Otterbein Middletown
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
#118 and CNA #140 were placed on suspension and removed from the schedule when the neglect allegation was made on 09/25/25 and all CNAs were educated on transportation. The Administrator also stated that all staff completed competencies on how to secure residents in the wheelchair van. The Administrator stated the facility interviewed residents that were transported within the past 30 days and no one had any additional concerns with transportation. The Administrator stated transportation was reinstated at the facility on 10/06/25 and a transportation audit was initiated to ensure all residents were appropriately strapped in the transport van before leaving. The Administrator also stated the facility initiated the transportation checklist. CNA #58 stated she interviewed both CNA #140 and CNA #118 after the incident.
CNA #58 verified CNA #118 admitted that she forgot to strap down the front of Resident #14's wheelchair prior to her appointment on 09/24/25. The Administrator stated the facility no longer used CNA #118 and CNA #140 as drivers at the facility and they were given a final written warning about the incident. The Administrator also reported that the facility discussed the incident in the Quality Assurance (QA) meeting.
Review of the wheelchair vans undated manufacture instructions revealed attach the four tie- down hooks to the solid frame members or weldments near seat level. Ensure the tie downs are fixed at approximately 45 degrees. Do not attach the hooks to wheels, plastic or removable parts of the wheelchair.Review of the facility's undated guidelines and regulations for a minibus carrier, revealed there should always be a total of four anchor points with two in the front of the wheelchair and two in the back of the wheelchair.As a result of
the incident, the facility took the following actions to correct the deficient practice by 10/06/25: On 09/24/25, Resident #14 was transported to the hospital for assessment.On 09/25/25, Resident #14 was assessed by PA #500 and psychiatric NP #600 with no new orders.On 09/25/25, the facility's QA committee held ad hoc meeting regarding transportation. Transportation education and demonstrations were scheduled for 09/29/25 and the transportation checklist was reviewed. The facility also developed a transportation audit.On 09/25/25, all CNAs were provided with education on securing wheelchairs in the wheelchair van by CNA #58.On 09/26/25, the Administrator completed interviews of the residents that had utilized the facility transportation with no findings.On 09/29/25, all CNAs were educated in person by Corporate Maintenance Director #700 on wheelchair transportation and all staff demonstrated their competencies on
the bus and transport van checklist.On 10/06/26, transportation audits were initiated by the Administrator, CNA #58, the DON or designee on all facility transportations to ensure residents were strapped in correctly, residents had the correct durable medical equipment and to ensure staff were following the transportation checklist. The Audits will be completed for four weeks. This deficiency represents non-compliance investigated under Complaint Number 2634560 and 2629140.
Event ID:
Facility ID:
If continuation sheet
OTTERBEIN MIDDLETOWN in FRANKLIN, 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 FRANKLIN, 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 MIDDLETOWN or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.