Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Otterbein Franklin Seniorlife Comm Res & Com Care during CMS and state inspections, most recent first.
An allegation of abuse involving a resident was not immediately reported to the Administrator or the state survey agency as required by facility policy. The incident was documented by an activity assistant who left a note under the DON's door describing a CNA making a kicking motion toward a resident during an activity. Staff interviews confirmed the delay in reporting the allegation.
During a random kitchen inspection, surveyors found a buildup of old food, dirty containers, silverware, and dust under serving and prep areas. Dietary staff confirmed that daily cleaning was required, but the facility could not provide a cleaning policy for kitchen floors.
Bathroom emergency call light cords were found wrapped around support bars in the bathrooms used by four residents, preventing the cords from being activated when pulled. The same condition was observed again later, and the Administrator stated the cords should not be tied or wrapped around the support bar and that the facility lacked a policy for the resident emergency call light system.
Dirty kitchenette used for resident food service: A family member reported the kitchenette on the Advanced Special Care Unit was dirty, and an observation found food being prepared in the area while the countertop and multiple drawers had dried stains, crumbs, sticky residue, food debris, and soiled items such as an apron and pot holders. CNA 5 said the area should be cleaned more often and was unsure who was responsible for cleaning it, while the Administrator stated the kitchenette should be kept clean and that the culinary supervisor was responsible.
A resident with anxiety disorder had PRN anti-anxiety psychotropic medications ordered without an end date, and the record did not include the required physician rationale or specified duration for use beyond the 14-day limit. The pharmacy review noted the 14-day restriction for PRN psychotropics, but the physician response only stated agreement, and the orders were not updated to show the time limit.
A resident with dementia and delirium, identified as a wander and elopement risk, exited the facility unsupervised after a wanderguard-equipped door failed to lock and alarm, and subsequently exited through sliding doors without alarms. The resident was found outside near the employee parking lot, despite interventions in place to prevent such incidents.
A severely cognitively impaired resident, identified as at risk for elopement and wearing a wanderguard, was able to exit the facility without staff knowledge after a staff member opened the elevator for her. The resident accessed the first floor, exited through the main entrance, and walked outside for several minutes before being assisted back inside. The incident revealed a failure in supervision and the effectiveness of elopement prevention measures.
Two residents were not protected from the misappropriation of their controlled medications. In one case, oxycodone tablets were missing without proper documentation, and in another, a resident received an unknown pill instead of her prescribed oxycodone. Staff discovered discrepancies in medication administration and reporting, and the DON did not promptly report the incidents as required by facility policy.
Two residents experienced misappropriation of their prescribed narcotic pain medications, with missing or substituted pills discovered by staff. In both cases, the incidents were reported to the DON but not promptly relayed to the Administrator as required by facility policy, resulting in delayed reporting to authorities.
The facility did not accurately reconcile or document controlled medications for two residents, resulting in incomplete records and unaccounted doses. In one case, a medication monitoring record for oxycodone was found with missing documentation and unexplained discrepancies. In another, a resident alleged not receiving her prescribed oxycodone, and a nurse found an unidentified pill in the medication packet. These incidents showed failures in following the facility's policy for controlled substance documentation and reconciliation.
A cognitively impaired resident with a history of exit-seeking behavior eloped from a secured memory care unit due to inadequate supervision. The resident, diagnosed with Alzheimer's and dementia, expressed a desire to go to work and was left unsupervised while a CNA assisted others. The resident exited through a courtyard door that did not latch properly and fell in the parking lot. The facility's elopement policy was not followed, leading to the incident.
The facility failed to maintain sanitary food service practices as staff were observed in the kitchen without proper hair coverings during meal preparation and plating. Despite the facility's policy requiring hair restraints, several staff members, including the Assistant Dietary Manager and Dietary Aides, had loose hair that was not covered, violating sanitation requirements.
