Health inspection·October 14, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fastened her own seatbelt and began driving towards the appointment. As CNA #140 approached the intersection to get onto the interstate, the traffic light was red. When the light turned green, CNA #140 made a left turn to get onto the ramp and while making the left turn, CNA #140 saw Resident #14's leg lift and her wheelchair tipped backwards. CNA #140 heard and saw her hit her head on the wheelchair ramp. CNA #140 immediately pulled the van over to the right side of the road, got out, and opened the back door to check on Resident #14's condition. Resident #14 told CNA #140 she was okay, and this wasn't her fault. Resident #14 stated CNA #118 did not finish locking the wheelchair. CNA #140 told Resident #14 that she could not move her until she was assessed. CNA #140 called Licensed Practical Nurse (LPN) #129 and LPN #129 who CNA #140 to call emergency medical services (EMS) due to the head impact. While waiting, Resident #14 unbuckled her seatbelt and rolled onto her side. CNA #140 called EMS and waited for EMS to arrive. When EMS arrived, Resident #14 initially said she was fine, but they encouraged her to be evaluated. Resident #14 agreed and left with EMS for further evaluation. CNA #140 took the van back to the facility. The statement was signed by CNA #140. Review of CNA #118's witness statement dated 09/24/25, revealed the statement was taken over the phone by CNA #58. CNA #118 reported CNA #140 offered to handle the appointment, but they still had two residents that needed to be changed. CNA #140 stated she would take care of doing those check and changes if CNA #118 could go ahead and get Resident #14 loaded into the van. CNA #118 proceeded to load Resident #14 in front of the house where she resided. CNA #118 secured the back wheelchair straps and buckled Resident #14's seatbelt. CNA #118 was unable to access the front wheelchair straps from behind, so she intended to secure them from the side doors afterward. After raising the ramp, CNA #118 got into the van and drove the van to another house. CNA #118 forgot to strap down the front of the wheelchair. When CNA #118 pulled up at the other house, CNA #140 came outside, and CNA #118 informed her that Resident #14 was ready to go. At that moment CNA #118 did not remember or did not think to mention that the front straps were not secured. The statement was signed by CNA #118.Review of Resident #14's progress note dated 09/25/25 at 4:21 P.M., revealed Resident #14 was observed sitting comfortably in her recliner upon entry to the room. No acute distress was noted. Resident #14 verbalized that she was experiencing pain in her neck and shoulders and was describing it as tightness and soreness. Nursing was notified, and as needed (PRN) Tylenol was administered. The on call provider was notified of the shoulder and neck pain. Resident #14's neuro checks were noted to be within normal limits.Review of Resident #14's progress note dated 09/25/25 and authored by Nurse Practitioner (NP) #650, revealed the Director of Nursing (DON) would like to know if Resident #14 could get a PRN oxycodone for breakthrough pain. Resident #14 was recommended to receive oxycodone routine, three times a day and was prescribed Tylenol 650 milligrams (mgs) PRN. Resident #14 was involved in a fall on 09/24/25 and was having more pain related to the fall. NP #650 sent the request to the primary care provider who could order the oxycodone if appropriate. Resident #14 was ordered ibuprofen 800 mgs everyday PRN for three days for breakthrough pain.Review of Resident #14's progress note dated 09/25/25 at 6:58 P.M., revealed Resident #14 received a new order from the on call provider for PRN ibuprofen. The psychiatric provider completed an on-site assessment and reported no concerns. Resident #14's daughter was notified of the NP visit and the new orders.Review of Resident #14's progress note 09/25/25 authored by Physician Assistant (PA) #500, revealed PA #500 saw the resident due to resident being transported to an appointment on 09/24/25 when the front wheels of her wheelchair were not locked causing the wheelchair to fall backward when the van went up a hill. Resident #14 hit her head during the fall but denied loss of consciousness, emesis, or seizure-like activity. Resident #14 was evaluated in the ED and imaging of the head and neck showed no acute traumatic pathology. Resident #14 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 2 of 6 Printed: 05/15/2026 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reported