F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, and staff interview, the facility failed to ensure nail care and grooming
was provided to a dependent resident. This affected one (Resident #7) of one resident reviewed for
activities of daily living (ADLs). The facility census was 19.
Residents Affected - Few
Findings include:
Medical record review revealed Resident #7 admitted to the facility on [DATE] with the diagnoses including,
hepatic failure, osteoarthritis, gastrostomy, dysphagia, dementia, protein calorie malnutrition, acute kidney
failure, pancytopenia, glaucoma, depression, hypertension, and hypothyroidism.
According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #7 had severe cognitive
impairment and was dependent on staff for the completion of ADLs.
Review of the care plan dated 07/22/22 revealed Resident #7 had ADL self-care deficit and physical
mobility deficit related to decrease in ability to perform ADLs, difficulty with mobility, and increase
dependence for most ADLs. Interventions included the following: ensure glasses are clean, assistance with
mobility as needed, check nail length, trim and clean on bath day and as necessary and report any
changes to the nurse, requires total dependence of one person with bathing, totally dependent to reposition
and move in bed with assistance of two persons, assist to choose simple comfortable clothing that
enhances ability to dress self, totally dependent with dressing with the assistance of one person, brush
teeth, rinse mouth with wash, requires total dependence with assistance of one person for toileting, and
encourage to participate to the fullest extent possible with each interaction.
Review of task completion documentation from 07/26/22 to 08/24/22 noted Resident #7 required full staff
performance and was totally dependent upon staff for the completion of maintaining personal hygiene.
Observations on 08/22/22 at 12:51 P.M. and 3:51 P.M. noted Resident #7 in bed wearing a hospital gown.
The resident had matted hair to the back of her head, lips with pealing skin and oral cavity with dry mucous
membranes, a dark substance under fingernails of both hands, and multiple grey hairs to her chin
measuring approximately one inch.
Observations on 08/23/22 at 8:55 A.M., 11:46 A.M., and 3:18 P.M. noted Resident #7 in bed a shirt with an
adult brief without pants. The resident had matted hair to the back of her head, lips with pealing skin and
oral cavity with dry mucous membranes, a dark substance under fingernails of both hands, multiple grey
hairs to her chin measuring approximately one inch.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
366148
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366148
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein Sunset House
4020 Indian Rd
Toledo, OH 43606
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
Observations 08/24/22 at 6:10 A.M. and 9:16 A.M. noted Resident #7 in bed wearing hospital gown. The
resident had matted hair to the back of her head, lips with pealing skin and oral cavity with dry mucous
membranes, a dark substance under fingernails of both hands, and multiple grey hairs to her chin
measuring approximately one inch. The resident had glasses on and the lenses had a film and debris to the
lens surface.
Residents Affected - Few
Interview and observation on 08/24/22 at 9:30 A.M. with State Tested Nurse Aide (STNA) #431 verified
Resident #7 had long hair on her face, matted hair to her head, dark substance under fingernails to both
hands, dry oral cavity with dry skin clinging to the lips and debris to glasses. STNA #431 verified providing
care to Resident #7 on 08/23/22 and 08/24/22. STNA #431 stated the resident was resistant to personal
care, however, she did not report the resistant interactions to the nurse for further guidance.
Interview on 08/24/22 at 9:20 A.M. with the Director of Nursing verified Resident #7 was dependent upon
staff for the completion of ADLs and confirmed the resident was not provided sufficient care to carry out
ADLs.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366148
If continuation sheet
Page 2 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366148
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein Sunset House
4020 Indian Rd
Toledo, OH 43606
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, resident interview, staff interview, and review of facility policy, the facility
failed to ensure fall interventions were in place as care planned. This affected one (Resident #10) of two
residents reviewed for falls. The facility census was 19.
Findings include:
Review of Resident #10's medical record revealed an admission date of 07/22/22. Diagnoses included
Parkinson's disease, heart disease, alcohol abuse, depression, protein calorie malnutrition, cognitive
communication deficit, and repeated falls.
Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental
Status (BIMS) score of 13, indicating Resident #10 was cognitively intact. Resident #10 required extensive
assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #10 displayed
no behaviors during the review period. Resident #10 was noted to have had a fall prior to admission but
none at the time of the review.
Review of Resident #10's care plan revised 08/01/22 revealed supports and interventions for self-care
deficit and the resident was at risk for falls. Fall interventions included anticipating needs, ensuring his call
light was in reach, and ensure he had access to a working and reachable call light.
Review of Resident #10's Fall Risk assessment dated [DATE] revealed Resident #10 was at high risk for
falls.
Observation on 08/22/22 at 10:35 A.M. of Resident #10 found him in his room alone, seated on the front
edge of the seat of his wheelchair, leaning forward out of his wheelchair, reaching down toward the floor.
