Otterbein Sunset Village

In the surveyor’s words

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

• Actual harm, isolatedF684Aug 13, 2026

  Based on record review, staff interview, and policy review, the facility failed to initiate prompt and appropriate care after a resident fell from a mechanical lift. This resulted in actual harm on 08/06/26 at approximately 3:00 P.M. when a mechanical lift being used to transfer Resident #78 had multiple batteries fail, requiring staff to use the mechanical lift's emergency release to lower the resident onto the floor. The facility also failed to recognize that Resident #78 suffered a fall and therefore the resident was not timely assessed, not provided a timely diagnosis and treatment resulting in the resident experiencing unnecessary pain. […]

• No harm, potential for more than minimal, widespreadF880Oct 24, 2024

  Based on observation, staff interview, review of the Legionella (bacteria that can cause a severe type of pneumonia) Risk Assessment, review of facility policy and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure appropriate handling of linen to prevent contamination. In addition, the facility failed to have an appropriate Legionella water management program in place. This had the potential to affect all 47 residents of the facility. The facility census was 47. Findings include: 1. Observation on 10/21/24 at 2:41 P.M. revealed State tested Nursing Assistant (STNA) #437 carried two large stacks of linens, with one stack of linens in each arm and pressed against the top half of her body. […]

• No harm, potential for more than minimal, widespreadF726Nov 30, 2023

  Based on medical record review and staff interview, the facility failed to ensure all staff working in the facility were aware of and trained on all available services, resources and treatment opportunities. This affected one (#45) of three residents reviewed for falls, with the potential to affect all residents of the facility. The facility census was 42. Findings include: Review of Resident #45's medical record revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included femur fracture, compression fracture of T5-T6 vertebra, osteoporosis and dementia. Review of the Minimum Data Set (MDS) assessment, dated 11/21/23, revealed Resident #45 was cognitively impaired and required substantial/maximum assistance for bed mobility. […]

• No harm, potential for more than minimal, widespreadF880Mar 11, 2021

  Based on observation, staff interview, policy review and review of the Centers for Disease Control and Prevention (CDC) Coronavirus Disease 2019 (COVID-19) Pandemic guidance, the facility failed to ensure healthcare personnel applied appropriate transmission based infection control precautions and personal protective equipment (PPE) to potentially prevent the spread of COVID-19. This deficient practice had potential to affect all 40 residents residing in the facility. Facility census was 40. Findings include: On 03/11/21 at 7:10 A.M. […]

• No harm, potential for more than minimal, patternF689Aug 13, 2026

  Based on observation, medical record review, and staff interviews the facility failed to ensure mechanical lift power sources were adequately maintained. This directly affected one (#78) of three residents reviewed for mechanical lift transfers and has the potential to affect 15 (#76, #77, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90 and #91) other residents the facility identified as requiring the use of a mechanical lift for transfers. The facility census was 47.Findings include:Review of the medical record for Resident #78 revealed she was admitted on [DATE] with diagnoses including active primary progressive multiple sclerosis, pleural effusion, type two diabetes mellitus, vitamin D deficiency, hyperlipidemia, depression, hypertensive heart disease with heart failure, and… […]