mild soreness and sustained abrasions to her chin, right cheek, and right neck. Resident #14 denied pain in her arms, hips, chest, or abdomen. Resident #14 had abrasions on the chin, right cheek and right neck. The note stated Resident #14 experienced a closed head injury yesterday when her wheelchair fell backward while being transported to an appointment and the resident sustained abrasions to the chin, right cheek, and right neck during the incident. Diagnoses listed on the progress note were unspecified injury of the head subsequent encounter and unspecified multiple injuries subsequent encounter.Review of Resident #14's psychiatric progress note dated 09/25/25, revealed Resident #14 was seen by psychiatric NP #600. Resident #14 denied any increase in depression or anxiety. Resident #14 had no change in sleep patterns or appetite and no signs of heightened arousal, intrusive memories, or avoidance behaviors. Resident #14 stated that she was frightened during the incident (fall in van) and felt trapped. She reported frustration about having to go to the ED and having to wait for a ride back to the facility. She stated that she would never ride in the transportation van again.Review of the facility's SRI created on 09/25/25 at 3:15 P.M., revealed Resident #14's daughter alleged neglect of the resident while in the facility's transportation van. On 9/24/25, Resident #14 was transported in the facility's transport van. The CNAs loading Resident #14 into the transport van had miscommunicated on fully securing Resident #14's wheelchair into the transport van resulting in Resident #14 tipping backward during the transport. The SRI was completed on 10/01/25 and the allegations of neglect or mistreatment were substantiated.Review of Resident #14's Interdisciplinary Team (IDT) progress note dated 09/29/25 at 1:40 P.M., revealed the IDT met to review Resident #14's fall on 09/24/25 which occurred during a scheduled transport. Resident #14 was seated in a wheelchair which had been secured with two of the four tie-downs when it tipped backwards. Resident #14 hit her head and was evaluated at the hospital. All tests were negative, and Resident #14 returned to the facility by family transportation. Resident #14 was noted with a small bump and scattered abrasions on her chin. Resident #14 stated the abrasions were from the neck brace that was placed by EMS. Resident #14's pain was treated with oral pain medications upon her return, and the physician was aware. Resident #14 remained at baseline with no concerns. The intervention was for anti-tippers to be placed on the wheelchair. Resident #14's family requested that all further transportation be completed by family or an outside transportation provider. The transportation staff were re-educated on securing wheelchairs in transport vehicles.Review of Certified Nursing Assistant (CNA) #118's bus and van transport checklist dated 11/07/24, revealed residents were to be secured with a four point lockdown system with a separate seat belt. Apply two lockdowns to the front of the wheelchair and two lockdowns to the back of the wheelchair and make sure the lockdowns are attached to the interlock system on the floor of the bus and on the wheelchair. The checklist was signed by CNA #118 on 11/07/24. Review of CNA #140's bus and van transport checklist dated 11/21/24, revealed residents were to be secured with a four point lockdown system with a separate seat belt for the resident. Apply two lockdowns to the front of the wheelchair and two lockdowns to the back of the wheelchair and make sure the lockdowns are attached to the interlock system on the floor of the bus and on the wheelchair. The checklist was signed by CNA #140 on 11/21/24. Review of CNA #140's disciplinary action notice dated 09/29/25, revealed CNA #140 was placed on a final written warning. The notice stated CNA #140 accepted responsibility for transporting a resident to a scheduled appointment. Prior to departure, CNA #140 did not verify that the resident's wheelchair was properly secured and as a result, the resident's wheelchair tipped backwards during transit posing a significant safety risk. The notice was signed by CNA #140 on 09/29/25.Review of CNA #118's disciplinary action notice dated 10/02/25, revealed CNA #118 was placed on a final written warning. The notice stated CNA #118 agreed to assist with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 3 of 6 Printed: 05/15/2026 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few loading and securing a resident for transport to a