Resident #10 was unstable and appeared close to falling. Coinciding interview with Resident #10 revealed
he was trying to reach his call light. Resident #10 reported he was looking for it and when he found it, it was
stuck under the recliner. Resident #10 stated he was not sure how it got there or how long it was there but
he needed to have it. A sign was noted on the wall of Resident #10's room reminding Resident #10 to use
his call light for assistance. Closer inspection of the call light found it was stuck in the gears of the recliner.
Interview on 08/22/22 at 10:40 A.M. with Physical Therapist (PT) #454 verified Resident #10 was at risk for
falls, his call light was not in reach and the call light was stuck in the gears of his recliner. PT #454
dislodged the call light chord and provided the call light to Resident #10.
Review of the facility policy titled, Falls Management revised 12/03/19 revealed the facility was to institute
interventions to prevent a further fall.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366148
If continuation sheet
Page 3 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366148
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein Sunset House
4020 Indian Rd
Toledo, OH 43606
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, staff interview, medical record review and review of the medication administration
policy, the facility failed to ensure two medications of 26 were provided within prescribed timeframe's,
resulting in a medication error rate of 7.69 percent (%). This affected one (Resident #7) of four residents
reviewed for medication administration. The facility census was 19.
Residents Affected - Few
Findings include:
Observation on 08/23/22 at 11:40 A.M. noted Registered Nurse (RN) #429 obtained Resident #7's
medications from the medication cart to prepare them for gastrostomy tube (G-tube) administration.
Medications included omeprazole suspension two milligrams (mg) per (/) one milliliter (ml) equaling 10 ml in
a medication cup and Lorazepam 0.5 mg crushed and placed into a medication cup. RN #429 proceeded to
Resident #7's room and administered the medications via G-tube. Interview with with RN #429 revealed the
medications were ordered twice daily by the physician and were scheduled for 10:00 A.M. However, RN
#429 was running behind.
Review of Resident #7's physician orders revealed an order dated 05/06/22 for omeprazole suspension two
milligrams (mg) per (/) one milliliter (ml) equaling 10 ml to be administered every day shift between and
evening shift.
No specified times were included. Continued review revealed an order dated 08/16/22 for Lorazepam 0.5
mg administered two times a day for anxiety and restlessness. Scheduled times were 10:00 A.M. and 9:00
P.M.
Review of the Medication Administration Record (MAR) revealed the omeprazole suspension was
scheduled for 6:00 A.M. and 2:00 P.M. and Lorazepam was scheduled for 10:00 A.M. and 9:00 P.M.
Interview on 08/24/22 at 3:05 P.M. with the Director of Nursing verified Resident #7's medications were not
administered within established timeframes.
According to medication administration policy revised on 08/30/16, medications ordered two times daily are
administered at 9:00 A.M. and 5:00 P.M. with an hour time before and after the designated times.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366148
If continuation sheet
Page 4 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366148
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein Sunset House
4020 Indian Rd
Toledo, OH 43606
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, staff interview, and review of facility policy, the facility failed to ensure frozen food
was stored in a safe and sanitary manner and ventilation ducts were kept clean. This had the potential to
affect all 19 residents in the facility. The facility census was 19.
Findings include:
Observation on 08/22/22 at 9:33 A.M. of the walk in freezer found ice build up along the edge of the door,
preventing the door from closing properly. Ice was built up on the inside of the door and covered the bars
and racks on the shelving unit along with the boxes of food items on the shelves. The food items were not
able to be identified due to the ice build up. Removal of some of the ice crystals from the front of the boxes
found they contained breadsticks, pretzel buns, burritos, strawberry rhubarb pie, cherry pie and whipped
topping. Also, boxes were found being stored on the floor containing chicken and tiramisu desserts. In
addition, a large box of frozen peas was found to be open, uncovered, and unlabeled.
Interview on 08/22/22 at 9:36 A.M. with Dietary Manager (DM) #419 verified the peas were not in use and
were most likely left open from the day before, the boxes of chicken and tiramisu were stored on the floor
and there was ice built up on the side of the door, the shelves, and food boxes. DM #419 reported the seal
on the door most likely needed to be replaced again or one of the staff did not ensure it was closed tightly.
Observation on 08/23/22 at 9:56 A.M. of the walk in freezer found ice build up continued to be on the inside
of the door, the shelves, and breadsticks, pretzel buns, burritos, strawberry rhubarb pie, cherry pie, and
whipped topping.
2. Observation on 08/22/22 at 9:27 A.M. of the ceiling ducts above the preparation area in the kitchen and
dishwashing area, found dusty-brown/gray buildup, consistent with the appearance of dust, on the
ventilation slats of the duct work.
Interview on 08/22/22 at 9:30 A.M. with DM #419 verified there was dust build up on the ventilation duct
work. DM #419 reported the local health department had completed an inspection and noted the same
concern. DM #419 reported maintenance completed the cleaning of the vents and she would make a report
again to have them address the dust as she did not think it had been taken care of from the previous
inspection.
