Cycle 1
Health 2025-05-01 · Fire 2025-05-01
8 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Toledo, OH
Otterbein Sunset House
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
4020 Indian Rd, Toledo, OH
(419) 536-4645
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
24
Certified beds
Average residents
21
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Otterbein Seniorlife
Operator or chain grouping
Approved since
1997-12-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.07
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.90
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.33
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.03
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,968
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.13
Baseline 17.07% · Performance 19.98% · Measure score 3.13 · Achievement 3.13 · Improvement 0
Healthcare-associated infections
1.21
Baseline 5.53% · Performance 7.47% · Measure score 1.21 · Achievement 1.21 · Improvement 0
Total nurse turnover
0
Baseline 39.29% · Performance 73.33% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.59% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 112 · Observed rate 13.39% · Lower 95% interval 7.97% |
| Discharge to community | 59.23% |
50.57%
8.7 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 55.77% · Lower 95% interval 49.98% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 65 · Denominator 65 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 65 |
| Discharge self-care score | 73.81% |
53.69%
20.1 pts better
|
Numerator 31 · Denominator 42 |
| Discharge mobility score | 26.19% |
50.94%
24.7 pts worse
|
Numerator 11 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 1.54% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 65 · Adjusted rate 1.61% |
| Healthcare-associated infections requiring hospitalization | 7.47% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 7.58% · Lower 95% interval 4.29% |
| Staff COVID-19 vaccination coverage | 1.42% |
8.2%
6.8 pts worse
|
Numerator 2 · Denominator 141 |
| Staff flu vaccination coverage | 7.76% |
42%
34.2 pts worse
|
Numerator 18 · Denominator 232 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 28 · Denominator 42 |
| Transfer of health information to provider | 86.36% |
95.95%
9.6 pts worse
|
Numerator 19 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 41 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 17.95% |
25.2%
7.2 pts worse
|
Numerator 7 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.4% |
78.1%
14.7 pts worse
|
81.7%
18.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 58.7% · Q2 52.9% · Q3 74.1% · Q4 66.4% · 4Q avg 63.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.9% |
12.5%
3.4 pts worse
|
12.0%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 17.0% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.2%
0.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.2% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.6% |
75.6%
28 pts worse
|
79.7%
32.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
25.1%
5.1 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 32.1% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-25 · Fire 2022-08-25
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-09-05 · Fire 2019-09-05
10 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-01
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-05-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-05-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-05-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-30
F · Potential for more than minimal harm
2022-08-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-09
F · Potential for more than minimal harm
2022-08-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-09
F · Potential for more than minimal harm
2019-09-05
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-10-11
F · Potential for more than minimal harm
2019-09-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-11
F · Potential for more than minimal harm
2019-09-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-10-11
F · Potential for more than minimal harm
2019-09-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-10-11
F · Potential for more than minimal harm
2019-09-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-10-11
E · Potential for more than minimal harm
2019-09-05
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2019-10-11
C · Minimal harm
2019-09-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-10-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-01
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-05-01
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-12-24
D · Potential for more than minimal harm
2025-05-01
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-01
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-01
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-30
D · Potential for more than minimal harm
2024-10-30
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-06-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-04-01
F620 · Resident Rights Deficiencies
Health
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-01-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-10
D · Potential for more than minimal harm
2023-03-03
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-30
D · Potential for more than minimal harm
2023-03-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-30
F · Potential for more than minimal harm
2022-08-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-09
F · Potential for more than minimal harm
2022-08-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-09
D · Potential for more than minimal harm
2022-08-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-10-09
D · Potential for more than minimal harm
2022-08-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-09
D · Potential for more than minimal harm
2022-08-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-10-09
F · Potential for more than minimal harm
2019-09-05
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2019-10-11
F · Potential for more than minimal harm
2019-09-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-10-11
D · Potential for more than minimal harm
2019-09-05
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-10-11
D · Potential for more than minimal harm
2019-09-05
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-10-11
D · Potential for more than minimal harm
2019-09-05
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-10-11
D · Potential for more than minimal harm
2019-09-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-10-11
D · Potential for more than minimal harm
2019-09-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-10-11
Penalties and ownership
What sits behind the stars
Ownership
Otterbein Home
5% Or Greater Indirect Ownership Interest · Organization
Otterbein Lsc LLC
5% Or Greater Direct Ownership Interest · Organization
App, Lynn
Operational/Managerial Control · Individual
Bartlett, Victoria
Operational/Managerial Control · Individual
Bartlett, Victoria
Corporate Director · Individual
Bayliff, Becky
Operational/Managerial Control · Individual
Brownson, William
Operational/Managerial Control · Individual
Burke, Daniel
Operational/Managerial Control · Individual
Coleman, Robert
Operational/Managerial Control · Individual
Fraley, Ralph
Operational/Managerial Control · Individual
Functional Pathways Of Tennessee LLC
Operational/Managerial Control · Organization
Glosser, Heidi
Operational/Managerial Control · Individual
Green, James
Operational/Managerial Control · Individual
Green, James
Corporate Officer · Individual
Hawkins, Rita
Corporate Officer · Individual
Hazelbaker, Tomas
Operational/Managerial Control · Individual
Miller, Jason
Corporate Officer · Individual
Otterbein Home
Operational/Managerial Control · Organization
Polisetty, Sudheer
Operational/Managerial Control · Individual
Soller, Brian
Operational/Managerial Control · Individual
Vonderhaar, Steve
Operational/Managerial Control · Individual
Wilson, Jill
Corporate Officer · Individual
Nearby options
Other facilities in reach
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1-star overall rating with 1-star inspections with Special Focus status with $121,683 in total fines with 35 recent health deficiencies with 23 fire-safety deficiencies in the latest cycle
#2
Divine Rehabilitation And Nursing At Toledo
Toledo, OH
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $54,152 in total fines with 52 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Ayden Healthcare Of Toledo
Toledo, OH
2-star overall rating with 1-star inspections with 31 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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