced that medication was not administered according to the six rights of medication administration, but did not specify the medication or dose given, nor did it contain detailed content of the incident, ongoing assessment of the resident’s health status, or physician instructions. Further information obtained through interview with the DON and the Administrator revealed that an LPN reported administering two different doses of Dilaudid in error to this resident instead of the ordered morphine. The DON was unable to identify the resident for whom the Dilaudid had been prescribed and there was no documentation in the medical record of the specific medication or dose administered. The DON also stated she did not check the Dilaudid suspension level before or after the LPN’s shift, and concluded that the LPN did not identify the correct medication before administration. The medical record lacked additional progress notes related to this medication error in the days following the incident. Another deficiency involved a resident with an order for metoprolol succinate ER 25 mg once daily for hypertension related to hypertensive chronic kidney disease, with instructions to hold the medication if systolic blood pressure was less than 100 mmHg or heart rate less than 60 beats per minute. Observation showed an RN preparing and administering this medication without obtaining vital signs beforehand, and the RN confirmed that no vital signs were taken prior to administration. A third resident had an order for cephalexin 500 mg by mouth four times daily for cellulitis, scheduled at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M., with facility policy specifying that such antibiotics must be administered at equally spaced times. Observation showed the RN administering the cephalexin at 9:19 A.M., outside the prescribed timeframe, and the RN confirmed the medication was given outside the ordered schedule. These actions were inconsistent with the facility’s medication administration policies requiring adherence to physician orders and specified timing.
Incomplete Documentation of Medication Error and Resident Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical record documentation regarding a medication error for one resident. The resident had multiple diagnoses, including cerebrovascular disease, type II diabetes mellitus, major depressive disorder, epilepsy, hypertension, cortical blindness, anxiety disorder, and morbid obesity, and was receiving antidepressant, diuretic, opioid, antiplatelet, and anticonvulsant medications, as well as oxygen therapy and hospice care. A physician order dated 11/24/25 directed that morphine sulfate oral solution 20 mg/mL be given at 0.5 mL by mouth every two hours as needed for pain or shortness of breath, and there was no active order for Dilaudid. On 11/25/25, an event note documented that the resident, who was sitting in a recliner watching television, reported pain, and that medication was not administered according to the six rights of medication administration. The assessment noted oxygen saturation below 90%, application of as-needed oxygen with improvement above 90% on 2.5 L via nasal cannula, and that the resident was drowsy but resting comfortably in bed. The medical record did not contain documentation of the specific medication error, including the medication name, dose given, or detailed description of the incident, nor did it include ongoing assessments of the resident’s health status or physician instructions related to the error. There were no additional progress notes between the event on 11/25/25 and 11/29/25, and the next progress note on 12/01/25 did not mention the medication error, ongoing assessments, or physician recommendations following the error. During interviews, the DON stated that an LPN had reported administering two different doses of Dilaudid in error instead of the ordered morphine, but the DON could not identify the resident for whom the Dilaudid was prescribed, and there was no verification of the amount of Dilaudid in the bottle before or after the incident. The DON confirmed that the medical record lacked documentation reflecting the details of the medication error, and the Administrator acknowledged there was no documented facility guidance or procedures to ensure accurate resident information and experiences, including medication errors, were consistently recorded in the medical record.
Failure to Monitor and Implement Wound Care Interventions
Penalty
Summary
A resident with multiple complex medical conditions, including hemiplegia, diabetes mellitus with a foot ulcer, and severe cognitive impairment, was not properly monitored or treated for a diabetic foot ulcer. The care plan required the application of protective boots, floating of legs with pillows, and ongoing monitoring and documentation of the wound's size, depth, margins, and healing progress. However, medical record review showed that weekly wound assessments were incomplete, often missing measurements and detailed descriptions of the wound bed. Additionally, hospice notes provided to the facility lacked detailed weekly wound documentation, and the DON confirmed she had not reviewed these reports, which misidentified the wound as a stage two pressure ulcer. Observation revealed the resident was found in bed without the required protective boots, and their heels and legs were directly on the mattress, contrary to care plan interventions. Staff interviews confirmed inconsistent understanding and implementation of the boot application schedule. Facility policy required comprehensive wound documentation with each dressing change or at least weekly, but this was not followed, resulting in a failure to monitor the resident's wound and implement necessary interventions as outlined in the care plan and facility policy.
Failure to Accurately Document and Implement Physician Orders for Protective Boots
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical records and the implementation of physician orders regarding the application of protective boots. A review of the medical record for a resident with multiple diagnoses, including hemiplegia, diabetes with a foot ulcer, and severe cognitive impairment, showed that the care plan and physician orders required bilateral green boots to be applied in the morning and removed at night, with legs floated on pillows twice daily. The Medication Administration Review (MAR) indicated that the boots were applied as ordered. However, during an observation, the resident was found in bed without the boots, and both an LPN and a CNA confirmed that the boots were not applied at that time, despite documentation in the MAR stating otherwise. The CNA also reported being told that the boots were to be applied at night and removed in the morning, which conflicted with the physician's orders. This discrepancy demonstrates a failure to maintain accurate medical records and to follow prescribed care interventions.