A resident with COPD and respiratory failure was not provided continuous oxygen therapy as prescribed. Observations showed the resident without oxygen, leading to low oxygen saturation and slurred speech. The facility's policy and care plan to administer oxygen as ordered were not followed.
The facility failed to document drug dispositions for two residents upon their discharge and death, respectively. Despite having a policy requiring medication disposal in accordance with regulations, the facility did not complete the necessary records for non-narcotic medications. This deficiency was acknowledged by the Administrator and Unit Manager during interviews.
Staff failed to follow enhanced barrier precautions for a resident with a stage 3 pressure ulcer. During wound care, an RN, LPN, and CNA wore gloves but did not don gowns as required. The RN also neglected hand hygiene after changing gloves. The resident's records and facility policy mandated the use of gloves and gowns, which the administrator confirmed should have been followed.
Failure to Immediately Report Alleged Abuse to Administrator and State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse was immediately reported to the Administrator and the state survey agency, as required by facility policy. An activity assistant made an allegation of abuse by leaving a handwritten note under the Director of Nursing's (DON) door, describing an incident where a CNA made a kicking motion toward a resident during a birthday gathering. At the time the note was left, neither the DON nor the Administrator was present in the facility. The note detailed that the resident had been redirected to her room twice and, while her back was turned, the CNA made the inappropriate motion. The resident subsequently rejoined the activity. Interviews with staff confirmed that the abuse allegation was not reported immediately to the Administrator or the state department of health, as required by the facility's policy on abuse, mistreatment, neglect, exploitation, and misappropriation of resident property. The delay in reporting was acknowledged by both the CNA and the Administrator during interviews. The documentation provided included the original handwritten note and the relevant facility policy, which clearly states the requirement for immediate reporting of abuse allegations.
Failure to Maintain Cleanliness in Kitchen Areas
Penalty
Summary
The facility failed to ensure thorough cleaning of the kitchen, as observed during a random inspection. Dietary staff indicated that kitchen floors were supposed to be swept and mopped daily, with particular attention to areas under the serving line, heat tables, and prep tables. However, during the observation, there was a noticeable buildup of old dried food particles, grapes, dirty food containers, silverware, and thick dust and debris under these areas. Additionally, the facility was unable to provide a policy regarding the cleaning of kitchen floors when requested.
Bathroom Emergency Call Lights Not Accessible
Penalty
Summary
Reasonably accommodate the needs and preferences of each resident was not met when bathroom emergency call light cords were found wrapped around support bars in the bathrooms used by four residents, preventing the cords from being activated when pulled. During observations, the call light cords in the bathrooms used by Resident 116, Resident 99, Resident 52, and Resident 108 were each seen wrapped around the bathroom support bar rather than being accessible for resident use. The same condition was observed again on a later date for Resident 116, Resident 99, Resident 52, and Resident 108, with the cords still wrapped around the support bars and unable to be activated when pulled. During interview, each resident indicated that the bathroom observed was the one they used. The Administrator stated that the bathroom emergency call light cord should not be tied or wrapped around the support bar and indicated the facility lacked a policy for the resident emergency call light system.
Dirty kitchenette used for resident food service
Penalty
Summary
The facility failed to ensure a kitchenette used to serve food on the Advanced Special Care Unit was clean and sanitary. During an interview, a family member of a resident on the unit stated the kitchenette was dirty. During a dining observation, food was being prepared to be served to residents in the kitchenette, and the white countertop had multiple dried pink stains. Multiple drawers in the kitchenette were observed to contain soiled or stained items and debris. One drawer contained a soiled apron with an unidentifiable light green soft food substance and pot holders used to carry prepared hot trays of food. Another drawer contained a reddish-orange flakey substance covering the entire bottom, along with 10 individual packages of instant hot chocolate. A different drawer contained a round half dollar-sized sticky brown substance and loose straws for resident use. Another drawer had a red stain, multiple crumbs, and three loaves of bread. One drawer also had laminate pulling apart from the sides and bottom, with warped and old dried stains, and contained a half bottle of mustard, loose straws, and paper. CNA 5 stated the kitchenette should be cleaned more often and was not sure who was supposed to clean it. The Administrator stated the area should be kept clean and that the supervisor for the culinary department was to ensure the task was completed.
