Otterbein Union Township: Improper Transfer Harm - OH
The resident, identified in inspection records as Resident 32, was harmed. Federal inspectors classified the violation at the "actual harm" level, the threshold that means an inspector determined a resident suffered real injury, not just exposure to risk.
The physician order requiring Hoyer lift transfers for Resident 32 had been written nearly three years earlier, on September 3, 2022. The problem was structural: the order existed, but it had not been configured to appear on the treatment administration record, the document nurses sign off on each time a care task is completed. Without that connection, the order was invisible to the nurses and aides responsible for carrying it out. Nobody was signing off because nobody was being prompted to.
CNA 168 transferred Resident 32 without the lift. Four days later, on June 27, the facility terminated the employee.
The gap between the 2022 order and the June 2025 incident is three years. The inspection report does not say how many times Resident 32 was transferred during that period, or how many of those transfers were completed without the Hoyer.
What the report does say is that once the incident surfaced, the facility moved quickly. On June 23, the interdisciplinary team held an emergency quality meeting with the medical director present. Audits were pulled on every resident's records, checking whether physician orders, care plans, and the working documents nurses use daily were all saying the same thing. The same broken link found in Resident 32's record turned up in the records of 11 other residents, all of them also dependent on Hoyer lifts for transfers. For each of those 11, the facility placed a corrected order so it would appear on the treatment administration record going forward.
Weekly quality meetings continued for four weeks after that. On June 25, staff completed skin assessments on all residents who could not speak for themselves. The report states no additional issues were identified in those assessments.
The complaint that triggered the inspection was filed under Ohio complaint number OH00167463. The inspection report does not identify who filed it or describe the nature of Resident 32's injury beyond the "actual harm" classification.
What the record shows is a physician order that existed on paper and failed in practice for years, a resident who was harmed when a staff member transferred them by hand instead of by machine, and a facility that discovered, once it started looking, that the same documentation failure applied to a dozen people in its care.
The corrected orders were placed. The audits were completed. The CNA was gone by June 27.
Resident 32 remains at the facility. The inspection report does not say what their injury was, whether they recovered, or what their transfers look like now.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Otterbein Union Township from 2025-08-15 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
OTTERBEIN UNION TOWNSHIP in BATAVIA, OH was cited for violations during a health inspection on August 15, 2025.
The resident, identified in inspection records as Resident 32, was harmed.
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.