Greentree Manor Nursing and Rehabilitation Center

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews, for one (1) of three (3) sampled residents (Resident #1) reviewed for change in condition, the facility failed to ensure the provider was notified of changes in the resident's status following an unwitnessed fall with a head injury. This included failure to notify the provider timely of increasing confusion, continued pain, uncompleted diagnostic imaging, and worsening symptoms. These failures resulted in delayed evaluation and delayed care.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for falls, the facility failed to ensure adequate supervision and assistive measures to prevent accidents. Specifically, the facility failed to address the resident's repeated behaviors of getting out of bed independently despite requiring assistance, resulting in an unwitnessed fall with injuries, and failed to ensure the resident was transferred to and evaluated timely in the Emergency Department (ED) following an identified head injury, limited range of motion, and complaints of pain.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for falls, the facility failed to ensure the resident's pain was treated timely following a fall with head trauma and identified pain.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for falls, the facility failed to ensure a full RN assessment was documented following a fall with injury, including documentation of the time the provider was notified, and failed to ensure pain medication was signed out under the correct licensed nurse's name in the Medication Administration Record (MAR).

Inspectors wroteBased on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #1) who was at risk for elopement and wore a wanderguard, the facility failed to ensure staff responded appropriately to a door alarm when the resident exited the facility unattended and was found by an off-duty staff member on the sidewalk located near the front driveway.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for five (5) of eight (8) sampled residents (Residents #1, #2, #3, #4, and #5) who were reviewed for allegations of misappropriation of personal property, the facility failed to ensure the residents' medications were not removed from the facility by staff.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for five (5) of eight (8) sampled residents (Residents #1, #2, #3, #4, and #5) who were reviewed for allegations of misappropriation of residents' personal property, the facility failed to establish a system of records of receipt and disposition to account for the administration and destruction of controlled medications.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure that documented grievance resolutions were implemented.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to review and revise the plan of care to include a new intervention following a fall in the facility.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure a physician's order was obtained timely for the removal of staples from a facility acquired scalp laceration which was sustained from a mechanical fall in the facility.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for two of two residents (Resident #1 and #2) reviewed for abuse, the facility failed to ensure the residents were free from mistreatment.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 sampled residents (Resident # 23) reviewed for accidents, the facility failed to utilize a gait belt for transfers, failed to conduct a Registered Nurse (RN) assessment following a fall and prior to further movement, once transferred failed to conduct a thorough assessment, and failed to contact the physician representing a failure to maintain professional standards of practice.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 sampled residents (Resident # 23) reviewed for accidents, the facility failed to ensure a resident was transferred appropriately, failed to end the transfer and call for the Registered Nurse to assess the resident when he/she complained of pain, failed to ensure a Registered Nurse conducted a thorough assessment that included a range of motion prior to transferring the resident off the floor, and failed to notify the physician of the fall which resulted in a major injury.

Inspectors wroteBased on review of clinical records, facility policy, and interviews for 1 of 3 sampled residents (Resident #22) reviewed for choices, the facility failed to make a reasonable accommodation for an individual with mobility needs.

Inspectors wroteBased on review of the clinical record, facility policy and interviews for 1 of 4 sampled residents (Resident #22) reviewed for abuse, for the only sampled resident (Resident # 27) reviewed for hospitalization, and for 1 of 3 residents, (Resident #36) reviewed for smoking, the facility failed to develop and implement comprehensive Resident Care Plans.

Inspectors wroteBased on review of clinical records, facility policy, and interviews for 1 of 3 sampled residents, (Resident #7), reviewed for choices, the only sampled resident (Resident #13) reviewed for rehabilitation, the only sampled resident, (Resident #22), reviewed for abuse, the only sampled resident (Resident # 27) reviewed for hospitalization, the only sampled resident (Resident #52) reviewed for care planning, and the only sampled resident (Resident #56) reviewed for hemolytic treatments, the facility failed to review and revise care plans per the requirement and failed to hold quarterly Resident Care Plan (RCP) meetings as required.

