Health inspection·February 12, 2020

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, review of standards from the U.S. Food and Drug Administration (FDA), and review of facility policy, the facility failed to ensure bed rails were safely maintained, placing the resident at risk for potential entrapment. This affected one (#4) resident of one reviewed for accident hazards. The facility census was four. Findings include: Review of Resident #4's medical record revealed an admission date of 12/19/19. Diagnoses included cerebral palsy, depression, morbid obesity, hypertension, unspecified convulsions, osteoarthritis, anxiety disorder, gastroesophageal reflux, insomnia, intellectual disabilities, and peripheral vascular disease. Review of the minimum data set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #4 had severe cognitive impairments, required extensive assistance with bed mobility, and was identified as having a seizure disorder. Observation on 02/11/19 at 9:45 A.M. revealed quarter side rails attached to both sides of Resident #4's bed. The side rails were found to have large gaps between the spaces in the rails. The gaps between the rails measured approximately five and a half (5-1/2) inches. Additionally, the rail on the right side of the bed was found to be loose and free moving, causing a large gap between the edge of the side rail and the mattress. The space between the edge of the rail and the mattress measured approximately 5 inches. Interview on 02/11/20 10:51 A.M., with State Tested Nursing Assistant (STNA) #100 revealed Resident #4 required extensive staff assistance with transfers to and from bed. STNA #100 stated that Resident #4 is capable of some independent movement while in bed such is rolling and turning from side to side. Interview on 02/11/20 at 5:04 P.M., with the facility Administrator (AD) and Director of Nursing (DON) confirmed the gaps between Resident #4's rails of measured approximately 5-1/2 inches. Additionally, the AD and DON verified the rail on the right side of the bed was not in a fixed position, creating a space between the mattress and edge of the bed rail measuring approximately five inches. DON stated Resident #4 had side rails in place at her admission due to her and her representative's request. DON stated the resident was assessed at that time for use of bed rails and documented in her record. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366358 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 366358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein North Shore 9400 North Shore Blvd Lakeside, OH 43440 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)