**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to timely revise care plans to accurately reflect dental and fall prevention needs. This affected two (#10 and #165) of sixteen residents reviewed for care plans. The facility census was 17. Findings include: 1. Review of Resident #10's medical record review admitted to the facility on [DATE], with diagnoses including: type II diabetes, unspecified persistent mood disorder, unspecified psychosis, unspecified hallucinations, and unspecified cerebral infarction. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition, was delusional, had no behaviors, did not wander, and rejected care one-to-three out of seven days per week. Resident #10 was independent with Activities of Daily Living (ADL's) and required supervision and setup assistance. Review of admission assessment dated [DATE] revealed Resident #10 had full lower dentures and an upper partial/bridge. Review of the facility consent form dated 03/25/20 revealed Resident #10's daughter (POA) declined consent for dental services. Review of Baseline care plan dated 12/07/19 revealed Resident # 10 had dietary care which included diabetic diet, preferred location for eating in the dining room, and wore dentures/partials. Review of the medical record revealed care plan dated 06/02/19 did not represent Resident's #10's need for supervision of dental care, including monitoring that denture and partial were intact/in place, resident behavior of misplacing denture/partial, resident behavior of making frequent statements that denture/partial were broken/missing, or POA's decline of dental services. During an interview on 08/15/22 at 10:17 A.M., Resident #10 stated she had broken her dentures at Christmas eating hard candy and needed new dentures. During an interview on 08/17/2022 at 11:51 A.M., Licensed Practical Nurse (LPN) #46 stated Resident # 10 frequently complained that her dentures were broken or missing. During an interview on 08/17/2022 at 11:57 A.M., the Director of Nursing (DON) stated Resident#10's family did not like taking her out for appointments and did not like to pay for additional services. Interview on 08/17/22 at 1:01 P.M., with Resident #10 re-stated she was out Christmas shopping with her family the Christmas before last (2020) and broke a tooth out of her upper partial. It hurt when it first happened to eat without her partial, but she had no problems now and was not sure if her family was going to replace her partial. The resident stated she had the broken partial in her purse but declined to show it. Interview on 08/17/22 at 3:42 P.M., the DON reviewed Resident #10's care plan dated 06/02/19 and verified there was no care plan for dentures or dental care/concerns. Interview via telephone on 08/18/22 at 8:50 A.M., Resident #10's daughter/POA states the resident had had a lower denture and upper partial for years, and she had regularly broke one of them. The family had them repaired/replaced by a local dentist. For quite a while, especially during COVID, it was difficult to get her to appointments. Around end of July 2022, Resident #10 told the POA's sister during a visit to the facility that her dentures had been stolen, but the dentures were observed by family to be intact in her denture cup on the nightstand. Family had received no recent reports from the facility about broken or missing dentures. Resident #10 frequently misplaced her things, was very forgetful, and became aggressive at times if people tried to look through her possessions. 2) Review of the electronic record revealed Resident # 165 was admitted to the facility on [DATE]. Her diagnoses included urinary tract infection, history of COVID-19, constipation, glaucoma, major depressive disorder, protein-calorie malnutrition, hypertension, dementia without behavioral disturbance, disorder of the thyroid, fracture of part of the neck of the right femur, displaced intertrochanteric fracture of the right femur, iron deficiency anemia, and encephalopathy. She had an admission Minimum Data Set (MDS) assessment completed on 07/26/22. She had severe cognitive impairment. She needed extensive assist of two staff for bed mobility, transfer, walking, locomotion, dressing, toilet use, and personal hygiene. She needed extensive assist of one staff for eating. She was totally dependent on one staff for bathing. She was frequently incontinent of bowel and bladder. Review of the medical record revealed Resident #165 had physician orders related to safety including non-skid socks at all times (08/06/22), sensor pads to bed/chair (08/09/22), and night light/frequently used items within reach (08/17/22). Review of facility post-fall review dated 08/08/22 revealed Resident #165 had an unwitnessed fall with minor injury in her room on 08/06/22 at 2:20 P.M., Resident #165 was re-educated to call light use and asking for assistance prior to transfer. New interventions for the fall included non-skid socks at all times and signs placed at eye-level to remind the resident to use the call light for assistance. The resident had dementia with poor safety awareness. Review of facility post-fall review dated 08/18/22 revealed Resident #165 had an unwitnessed fall with no injury in her room on 08/17/2022 at 12:17 A.M. Previous interventions already in place included non-skid socks, scoop mattress and sensor alarms. The new fall interventions included to keep frequently used items within reach and provide a night light. Interview on 08/18/22 at 1:15 P.M., the DON verified Resident #165's care plan for falls was not updated timely to represent all fall prevention interventions implemented after Resident #165 fell on [DATE]. The DON verified the care plan did not have the intervention for the visual signs which was initiated after the fall on 08/06/2022. The DON stated floor nurse did not make changes to the care plan. The DON, MDS nurse, or clinical manager updated care plans after reviewing falls. Review of a facility policy undated titled Care Planning and Discharge Care Planning Policy/Procedure revealed the chronic care plans will accurately reflect the resident's status and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) Review of the medical record revealed Resident #5 admission on [DATE], with diagnoses including: Parkinson's disease, Malignant neoplasm of the prostate, and Malignant neoplasm of the colon. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 5 had moderately impaired cognition, had no behaviors, did not wander, and rejected care one to three out of seven days per week. Resident # 5 was a two-person assist and required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Review of admission assessment dated [DATE] Resident # 5 had half side rails indicated to promote independence and bed mobility and no consent received for bilateral side rails. Review of side rail assessments dated 03/06/21, 09/08/21, 12/07/21, 03/07/21, and 06/03/21 revealed Resident # 5 had expressed no desire to use side rails, Resident # 5 did not use side rails for positioning/support, and use of side rails was not indicated. Review of the medical record revealed Resident # 5 had no signed consent for side rails and there was no risk agreement for using side rails without clinical indication. Review of the medical record revealed Resident # 5 had physician orders dated 03/05/021 for 1/2 side rails up times two to promote bed mobility due to weakness. Check placement every day and night shift. Interview on 08/17/22 at 12:42 P.M., with Resident # 5 stated he did not request side rails, he did not use side rails to assist with mobility, and the rails had been on the bed since admission. Resident # 5 stated he had never had any accidents related to side rails. Interview via telephone on 08/18/22 at 11:09 A.M., with Resident #5's daughter/ Power of Attorney (POA) stated she gave consent to provide services to promote all aspects of care upon admission. Stated she was aware of risks versus benefits of side rails. Based on observation, resident, family and staff interviews, bed manual review, policy review, and review of the Food and Drug Administration (FDA) guidance, the facility failed to ensure the resident's side rails did not present an entrapment hazard and consent to utilize the side rails was obtained. This affected four (#5, #9, #163 and #164) of 15 residents identified as having side rails. The facility census was 17. Findings included: 1) Review of the medical record for Resident #9 revealed an admission on [DATE]. Resident #9's diagnoses included: acute and chronic respiratory failure with hypoxia, heart failure, chronic obstructive pulmonary disease, constipation, hemorrhoids, occlusion and stenosis of bilateral carotid arteries, chronic kidney disease, myalgia, obesity, polyosteorarthritis, encephalopathy, Vitamin D deficiency, pure hypercholesterolemia, hypertension, paroxysmal atrial fibrillation, hypertrophic osteoarthropathy multiple sites, pulmonary hypertension, panlobular emphysema, hyperosmolality and hypernatremia, non-ischemic myocardial injury (non-traumatic), supraventricular tachycardia, acute and chronic respiratory failure with hypercapnia, sick sinus syndrome, COVID-19, pneumonia, dementia without behavioral disturbance, hypotension, chronic venous hypertension (idiopathic) with ulcer of the left lower extremity, non-pressure chronic ulcer of part of the left lower leg, chronic venous hypertension (idiopathic) with ulcer to right lower extremity, non-pressure chronic ulcer of part of the right lower leg, chronic diastolic (congestive) heart failure, abnormalities of plasma proteins, presence of cardiac pacemaker, amnesia, nonrheumatic aortic (valve) stenosis, age-related osteoporosis, and peripheral vascular disease. She had an admission Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE]. She had severe cognitive impairment. She needed extensive assist of two staff for bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. She needed extensive assist of one staff for eating. She was totally dependent on two staff for bathing. Review of the physician order summary revealed an order dated 07/01/22 for half upper side rails up times two to promote bed mobility. Observation on 08/15/22 at 1:05 P.M., of Resident #9 lying on an air mattress, with bilateral upper side rails raised and one half foot rail raised. It was noted there was a large gap in the center of the side rails at the top and bottom measured by the surveyor at that time to be 9 inches x 8 inches (all three openings) with a two inch gap between the mattress and side rail. 2) Review of the medical record for Resident #163 revealed an admission on [DATE]. Resident #163's diagnoses included: obstructive and reflux uropathy, type II diabetes, mild protein-calorie malnutrition, adult failure to thrive, neuromuscular dysfunction of the bladder, unsteadiness on feet, reduced mobility, major depressive disorder, muscle weakness, hypertension, urinary tract infection, accidental puncture and laceration of skin and subcutaneous tissue during a procedure, Alzheimer's disease with early onset, encounter with palliative care, hyperlipidemia, occular hypertension, retention of urine, benign prostatic hyperplasia without lower urinary tract symptoms, Methicillin Susceptible Staphylococcus aureus infection, hypertensive heart disease without heart failure, insomnia, and dementia with behavioral disturbance. He did not have a comprehensive assessment due to being newly admitted . Review of the physician order summary revealed an order dated 08/13/22 for half upper side rails times two to promote bed mobility due to weakness. On 08/15/22 at 12:24 P.M., revealed Resident #163 was observed to be lying in a bed with bilateral side rails raised. There was a large opening in the middle of the side rails. The same style side rail (identified by the facility as being an Advance Series Bed From Hill Rom) was measured by the surveyor as being 9 inches by 8 inches. 