Inaccurate Medical Record Keeping for Resident's Dressing Change
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident, identified as Resident #30, who was admitted with multiple complex medical conditions including hemiplegia, diabetes, and atherosclerotic heart disease, among others. The resident required substantial assistance for all functional abilities and was dependent on others for transfers. A discrepancy was found in the documentation of a dressing change for the resident's left foot ulcer. The resident's daughter reported that the dressing was not changed on a specified date by the facility nurse, despite documentation indicating otherwise. Interviews with the Director of Nursing and a Hospice Registered Nurse confirmed that the dressing change documented by an LPN did not occur. The hospice nurse verified that the dressing she applied on a previous date was still in place, indicating that the facility nurse had not performed the dressing change as recorded. This discrepancy in the medical record was identified during a complaint investigation, highlighting a failure to adhere to the facility's policy on skin care management and accurate record-keeping.
Deficiencies in Linen Handling and Legionella Management
Penalty
Summary
The facility failed to ensure proper handling of linens to prevent contamination. During an observation, a State tested Nursing Assistant (STNA) was seen carrying two large stacks of linens pressed against her body and the door while entering a code to unlock doors, confirming that the linens were transported uncovered and pressed against her body. Additionally, in the laundry room, it was observed that gowns were not worn by the Laundry Aide when handling soiled linens, which could lead to cross-contamination. The facility also lacked an appropriate Legionella water management program. The Legionella Risk Assessment indicated a high risk for Legionella, but the Administrator and the Director of Environmental Services (DES) were not familiar with the necessary elements of the plan. The DES was unable to articulate routine control measures, and there was no regular monitoring of water temperatures or flushing of faucets in empty rooms to prevent Legionella growth. The facility's policy required competent personnel to carry out maintenance and monitoring, but this was not effectively implemented.
Sanitation Deficiency in Memory Care Unit Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary serving kitchen in the secured memory care unit, which had the potential to affect 18 residents. During an observation, the floor was found to be sticky and covered in food debris and splatters, with a build-up of food debris in the corners and along the bottom of the cabinets and equipment. The stickiness of the floor was significant enough to cause a shoe to become partially stuck. Additionally, there were splatters and dried food on the front of the lower cabinets and on the wall behind the kitchen sink and steam table. The juice machine also had a build-up of a sticky substance behind the nozzles and along the wall next to it. Dietary Staff #342 confirmed the presence of food build-up on the floor, the stickiness of the floor, and the need for cleaning the juice machine, cabinets, and walls. The staff member was unable to recall the last time the serving kitchen had been cleaned, stating that she attempted to clean it once a week during her dinner service shifts, but could not remember the last time she worked that shift. A subsequent observation revealed that while the floors had been swept and mopped and the juice machine wiped down, dried food remained on the lower cupboards and walls behind the steam table, next to the juice machine, and behind the sink.
Sanitation and Odor Issues in Facility
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by the condition of Resident #4's wheelchair and the persistent odor in Resident #15's room. Resident #4, who has severe cognitive impairment and multiple health conditions, was observed in a wheelchair that was heavily soiled with dirt, food crumbs, and an intact pretzel. Despite the facility's protocol for cleaning wheelchairs on shower days and as needed, the wheelchair remained dirty over multiple observations. Staff interviews confirmed the lack of cleanliness, indicating a lapse in the facility's maintenance procedures. Additionally, Resident #15's room was consistently malodorous over several days, with staff acknowledging the persistent unpleasant smell. The Director of Nursing also verified the odor issue, highlighting a failure in maintaining a comfortable and odor-free environment for residents. Furthermore, the dining room was found to have food debris on the floor from the previous night's dinner, which was not cleaned up by the kitchen staff during breakfast service. This indicates a broader issue with cleanliness and sanitation practices within the facility.
Failure to Maintain Resident Dignity Post-Meal
Penalty
Summary
The facility failed to ensure the dignity of a resident, identified as Resident #33, by not cleaning them up after meals. Resident #33, who has dementia, a history of stroke, and aphasia, was observed sitting in a wheelchair at a dining room table with food spilled on their shirt saver and lap blanket. Despite multiple staff members, including nursing students and State Tested Nursing Assistants (STNAs), passing by the resident, none addressed the spilled food on the resident's clothing or provided assistance. This lack of action persisted over a period of time, as various staff members were observed walking past the resident without offering help. Further observations revealed that Resident #33 had a quarter-sized glob of oatmeal in their hair, food on their headband, and dried food on their face and right hand. These conditions were verified by a Licensed Practical Nurse (LPN) during an interview. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, which was not upheld in this instance, as the resident remained in a soiled state for an extended period, affecting their dignity and quality of life.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach of residents, specifically affecting one resident. The medical record for the resident indicated a history of bipolar disorder, panic disorder, anxiety, and epilepsy, and the care plan, revised in October 2024, included an intervention to keep the call light within reach due to the resident's need for assistance with activities of daily living and fall risk. However, during an observation, the call light was found at the bottom of the bed, out of the resident's reach. A State Tested Nursing Assistant confirmed the call light's location and acknowledged that the resident was capable of using it to communicate needs. The facility administrator admitted that there was no policy in place regarding call lights.
