Otterbein Sunset House

In the surveyor’s words

From the most serious findings on record at Otterbein Sunset House, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 28, 2022

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of facility investigation, observations, and review of facility inservices, the facility failed to ensure a resident was provided with sufficient staff supervision when positioned in bed during direct care. Actual harm occurred when Resident #1's bed was raised from the low position and staff stepped away from the bed, out of sight of the resident. Resident #1 subsequently rolled from the bed hitting her head causing a cognitive and respiratory change which resulted in a concussion. This deficient practice affected one (#1) of three residents reviewed for falls and bed mobility. The facility census was 18. […]

• No harm, potential for more than minimal, widespreadF727May 1, 2025

  Based on staff interview and review of facility staffing documentation, the facility failed to ensure the facility was staffed with sufficient Registered Nursing staff each day. This affected all residents residing in the facility. Facility census was 14. Findings include: Review of facility nursing schedules between 04/21/25 and 04/27/25 revealed the schedule lacked documentation indicating a Registered Nurse (RN) was scheduled to work in the facility on 04/26/25 and 04/27/25. On 04/30/25 at 1:37 P.M. interview with the Administrator and Director of Nursing (DON) during a review of the nurse staffing scheduled between 04/21/25 and 04/27/25 verified the facility was not staffed with a Registered Nurse on 04/26/25 or 04/27/25. […]

• No harm, potential for more than minimal, widespreadF880May 1, 2025

  Based on interview, facility documentation, and a policy for water management, the facility failed to ensure a sufficient water management program based on an accurate risk assessment. This had the potential to affect all residents. The census was 14. Findings include: Review of a document titled Legionnaire's Risk Assessment revealed the document was undated, unsigned, and did not include the name of the facility. Interview on 05/01/25 at 9:15 A.M. with Administrator and Environmental Services Director #233 confirmed the risk assessment did not include the date of the assessment, a signature, or the name of the facility. Both denied knowledge of when the risk assessment was completed and by whom. […]

• No harm, potential for more than minimal, widespreadF921May 1, 2025

  Based on staff interview and review of fire drill reports, corrective action plans, and a state fire marshal report, the facility failed to conduct fire drills across all shifts during the twelve-month review period preceding the survey. This had the potential to affect all residents. The census was 14. Findings include: Interview on 05/01/25 at 9:15 A.M. with the Administrator and Environmental Services Director (ESD) #233 revealed fire drills were not conducted on first or third shift in the first quarter of 2024, and no fire drill was conducted on third shift in the third quarter of 2024. Follow-up interview on 05/01/25 at 1:15 P.M. […]

• No harm, potential for more than minimal, widespreadF812Jun 24, 2024

  Based on observation, staff interview, and review of the facility policy, the facility failed to seal and date opened food items in the freezer. This had to potential to affect all 19 residents residing in the facility. Findings include: Observation on 06/24/24 of the kitchen's freezer from 7:20 A.M. to 7:45 A.M. revealed an opened, unsealed, undated bag of Alaskan polluck, an opened, unsealed, undated bag of turkey sausage, an opened, unsealed, undated bag of seasoned beef patties. Interview on 06/24/24 at 7:25 A.M. with Dietary [NAME] #202 verified the finding. Interview on 06/24/24 at 1:26 P.M. with the Administrator stated all residents were getting food from the kitchen and there were no residents nothing by mouth. […]