PRN Anti-Anxiety Medications Lacked Required Time Limit and Rationale
Penalty
Summary
The facility failed to ensure that PRN anti-anxiety psychotropic medications were not prescribed beyond 14 days without a documented clinical rationale and a specified extended duration for one resident with an anxiety disorder. Resident 4’s record showed orders for hydroxyzine HCL 25 mg every 8 hours PRN, ordered 6/16/25, and lorazepam 0.5 mg every 24 hours PRN, ordered 7/2/25, with no end date noted on either order. The resident’s admission MDS dated 6/22/25 identified anxiety disorder and indicated the resident was prescribed anti-anxiety medications. The monthly pharmacy review for Resident 4, completed 7/21/25, noted that PRN psychotropic medications are limited to 14 days and that if they are needed beyond that period, the prescriber must document the clinical rationale and specify the duration of use. The physician’s written response to the pharmacy note stated “Agree,” but the clinical record did not contain a physician rationale for continuing the PRN anti-anxiety medications beyond the initial 14-day period. The original physician orders were also not updated to reflect a 14-day time limit for the PRN psychotropic medications.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses of dementia and delirium exited the facility without staff knowledge. The resident, who had a history of wandering and was assessed as being at risk for elopement, was wearing a wanderguard device intended to lock doors and sound an alarm when a resident at risk approaches an exit. On the day of the incident, the resident left the rehab unit, which was not a secured unit but had a door equipped with a wanderguard alarm and keypad. However, the door did not lock or alarm as intended when the resident approached, allowing her to exit. The resident then proceeded to another set of sliding glass doors, which did not have a wanderguard alarm, and exited the building. She was found by staff on a sidewalk near the employee parking lot, approximately 150 feet from the building. Interviews and record reviews confirmed that the resident had previously displayed exit-seeking behaviors and was disoriented to place, with poor safety awareness. The care plan identified her as being at risk for wandering and elopement, and she had previously attempted to follow family members out of the facility. Despite these known risks and interventions in place, the failure of the wanderguard system and lack of alarms on the sliding doors allowed the resident to leave the facility unsupervised.
Resident Elopement Due to Inadequate Supervision and Access Control
Penalty
Summary
A severely cognitively impaired resident with diagnoses including Alzheimer's disease, anxiety disorder, and osteoporosis was able to exit the facility without staff knowledge. The resident was identified as being at risk for elopement and had interventions in place, such as wearing a wanderguard and being provided with diversions and structured activities. Despite these measures, the resident was able to access an elevator after a dietary aide scanned their badge to open the elevator doors, which allowed the resident to reach the first floor and exit through the main entrance. Observations and interviews revealed that the elevator was equipped with a wanderguard alarm system, which should have sounded when the resident approached the threshold. The system required staff to scan a badge or enter a code to silence the alarm. On the day of the incident, the resident was able to use the elevator and leave the building, walking outside and around the premises for several minutes before being assisted back inside by another resident and staff. Security footage confirmed the resident's path from the elevator to the exterior and eventual re-entry into the facility. Documentation showed that the resident's care plan included elopement risk interventions, and a recent assessment had categorized the resident as low risk for elopement. However, the resident was able to leave the secured area without staff awareness, indicating a failure in supervision and the effectiveness of the elopement prevention measures in place at the time of the incident.