Inspectors wroteBased on observations, review of clinical records, facility documentation, facility policy, and interviews on 1 of 4 units reviewed for medication to residents, (Resident #1, Resident #4, Resident #8, Resident #16, Resident #17, Resident #36, Resident #37, Resident #38, Resident #39, Resident #45, Resident #46, Resident #49, Resident #50, Resident #55, Resident #56, Resident #66, Resident #68, Resident #75, Resident #77, Resident #233 and Resident #282), the facility failed to ensure meds given greater than once daily were administered at the correct time per the physicians orders.

Inspectors wroteBased on clinical record review, facility policy, and interviews for 1 of 2 residents, (Resident #22), reviewed for food, the facility failed to accommodate a resident's preferences for meal items.

Inspectors wroteBased on observations, facility documentation, facility policy, and interviews the facility failed to ensure the steam table was washed and sanitized after every use, failed to ensure open food items were appropriately dated, and failed to ensure expired foods were removed from storage.

Inspectors wroteF814 [NAME] final Scope and Severity: E Based on observation and interview, the facility failed to ensure the dumpster area was maintained in a clean and sanitary manner and refuse was appropriately contained.

Inspectors wroteBased on record review, interviews, and facility policy for 3 of 4 sampled residents, (Resident #13, Resident #285, and Resident #287), reviewed for advance directives, the facility failed to ensure that residents had the opportunity to make care decisions and obtain signed consents regarding care to be provided upon admission.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 sampled residents (Resident # 23) reviewed for accidents, the facility failed to notify the physician following a fall with a major injury.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #18) reviewed for Activities of Daily Living (ADL), the facility failed to provide showers as scheduled for a dependent resident.

Inspectors wroteBased on observations, review of clinical records, facility policy, and interviews for 1 of 3 sampled residents (Resident #20) reviewed for pressure ulcers, the facility failed to follow physician orders for wound care, failed to obtain physician orders for wound care treatment, failed to report a change in skin integrity, and failed to ensure the wound care nurse conducted weekly head to toe skin assessments for a resident with a pressure ulcer per the facility practive, and for 1 of 4 sampled residents, (Resident #52) reviewed for nutrition, the facility failed to follow a physician order to obtain weekly weights.

Inspectors wroteBased on observations, review of the clinical record, facility policy, and interviews for 2 of 4 sampled residents (Resident #54 and Resident #285) reviewed for nutrition, for Resident #54, the facility failed to reweigh a resident after a significant weight loss and for Resident #285 the facility failed to obtain a timely admission weight and and failed to reweigh a resident with noted weight loss and receiving nutrition via a gastrostomy tube.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident # 27) reviewed for hospitalization, the facility failed to assess a symptomatic resident with a history of congestive heart failure and for the only sampled resident (Resident #44) reviewed for respiratory care, the facility failed to change oxygen tubing in a timely manner.

Inspectors wroteBased on observations, review of clinical records, facility policy, and interviews for the only sampled resident (Resident #56) reviewed for hemolytic treatments, the facility failed to ensure the treatment center was notified when appointments were going to be missed due to transportation and failed to reschedule the appointment per the hemolytic center's request.

Inspectors wroteBased on observations, review of the clinical record, facility policy, and interview for 1 of 5 residents (Resident #1) observed for medication pass the facility failed to ensure unused medications were properly stored/destroyed.

Inspectors wroteBased on review of clinical records, facility policy, and interviews for 1 of 5 sampled residents (Resident #69) reviewed for unnecessary medications, the facility failed to ensure pharmacy recommendations were reviewed and acted upon.

Inspectors wroteBased on observations, facility documentation, facility policy, and interviews for 1 of 4 medication carts reviewed for medication storage and labeling, the facility failed to ensure medication carts were locked when not attended and failed to remove expired medications.

