Otterbein Sunset Village
Inspection Findings
F-Tag F0687
F 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
11:10 A.M. of Resident #30 revealed the resident was in bed with no boots applied. Interview on 09/04/25 at 11:23 A.M. with Certified Nursing Assistant (CNA) #170 verified Resident #30's bilateral boots were not applied and the resident's heels and legs were directly on the air mattress. CNA #170 stated she was told
the boots were applied at night and taken off in the morning and would not have applied them during her shift. Review of the policy, Skin Care Management Procedure, revised 12/09/22, verified with each dressing change or at lease weekly at a minimum documentation should include the date observed, location and staging, size, depth, the presence, location, and the extent of any undermining or tunneling/sinus tract, exudates (if present the type, color, odor, and approximate amount), pain (if present the nature and frequency), wound bed (color and type of tissue/character including evidence of healing or necrosis and percentage of tissue, and description of wound edges and surrounding tissue. This deficiency represents non-compliance investigated under Complaint Number 2593574.
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Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Otterbein Sunset Village
9640 Sylvania-Metamora Road Sylvania, OH 43560
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-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure accurate resident medical records. This affected one (#30) of three residents reviewed for accurate medical records. The facility census was 42. Findings Include:Review of the medical record revealed Resident #30 was admitted
on [DATE REDACTED]. Diagnoses included hemiplegia affecting right dominant side, type two diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of unspecified foot with unspecified severity, neuromuscular dysfunction of bladder, diabetes mellitus due to underlying condition with foot ulcer, atherosclerotic heart disease of native coronary artery without angina pectoris, malignant neoplasm of head (face and neck), and cerebral infarction. Review of the Minimum Data Set (MDS) assessment, dated 08/01/25, revealed the resident was severely cognitively impaired. The resident was dependent for showering, personal hygiene, lower body dressing, and footwear. Resident #30 had a diabetic foot ulcer.
Review of the care plan, dated 04/25/24, revealed Resident #30 was care planned for activities of daily living self-care and mobility performance due to diabetes with foot ulcer, Alzheimer's, and hemiplegia.
Interventions included to apply boots bilaterally in the morning and remove at night and float legs with pillows. Review of physician orders, dated 01/10/25, revealed an order to apply [NAME] green boots bilaterally in the morning and remove at night and float legs with pillows two times a day left plantar foot wound. Review of the Medication Administration Review (MAR), dated September 2025, revealed Resident #30's [NAME] green boots were applied in the morning. Observation on 09/04/25 at 11:10 A.M. of Resident #30 revealed the resident was in bed with no boots applied. Interview on 09/04/25 at 11:17 A.M. with Licensed Practical Nurse (LPN) #178 verified Resident #30's bilateral boots were not applied and had been marked in the MAR as applied. Interview on 09/04/25 at 11:23 A.M. with Certified Nursing Assistant (CNA) #170 verified Resident #30's bilateral boots were not applied and the resident's heels and legs were directly
on the air mattress. CNA #170 stated she was told the boots were applied at night and taken off in the morning and would not have applied them during her shift.
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OTTERBEIN SUNSET VILLAGE in SYLVANIA, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SYLVANIA, OH, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from OTTERBEIN SUNSET VILLAGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.