Failure to Protect Residents from Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled medications for two residents. In the first instance, a medication monitoring record for a resident with diagnoses including cerebral palsy and cervical disc disorder showed that two oxycodone 15 mg tablets were unaccounted for, with no documentation of waste, spoilage, or disposition. The discrepancy was discovered when the medication monitoring record was found in an incorrect location, and upon review, the remaining medication was missing. The resident was cognitively intact, and the medication was prescribed for pain management. In the second case, another cognitively intact resident with chronic respiratory and anxiety conditions reported that an RN had not been administering her prescribed oxycodone 15 mg, but instead was giving her an unknown white pill. Staff statements confirmed that a white pill was found taped into the resident's oxycodone packet, and that a suspicious pink liquid, purported to be destroyed oxycodone, was also observed. The resident noticed differences in her reaction to the medication and became concerned, leading to further investigation by staff. The facility's policy states that residents have the right to be free from misappropriation of property. Staff interviews and documentation revealed that the DON was made aware of both incidents but failed to report the allegations of misappropriation to the Administrator in a timely manner. The lack of proper medication reconciliation and failure to follow reporting protocols contributed to the deficiency.
Failure to Timely Report Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to report allegations of misappropriation of residents' narcotic pain medications to the Administrator in a timely manner for two residents. In the first instance, a Unit Manager discovered that two oxycodone tablets were missing from a resident's medication packet, despite the medication monitoring record indicating they should have been present. This finding was reported to the Director of Nursing (DON) on the same day, but there is no indication that it was reported to the Administrator as required. In the second instance, a nurse found an unknown white pill taped into a resident's oxycodone packet, replacing a missing oxycodone tablet. The nurse immediately reported this to the DON, but the DON did not inform the Administrator until several days later. Facility policy requires all allegations of misappropriation of resident property to be reported to the state health department immediately, but this protocol was not followed in these cases.
Failure to Accurately Reconcile and Document Controlled Medications
Penalty
Summary
The facility failed to ensure accurate reconciliation and documentation of controlled medications for two residents, resulting in incomplete records and unaccounted controlled substances. For one resident with diagnoses including cerebral palsy, spondylosis, contractures, and cervical disc disorder with myelopathy, a medication monitoring record for oxycodone 15 mg was found misplaced in a binder. The record, covering several days, showed multiple documentation errors such as missing dates, times, signatures, and amounts administered or remaining. Additionally, the final count did not account for two remaining oxycodone tablets, and the process for staff reconciliation did not consistently involve both staff members observing the controlled medication during shift changes. Another incident involved a resident with anxiety, COPD, and chronic respiratory failure, who alleged that a nurse had not been administering her prescribed oxycodone 15 mg but was instead giving her allergy pills. A nurse discovered a white pill, not matching the prescribed oxycodone, taped into the resident's oxycodone packet. The nurse also noted that the oxycodone packet was not present during the morning controlled substance reconciliation, raising further concerns about the accuracy and integrity of the medication administration and documentation process. The facility's policy required maintaining a signed medication count record for controlled substances, but the observed practices and documentation did not meet this standard. The deficiencies included incomplete and inaccurate medication monitoring records, lack of proper reconciliation procedures, and failure to account for all controlled drugs, as evidenced by the findings for both residents.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent a cognitively impaired resident from eloping from a secured memory care unit. On the morning of the incident, a resident with a history of exit-seeking behavior, diagnosed with Alzheimer's disease and dementia, expressed a desire to go to work. Despite being informed by a CNA that he did not need to work, the resident was left unsupervised while the CNA assisted another resident and a phlebotomist. During this time, the resident exited the unit through a courtyard door that did not latch properly and made his way to the parking lot, where he fell. The facility's investigation revealed that the courtyard door was unlocked, and the wooden door leading to the parking lot was found open. The resident's care plan identified him as an elopement risk and included interventions such as offering distractions and residing on a secured unit. However, these measures were not effectively implemented, leading to the resident's unsupervised exit and subsequent fall. The facility's policy on elopement, which mandates steps to protect residents from elopement risks, was not adhered to in this instance.