scheduled appointment. During the process, CNA #118 secured the back of the wheelchair and fastened the resident's seatbelt. After completing these steps, CNA #118 closed the ramp and handed off the keys to the CNA responsible for driving the resident. CNA #118 forgot to lock down the front of the wheelchair. The failure to fully secure the wheelchair resulted in the resident's wheelchair tipping backwards during transit. The notice was signed by CNA #118 on 10/02/25.Interview with LPN #129 on 10/09/25 at 7:56 A.M., revealed CNA #140 called her about an incident with the facility's van on an unknown date between 2:40 P.M. and 3:00 P.M. LPN #129 stated that CNA #140 informed her that Resident #14 fell backwards in the facility's van when CNA #140 was driving onto the highway. LPN #129 informed CNA #140 to call EMS and not to move Resident #14. LPN #129 reported she informed RN #125 about the incident and RN #125 took over the incident after she was informed. Interview with CNA #140 on 10/09/25 at 9:13 A.M., revealed she could not remember the date of the incident, but her shift was supposed to end at 3:00 P.M. on that date. CNA #140 stated that CNA #118 did not feel well and was tired. As a result, CNA #118 asked CNA #140 if she would take Resident #14 to her appointment. CNA #140 stated she told CNA #118 that she did not want to transport Resident #140, but CNA #118 continued to ask her. CNA #140 reported she felt bad for CNA #118 and agreed to transport Resident #14 to the appointment if CNA #118 would get the van, get Resident #14's paperwork together, get Resident #14 ready and would pick her up in the van while CNA #140 finished caring for the last two residents and took out the trash. CNA #140 stated that CNA #118 pulled up in the van with Resident #14, handed CNA #140 the paperwork and said that Resident #14 was ready to go. CNA #140 stated she got in the van and said hi to Resident #14 and noted that Resident #14 had her seatbelt fastened. CNA #140 stated she started to drive to the appointment and CNA #140 stopped at a red light to turn left on to Interstate 75 going southbound. CNA #140 reported the light turned green and she turned left onto the ramp to the highway. CNA #140 stated that she saw Resident #14 go backwards with her feet up in the air as she turned and was going up the ramp to the highway. CNA #140 reported she pulled over on the ramp, turned on her hazard lights and got out of the van. CNA #140 stated she opened the door of the van and saw Resident #14's wheelchair had flipped over and Resident #14's head was up against the van's wheelchair ramp. CNA #140 reported Resident #14 stated just get me up and it's okay it's not your fault. CNA #140 stated she told Resident #14 that she could not move Resident #14, but Resident #14 stated she was fine and there was nothing wrong with her. CNA #140 stated she observed that Resident #14 had the back two straps attached to her wheelchair, but the front straps were not in place when she opened the door. CNA #140 called the facility and reported the incident to LPN #129. CNA #140 was advised by LPN #129 to call EMS and CNA #129 called EMS and her supervisor, CNA #58. CNA #140 stated EMS arrived on the scene and blocked the ramp. CNA #140 reported EMS got Resident #14 out of the van and placed her in her wheelchair. CNA #140 reported Resident #14 unfastened her own seatbelt and was trying to reposition herself on the floor of the van prior to EMS arriving at the scene. CNA #140 stated that EMS took Resident #14's vitals and Resident #14 was refusing to go to the hospital because she stated she was fine. CNA #140 called LPN #129 back and told her that Resident #14 was refusing to go to the hospital and LPN #129 spoke with EMS. EMS informed Resident #14 that she needed to go to the hospital to be checked out because of her medications and Resident #14 agreed. CNA #140 stated EMS put Resident #14 on the stretcher from her wheelchair and they took her to the hospital. CNA #140 reported she transported residents a lot and had never had any incidents prior to the incident with Resident #14. CNA #140 stated she was educated on transportation after the incident.Interview with CNA #118 on 10/09/25 at 9:31 A.M., revealed CNA #140 offered to transport Resident #14 to an appointment on an unknown date around 2:30 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 4 of 6 Printed: 05/15/2026 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few P.M. if CNA #118 got Resident #14 in the van while CNA #140 finished caring for her last two residents. CNA #118 