Inspectors wroteBased on observations, review of clinical records, facility documentation, facility policy, and interviews for 1 of 5 residents, (Resident #1), reviewed for medication administration, the failed to ensure medications were handled in a clean manner, for 1 of 3 sampled residents, (Resident #20), reviewed for pressure ulcers, and for 1 of 4 residents reviewed, (Resident #285), for nutrition, the facility failed to ensure Personal Protective Equipment (PPE) was worn for residents on Enhanced Barrier Precautions (EBP), for Resident #20 failed to perform hand washing and changing gloves during wound care, and for 1 of 2 medication rooms reviewed, failed to ensure a clean and sanitary environment in the medication room was maintained.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 4 of 5 residents (Resident #13, Resident #282, Resident #285, Resident #287) reviewed for immunizations, the facility failed to obtain a current status for immunizations, failed to offer immunizations, and failed to obtain consent for immunizations.

Inspectors wroteBased on record review, interviews, and facility policy for 1 of 3 residents, (Resident #13), reviewed for advance directives, the facility failed to offer a covid vaccine.

Inspectors wroteBased on observations, review of facility documentation, and interviews for two (2) nursing units, the facility failed to provide a clean, comfortable, and homelike environment.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse and/or neglect, the facility failed to ensure an allegation of abuse was reported immediately to the State Agency as required.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse and/or neglect, the facility failed to provide evidence that an allegation of abuse was investigated. The findings inlcude: Resident #1's diagnoses included bipolar disorder with psychotic features, anxiety disorder and delusional disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of eleven (11) indicative of moderately impaired cognition and was dependent on staff for toileting hygiene and transfers, and required substantial assistance with bed mobility. The Resident Care Plan dated 7/11/24 identified that Resident #1 had accusatory behaviors and refused care and services at times. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse and/or neglect, the facility failed to ensure the resident was provided social services support timely after allegations of abuse.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for two (2) of three (3) sampled residents (Residents #1 and #2) who were reviewed for an allegation of physical abuse, the facility failed to ensure Resident #1 was not punched by Resident #2.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Residents #3) who were reviewed for an allegation of abuse, the facility failed to stop the provision of care and attempt again later when Resident #3 became agitated during incontinence care and failed to notify the charge nurse Resident #3 was resistive to care as outlined in the care plan.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3)residents, (Resident #1), reviewed for elopement, the facility failed to supervise a resident who required assistance with ambulation resulting in the resident leaving facility grounds unsupervised

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who was reviewed for the end of Medicare coverage and the appeals process, the facility failed to review the appeals decision and know that Resident #1 had won the insurance appeal that was filed and not discharge Resident #1 without giving him/her the option to remain at the facility for continued care.

Inspectors wroteBased on clinical record review, interviews and review of facility documentation for one of three residents reviewed for abuse or neglect (Resident #2), the facility failed to report a resident-to-resident threat of bodily harm to the proper authorities.

Inspectors wroteBased on review of facility documentation and interviews the facility failed to ensure a Registered Nurse was on duty 24 hours per day.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #2) who was at risk for skin breakdown, the facility failed to ensure Resident #1's Conservator of Person was notified when the resident developed a pressure ulcer.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies, and interviews for one of three sampled residents (Resident #3) who were reviewed for an allegation of neglect, the facility failed to ensure the resident was fed breakfast and failed to check and provide incontinent care during the 7AM-3PM shift.

Inspectors wroteBased on clinical record review, review of facility documentation, policies and interviews for one sampled resident (Resident #4) who was transferred to an acute care hospital, the facility failed to re-admit the resident and serve the resident a thirty (30) day involuntary discharge notice when the resident was ready for discharge from the hospital.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who were reviewed for pressure ulcer prevention, the facility failed to document weekly skin assessments to include measurements, staging, and characteristics of a current pressure ulcer, and failed to identify a new pressure ulcer prior to Resident #1 being transferred to the hospital, the new pressure ulcer was noted in the emergency department.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #55) reviewed for an allegation of mistreatment, the facility failed to ensure the resident was free from neglect.

Inspectors wroteBased on clinical record reviews, observations, facility documentation review, facility policy review, and interviews for 1 of 3 residents ( Resident # 16 ) who require assistance with transfers out of bed, the facility failed to transfer the resident out of bed per plan of care and for 3 of 3 residents (Resident #1, Resident #54 and #55) reviewed for ADLs, for Resident #1 under constant observation, the facility failed to respond to a sounding and illuminated call bell in a timely manner, for Resident #54 the facility failed to provide personal hygiene care including showering and shaving according to the plan of care, and for Resident #55, the facility failed to provide nail care according to the plan of care and for (Resident # 176), the facility failed to consistently provide ADL.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #55) reviewed for abuse, the facility failed to ensure appropriate staffing to provide the resident with timely care and services.

