Otterbein Sunset Village: False Medical Records - OH
Resident 30 arrived at Otterbein Sunset Village with multiple serious conditions including right-side paralysis, diabetes with foot ulcer, heart disease, and malignant cancer of the head, face and neck. The resident had suffered a stroke and was severely cognitively impaired, unable to shower, dress, or care for personal hygiene independently.
The resident's diabetic foot ulcer required specific protective care. A physician ordered bilateral green boots to be applied every morning and removed at night, with legs elevated on pillows twice daily for the left plantar foot wound. The facility's care plan reinforced these requirements, stating boots should be applied bilaterally in the morning and removed at night.
Medical records showed consistent compliance. The September 2025 Medication Administration Review indicated staff applied the resident's green boots each morning as ordered.
The documentation was false.
When inspectors observed Resident 30 at 11:10 A.M. on September 4, the resident lay in bed with no protective boots applied. The resident's heels and legs rested directly against the air mattress, exactly the contact the medical orders were designed to prevent.
Licensed Practical Nurse 178 admitted during an interview seven minutes later that the bilateral boots were not applied to Resident 30, despite being marked in the medical records as completed. The nurse verified the false documentation while confirming the resident's feet remained unprotected.
Certified Nursing Assistant 170 provided additional confirmation during a separate interview at 11:23 A.M. The aide verified the bilateral boots were not applied and acknowledged the resident's heels and legs were directly on the air mattress. She explained her understanding that boots were applied at night and removed in the morning, the exact opposite of the doctor's orders.
The confusion over timing revealed deeper problems with care coordination. While the physician specifically ordered morning application and nighttime removal, the nursing assistant believed the reverse schedule applied. This fundamental misunderstanding of medical orders occurred while staff continued documenting treatments as completed.
The false documentation affected a particularly vulnerable resident. Beyond the diabetic foot ulcer requiring careful wound management, Resident 30 dealt with severe cognitive impairment from Alzheimer's disease and physical limitations from stroke-related paralysis. The resident depended entirely on staff for lower body dressing and footwear, making accurate implementation of medical orders critical.
Diabetic foot ulcers require meticulous care to prevent complications that can lead to amputation. The protective boots ordered by the physician serve multiple purposes: they cushion pressure points, maintain proper foot positioning, and prevent the heel contact that can worsen existing wounds or create new pressure injuries.
The facility's care plan acknowledged these risks, specifically addressing activities of daily living and mobility performance challenges related to diabetes with foot ulcer, Alzheimer's, and paralysis. The interventions listed were precise: apply boots bilaterally in the morning, remove at night, and float legs with pillows.
Yet the gap between written protocols and actual care delivery was stark. While medical records suggested consistent compliance with wound care protocols, the reality involved a resident lying unprotected with heels pressed against a mattress surface.
The timing of the false documentation added another layer of concern. The September 2025 medication administration records showed recent entries marking boot application as completed, suggesting the inaccurate charting was not an isolated incident but part of an ongoing pattern.
Staff interviews revealed the documentation failures extended beyond simple oversight. The licensed nurse who confirmed the boots were not applied had actively participated in marking them as completed in official medical records. This represented a deliberate falsification of care documentation rather than an administrative error.
The certified nursing assistant's confusion about the treatment schedule highlighted additional problems with staff training and communication. Basic medical orders for diabetic wound care had been misunderstood, with staff implementing the opposite of prescribed treatments while documenting compliance with the original orders.
For Resident 30, the consequences extended beyond immediate discomfort. Diabetic patients with foot ulcers face elevated risks of infection, delayed healing, and potential amputation when protective protocols are not followed. The resident's additional diagnoses of severe cognitive impairment and stroke-related paralysis created compounding vulnerabilities that made accurate medical record keeping and treatment compliance essential.
The inspection findings affected one of three residents reviewed for accurate medical records at the 42-bed facility. The violation was classified as minimal harm or potential for actual harm, affecting few residents. However, the deliberate nature of the false documentation and the specific vulnerability of the affected resident raised questions about broader care practices and record-keeping accuracy throughout the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Otterbein Sunset Village from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
OTTERBEIN SUNSET VILLAGE in SYLVANIA, OH was cited for violations during a health inspection on September 4, 2025.
The resident had suffered a stroke and was severely cognitively impaired, unable to shower, dress, or care for personal hygiene independently.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.