Failure to Maintain Sanitary Food Service Practices
Penalty
Summary
The facility failed to ensure that food was served in a sanitary and safe manner, as observed during multiple kitchen inspections. During these observations, several staff members, including the Assistant Dietary Manager, Chef, Dietary Aides, and a Kitchen Contractor, were seen in the kitchen food preparation area without their hair properly covered. This was noted during the preparation and plating of meals, where staff had loose hair that was not restrained, contrary to the facility's policy and sanitation requirements. Interviews with the Dietary Manager and the Corporate Traveling Chef confirmed that all staff were expected to keep their hair covered while in the kitchen. The facility's Employee Sanitary Practices policy, dated 2013, mandates that kitchen employees wear hair restraints to prevent hair from contacting exposed food. This policy aligns with the Retail Food Establishment Sanitation Requirements, which also require food employees to wear hair restraints. Despite these guidelines, the facility did not adhere to these standards, resulting in the observed deficiencies.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure continuous oxygen therapy for a resident diagnosed with Chronic Obstructive Pulmonary Disease and acute and chronic respiratory failure with hypoxia. During multiple observations, the resident was found without the prescribed oxygen therapy. On one occasion, the resident was observed in bed with the oxygen tubing out of reach, resulting in slurred speech and difficulty keeping her eyes open. A pulse oximeter reading showed an oxygen saturation level of 75 percent, significantly below the physician's order to maintain levels greater than 90 percent. After the nasal cannula was placed on the resident, her condition improved, becoming more alert with clear speech. Further observations revealed the resident propelling herself in a wheelchair in the hallway without oxygen, despite having a physician's order for continuous oxygen therapy. The facility's Oxygen Therapy Policy, which mandates administering oxygen in accordance with physician's orders, was not adhered to, as evidenced by the resident's lack of access to necessary oxygen therapy. The resident's care plan also included interventions to administer oxygen as ordered, which were not followed, leading to the deficiency.
Failure to Document Drug Dispositions for Discharged and Deceased Residents
Penalty
Summary
The facility failed to document the drug dispositions for two residents, Resident 139 and Resident 44, upon their discharge and death, respectively. Resident 139, who had multiple diagnoses including multiple sclerosis, dementia, and epilepsy, was discharged home without a documented drug disposition for their non-narcotic medications. Similarly, Resident 44, who had conditions such as hypertension, type 2 diabetes, and chronic kidney disease, passed away without a documented drug disposition for their non-narcotic medications. The facility's records lacked the necessary documentation to confirm the proper disposal of these medications. During interviews, the Administrator and Unit Manager acknowledged the absence of non-narcotic drug disposition records for these residents. The facility's policy, dated 2017, required the disposal of medications in accordance with local, state, and federal regulations, but this was not adhered to in these cases. The failure to complete the drug disposition records was identified as a deficiency in the facility's pharmaceutical services, as it did not meet the regulatory requirements for documenting the disposal of medications.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to the required infection prevention and control protocols for a resident under enhanced barrier precautions. During an observation, a registered nurse (RN), a licensed practical nurse (LPN), and a certified nursing assistant (CNA) entered the room of a resident with a stage 3 pressure ulcer to provide wound care. Although they donned gloves, they did not wear gowns as mandated by the enhanced barrier precautions for wound care. Additionally, the RN did not perform hand hygiene after changing gloves during the procedure. The resident's clinical record indicated a diagnosis of a stage 3 pressure ulcer on the right buttock, and physician orders required the use of gloves and gowns during treatment. The resident reported that nurses never wore gowns during wound care. The facility's policy on isolation precautions, revised in August 2022, specified that gloves and gowns should be worn during high-contact resident care, including wound care. The administrator confirmed that staff should have worn gloves and gowns as per the enhanced barrier precautions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Franklin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Franklin Meadows | 0.6 mi | ★★★★★ | 8 | 0 |
| Hickory Creek At Franklin | 1 mi | ★★★★★ | 6 | 0 |
| Homeview Center Of Franklin | 1.5 mi | ★★★★★ | 3 | 0 |
| Compass Park | 1.5 mi | ★★★★★ | 5 | 0 |
| Aspen Trace Health & Living Community | 8.3 mi | ★★★★★ | 1 | 0 |
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