3) Review of the medical record for Resident #164 revealed an admission date of 08/13/22. Resident #164's diagnoses included: bipolar disorder, type II diabetes with hyperglycemia, severe protein-calorie malnutrition, acute respiratory failure with hypoxia, diabetic neuropathy, morbid obesity, dysphagia, unsteadiness on feet, pneumonia due to gram-negative bacteria, muscle weakness, iron deficiency anemia, hypothyroidism, anxiety disorder, sleep apnea, hypertension, gastro-esophageal reflux disease, drug induced constipation, major depressive disorder, ocular hypertension bilaterally, hypokalemia, edema, chronic pain, major depressive disorder, chronic pain syndrome, irritable bowel syndrome and nonalcoholic steatohepatitis. She did not have a comprehensive assessment due to being newly admitted . Review of the physician order summary revealed an order dated 08/13/22 for half upper side rails times two to promote bed mobility due to weakness. Observations on 08/15/22 at 12:26 P.M., revealed Resident #164 was observed to be lying in a bed with bilateral side rails raised. There was a large opening in the middle of the side rails. The same style side rail (identified by the facility as being an Advance Series Bed From Hill Rom) was measured by the surveyor as being 9 inches by 8 inches. Observation on 08/15/22 at 1:28 P.M., with the Director of Patient Services #5 verifying Resident #163's side rail to his right had a large gap in the center measuring 7.5 inches x 7 inches with a two inch gap between the mattress and side rail. The side rail to his left measured 8 inches x 7 inches with a gap of two inches. Resident #164 was also in a bed with the same side rails with a bilateral gap measuring 7.5 inches x 7 inches, with a gap between the mattress and side rails of two inches. Resident #9 had a side rail with an opening measuring 7.5 inches x 8 inches with a two inch gap between the mattress and side rail bilaterally. This was all verified by measurements completed by the Director of Patient Services #5 on 08/15/22 at 1:28 P.M. A list was requested of all residents using the same type of side rail. On 08/15/22 at 1:35 P.M., the Director of Patient Services #5 indicated Resident #5 had the same side rails in use with the same measurements (approximately 7.5 inches x 7 inches). A request was made for a copy of the consent for the side rails. The facility provided consents for each of the residents signed on 08/15/22. There were no previous side rail consents on the record for Residents #5, #9, #163 and #164. This was verified by the DON on 08/17/22 at 3:42 P.M. The facility identified the bed as being an Advance Series Bed From Hill Rom. A review of the service manual did not reveal the dimensions of the side rail openings. Review of the Guidance for Industry and FDA Staff, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued on 03/10/06 revealed to reduce the risk of head entrapment, openings in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. Country-specific anthropometric data show that a 1st percentile female head breadth may be as small as 95 mm (3 ¾ inches). A dimension of 120 mm (4 ¾ inches) encompasses the 5th percentile female head breadth in all data sources used to develop these recommendations, and includes 1st percentile female head breadth as reported in some data sources. It also indicated the FDA was therefore using a head breadth dimension of 120 mm (4 ¾ inches) as the basis for its dimensional limit recommendations. This dimension is consistent with the dimensions recommended by the HBSW (hospital bed safety workshop) and the IEC (international electrotechnical commission). Review of an undated facility policy titled Morris Nursing Home Side Rail Policy/Procedure indicated the FDA (Food and Drug Administration) guidelines for bed rails will be followed.

Based on medical record review and staff interview, the facility failed to ensure the advance directives on file were accurate. This affected two (#4 and #12) of four residents reviewed for advance directives. The facility census was 18. Findings include: 1. Medical record review for Resident #4 revealed an admission date of 06/18/17. Medical diagnoses included dementia. Review of the physician's progress note, dated 06/01/18, and face sheet for Resident #4 revealed a code status of Do Not Resuscitate Comfort Care (DNRCC). A review of the advance directive form in the resident's hard chart revealed a code status of DNR Comfort Care Arrest (DNRCCA). 2. Medical record review for Resident #12 revealed an admission date of 02/17/18. Medical diagnoses included Alzheimer's disease. Review of the physician's progress notes, dated 06/07/18 and 02/23/18, revealed a code status of DNRCC. Review of the admission paperwork revealed a code status of DNRCC. Review of the medication administration record for May 2018 revealed a code status of DNR. Review of the advance directive form in the resident's hard chart revealed a code status of DNR. Interview on 07/03/18 at 11:19 A.M. with Director of Nursing (DON) who verified the code status in the electronic chart and in the hard chart did not match for Resident #4 and #12.