Failure to Notify Physician and Family of Missed Medications
Penalty
Summary
The facility failed to ensure that the physician and responsible party were notified when medications were not administered as ordered by the physician. This deficiency affected a resident who was moderately cognitively impaired and required substantial assistance with activities of daily living. The resident had multiple diagnoses, including type II diabetes mellitus, seizure disorder, and depression, among others. The resident's physician orders included medications for diabetes, atrial fibrillation, Alzheimer's disease, benign prostatic hypertrophy, and depression. The Medication Administration Record (MAR) for October 2024 showed that an LPN documented that the resident was nauseated or vomiting, leading to missed doses of several medications on multiple occasions. The LPN confirmed that the resident refused the bedtime doses of medications, including insulin, an anticoagulant, and mood disorder medications, on specific dates. However, there was no evidence that the physician or the resident's family were notified of these medication refusals, which was a requirement according to the facility's policy on Notification of Change of Condition.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to implement fall interventions for a resident, leading to a deficiency in ensuring a safe environment free from accident hazards. Resident #9, who was admitted with diagnoses including osteoarthritis, dementia, anxiety, and bipolar disorder, was identified as being at risk for falls. The resident's care plan, revised in October 2024, included the use of a fall mat as an intervention. However, observations on two consecutive days revealed that the fall mat was not in place next to the resident's bed as required, but was instead leaning against the wall. An interview with LPN #473 confirmed that the fall mat should have been positioned next to the bed when the resident was in bed, indicating a failure to adhere to the care plan. The facility's Falls Management policy, revised in December 2019, mandates that care plans be reviewed and updated to reflect the current needs of residents to prevent falls.
Failure to Serve Meals at Appetizing Temperature
Penalty
Summary
The facility failed to ensure that meals were served at an appetizing temperature, affecting two residents who received food from the secured memory care unit serving kitchen but did not reside on the secured unit. Resident #98 and Resident #3, both alert and aware, reported that their meals were consistently cold when served in their rooms. Observations confirmed that the lunch meal cart was delivered to the serving kitchen with food temperatures initially within acceptable ranges. However, the plates used were not heated, and there were no insulated bases or lids to maintain the food's temperature. The clear plastic covers used had holes, which contributed to the cooling of the food. Further observations revealed that the meals were plated and placed on an open cart without sufficient covers, leading to a delay in delivery. Approximately 30 minutes after plating, the meals were delivered, resulting in cold food. Resident #3 reported that the burger was cold and the cheese unmelted, while the soup was lukewarm. A test tray confirmed that the food temperatures had dropped significantly, with mashed potatoes at 113 degrees F, pureed green beans at 100 degrees F, and soup at 110 degrees F. The Resident Council Meeting Minutes from May and June also documented concerns about food temperatures, indicating a recurring issue.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered or administered pneumococcal vaccinations according to CDC recommendations. This deficiency affected two residents. Resident #22, who was cognitively intact, had not received an updated pneumococcal vaccine since 2017. Although the resident initially consented to receive the PCV20 vaccine, she later refused it, believing she was not due for another dose for ten years. The facility did not provide evidence that Resident #22 was educated on the different pneumococcal vaccinations and CDC recommendations until the day of the survey. Resident #30, who was moderately cognitively impaired, had no record of being offered or receiving a pneumococcal vaccination. The resident's representative had consented to influenza and COVID-19 vaccines, but the pneumococcal vaccination section was left blank. An email communication with the resident's representative did not mention the pneumococcal vaccine. The facility's policy required that each resident be offered the pneumococcal immunization upon admission, with education provided regarding its benefits and potential side effects, but this was not followed for Resident #30.
Medication Administration Error Due to Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician, resulting in a medication error rate of 25%, which is above the acceptable threshold of 5%. During an observation of medication administration, an LPN prepared and crushed several medications for a resident without a physician's order to do so. The medications included Amlodipine, Cholecalciferol, Citalopram, Famotidine, Ferrous Sulfate, Magnesium Oxide, Senna-Docusate Sodium, and Calcium Citrate. The LPN confirmed that there was no physician order to crush the medications, which was a deviation from the facility's medication administration procedure. The facility's procedure requires medications to be administered according to the written orders of the attending physician. Crushing medications is only permitted if indicated in the resident's orders and the Medication Administration Record (MAR), ensuring all personnel are aware and the consultant pharmacist can advise on safety issues. The failure to adhere to these procedures led to a medication error rate of 25%, affecting one of the three residents observed during the medication administration process. This deficiency was investigated under Complaint Number OH00158467.
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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 Sylvania
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakes Of Sylvania, The | 1 mi | ★★★★★ | 9 | 0 |
| Kingston Health Center Of Sylvania | 3.3 mi | ★★★★★ | 37 | 0 |
| Rosary Care Center | 3.7 mi | ★★★★★ | 0 | 0 |
| Arbors At Sylvania | 4.4 mi | ★★★★★ | 1 | 0 |
| Franciscan Care Ctr Sylvania | 4.9 mi | ★★★★★ | 30 | 1 |
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