Interview on 08/25/22 at 12:15 P.M. with the Administrator revealed the walk in freezer was last serviced on
06/30/22. The Administrator showed photographs of the ventilation ducts having been cleaned of dust. The
Administrator provided documented training that was held on 06/09/22 which included a server cleaning
schedule and cook duties. None of the training included cleaning of the walk in cooler/freezer or the vents.
The Administrator reported they had no food borne illnesses, and no complaints from resident council
regarding food.
Review of the Food Inspection Report dated 04/21/22 revealed the local health department had a
non-critical finding of build up on the shelving in the the walk in cooler and observed build up on fan and
ceiling in the dish wash area.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366148
If continuation sheet
Page 5 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366148
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein Sunset House
4020 Indian Rd
Toledo, OH 43606
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility policy titled, Food Storage and Procurement, revised 06/20/17 revealed foods should
be stored, prepared and distributed in accordance with professional standards for food services safety.
Once a package was opened any remaining food should be placed in a sealed container or bags and
marked to identify what was in the container. If the items were placed in a freezer it must be labeled with
the date the product/food item was opened.
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366148
If continuation sheet
Page 6 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366148
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein Sunset House
4020 Indian Rd
Toledo, OH 43606
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, staff interview, review of facility policy, and review of Centers for
Disease Control and Prevention (CDC) guidance, the facility failed to ensure facility staff wore proper
Personal Protective Equipment (PPE) when in contact with a resident on Transmission-Based Precautions
(TBP). This affected one (Resident #12) of two residents reviewed for TBP. The facility census was 19.
Residents Affected - Many
Findings include:
Medical record review revealed Resident #12 admitted to the facility on [DATE] with the diagnoses
including, gangrene to right leg, right foot amputation, anxiety disorder, peripheral vascular disease,
hypothyroidism, history of venous thrombosis and embolism, hypertension, chronic obstructive pulmonary
disease, lymphedema, macular degeneration, and myocardial infarction.
According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #12 was alert, oriented,
and able to make needs known. The resident was dependent on staff for the completion of activities of daily
living.
Further review of the medical record revealed no documentation indicating Resident #12 was vaccinated for
COVID-19.
Review of Resident #12's physician orders revealed an order dated 08/18/22 for Resident #12 to be placed
in COVID-19 isolation per facility protocol due to unvaccinated status.
Observation on 08/22/22 at 3:47 P.M. noted Resident #12 in their room with a sign posted on the door
noting the resident was in droplet isolation. There was a cabinet with PPE placed outside the door.
Observation on 08/23/22 at 1:10 P.M. revealed Registered Nurse (RN) #429 was observed in Resident
#12's room, standing at the bedside. RN #429 was wearing a face shield and N95 mask. RN #429 was not
wearing any additional PPE, including gloves or a gown. The droplet isolation sign was still posted to
Resident #12's door.
Interview on 08/23/22 at 3:50 P.M. with RN #429 confirmed when in Resident #12's room, staff were to
wear full PPE due to the resident being in droplet isolation. RN #429 stated she was unaware full PPE was
required when in the residents room.
Interview on 08/24/22 at 8:03 A.M. with the Director of Nursing (DON) verified RN #429 was required to
wear full PPE (gown, gloves, eye protection, and N95 mask) when entering and working with Resident #12.
The DON indicated due to the resident being unvaccinated for COVID-19 and going out to appointments in
a healthcare setting on 08/22/22, the resident was in droplet isolation for seven days.
Additional observation on 08/25/22 at 6:14 A.M. noted State Tested Nurse Aide (STNA) #440 in Resident
#12's room assisting the resident at the bedside. STNA #440 was wearing surgical gloves, an N95 mask,
and a face shield applied. STNA #440 was not wearing a gown.
Interview on 08/25/22 at 6:20 A.M. with the DON verified STNA #440 should have applied all PPE,
including a gown due to Resident #12 being placed on droplet isolation.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366148
If continuation sheet
Page 7 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366148
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein Sunset House
4020 Indian Rd
Toledo, OH 43606
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
According to the facility's COVID-19 policy dated 02/07/22 revealed new residents or those that have been
readmitted and are not up to date with vaccines, are required to quarantine in their private room with
transmission based precautions on the appropriate unit, for 10 days or seven days with a negative test
within 48 hours or longer if showing signs and symptoms. Place precaution signage on resident door.
Personal Protective Equipment (PPE) required includes: Gloves, isolation gowns, facemask, respiratory
protection N95 masks or equivalent are recommended, eye protection that covers both the front and sides
of the face, hand hygiene using Alcohol Based Hand Sanitizer before and after all patient contact, contact
with infectious material and before and after removal of PPE, including gloves if hands are soiled, washing
hands with soap and water is required for at least 20 seconds.
Review of CDC guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare
Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 02/02/22 revealed
recommended infection prevention and control (IPC) practices when caring for a patient with suspected or
confirmed SARS-CoV-2 infection included staff should wear an N95 mask, gown, gloves, and eye
protection.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366148
If continuation sheet
Page 8 of 8