stated she did not go on the transport, but she got Resident #14 ready, hooked up her oxygen and wheeled her into the van. CNA #118 reported she locked the back two straps of Resident #14's wheelchair to the van and she fastened Resident #14's seatbelt. CNA #118 stated she could not reach the front two straps for Resident #14's wheelchair and she planned to enter the front of the van to strap the front two wheelchair straps. CNA #118 stated she put the ramp to the van up and it slipped her mind to anchor the front two straps of Resident #14's wheelchair. CNA #118 reported CNA #140 came out and left with Resident #14. CNA #118 stated she had been doing transportation for 2.5 years and had never had any incidents prior to the incident. CNA #118 reported that she was reeducated on transporting residents. Observation of Resident #14 on 10/09/25 at 9:07 A.M. revealed Resident #14 was lying in bed. Resident #14 appeared clean and dressed appropriately. Interview with Resident #14 at the same time revealed the resident did not know the staff names but reported one CNA placed her in the van and the other CNA drove her to an appointment a few weeks ago. Resident #14 stated the two CNAs never corresponded together and the CNA that drove never tied down her wheelchair. Resident #14 reported she put on her own seat belt, but she did not have any tie downs on her wheelchair. Resident #14 stated that her whole wheelchair went backwards when the CNA turned the corner onto the highway. Resident #14 reported she was pinned under her wheelchair, and her oxygen fell off. Resident #14 stated the CNA pulled over but would not touch her. Resident #14 reported she hit her head on the door of the van and EMS arrived and got her out of the van and took her to the hospital. Resident #14 stated she sustained a bump on the back of her head which was sore. Resident #14 also reported she had pain to her back and shoulders. Resident #14 denied any respiratory issues or issues with her oxygen during the transportation incident. Resident #14 stated the incident was very scary.Interview with the Administrator, CNA #58 and the DON on 10/09/25 at 10:32 A.M., revealed CNA #118 and CNA #140 were splitting transportation duties for Resident #14's appointment on 09/24/25. The Administrator reported CNA #118 would get Resident #14 ready and loaded into the van and CNA #140 would drive her to the appointment. The Administrator stated that CNA #118 and CNA #140 completed the switch off of the van and Resident #14 had her seatbelt fastened so CNA #140 drove off not knowing that CNA #118 only strapped in the back to straps of Resident #14's wheelchair in the van. The Administrator stated CNA #140 started driving onto the highway ramp and CNA #140 heard Resident #14 tip backwards. The Administrator reported that CNA #140 pulled over and called LPN #129. LPN #129 informed CNA #140 to call EMS and CNA #58. The Administrator stated that CNA #140 called EMS and waited for EMS to arrive. The Administrator reported CNA #140 did not move Resident #40 and Resident #14 was transported to the hospital by EMS. The DON reported she called Resident #14's daughter and the resident's daughter returned her call and was notified of the incident. The Administrator stated that Resident #14's CT scans at the hospital were negative and no injuries were noted except for tenderness to the back of her head. The DON stated Resident #14 was assessed by the physician and psychiatry on 09/25/25 with no findings and that Resident #14 was given some PRN Tylenol and ibuprofen for her shoulders after the incident as Resident #14 already was prescribed narcotic pain medication three times a day. The DON stated Resident #14 was placed on neuro checks and those were within normal limits and Resident #14 appeared to be at her baseline. The Administrator stated the facility immediately suspended CNA #118 and CNA #140 from driving to appointments. The Administrator reported that an SRI was opened on 09/25/25 because Resident #14's daughter reported that she felt that Resident #14 was neglected by the facility on that date. The Administrator stated the van was not utilized during the investigation and the facility outsourced transportation to companies. The Administrator reported CNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366376 If continuation sheet Page 5 of 6 Printed: 05/15/2026 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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 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: 366376 If continuation sheet Page 6 of 6