Inspectors wroteBased on observations of the kitchen, facility policy and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure the facility emergency food and water supply were within acceptable expiration dates.

Inspectors wroteBased on review of the facility Infection Control Program, observations, review of facility documentation and interviews for 2 of 2 ( Housekeeper #1 and Nurse Aide #1), the facility failed to follow the manufacturer's directions for disinfection of surfaces and the facility failed to ensure that COVID 19 outbreak for two employees ( NA # 12 and NA # 14) was reported to the state agency timely and for 1 of 2 residents reviewed for wound care for ( Resident # 7), the facility failed to ensure licensed staff used acceptable infection control practices when conducting wound care.

Inspectors wroteBased on clinical record reviews, observations, facility policy and interviews for 2 of 5 residents (Resident# 20) reviewed for dining, the facility failed to ensure staff provided a dignified dining experience and for 1 of 2 residents (Resident# 53) observed for dignity, the facility failed to ensure privacy of a urinary collection bag at the bedside free from public eyesight.

Inspectors wroteBased on review of the clinical record and interviews for 1 of 3 residents (Resident #32) reviewed for grievances, the facility failed to honor resident choice related to getting in and out of bed timely for activities.

Inspectors wroteBased on clinical record reviews and interviews for 2 of 6 residents (Resident # 13 and Resident # 16) reviewed for advanced directive, the facility failed to obtain a physician's order for the resident's advanced directive in accordance with facility practice.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #32) reviewed for grievances, the facility failed to educate the staff regarding the resident's resolution to be out bed for recreational activities.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 1 of 6 residents( Resident # 39) reviewed for an allegation of mistreatment, the facility failed to ensure the resident was free from neglect.

Inspectors wroteBased clinical record reviews, review of facility documentation and staff interviews for 3 of 6 residents reviewed for abuse/ neglect (Resident # 36 and Resident # 39), the facility failed to report an allegation of neglect timely to the state agency and for (Resident #55), the facility failed to ensure the resident was free from neglect.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #55) reviewed for mistreatment, the facility failed to ensure a thorough investigation was conducted following an allegation of neglect.

Inspectors wroteBased on clinical record reviews and staff interview for 1 sampled for ( Resident # 23) reviewed for Preadmission Screening and Resident Review , the facility failed to accurately code the resident assessment an for 1 of 3 residents reviewed for discharge (Resident #174) the facility failed to accurately code the MDS to reflect the resident's current location.

Inspectors wroteBased on clinical record reviews, observations, facility policy and interviews for 1 resident (Resident # 23) reviewed for PASSR, the facility failed to ensure completion of a PASSR level 1 and level 2 in a timely manner.

Inspectors wroteBased on observations, clinical record review, review of facility policy, and interviews for the only sampled resident (Resident #55) reviewed for respiratory care, the facility failed to develop a comprehensive care plan for the use of a sleep apnea device.

Inspectors wroteBased on clinical record reviews, facility documentation review, facility policy review, and interviews for 1 of 2 sampled resident (Resident #72) reviewed for advance directives, the facility failed to maintain medical to accurately documented per policy when Cardiopulmonary Resuscitation (CPR) was implemented to meet professional standard of practice and for 1 of 2 residents (Resident #44) who was observed during Medication Administration, the facility failed to properly identify the resident prior to administering medication .

Inspectors wroteBased on clinical record review and staff interviews for 1 of 1 sampled resident (Resident #62) reviewed for activities, the facility failed to ensure that activities meet the needs the resident.

Inspectors wroteBased on clinical record review and staff interview for 1 of 2 residents (Resident # 3), the facility failed to ensure that staff consistently turn and repositioned the resident according to the plan of care.

Inspectors wroteBased on observations, facility policy, and interviews for 1 of 1 resident (Resident# 50) who was reviewed for smoking, the facility failed to ensure that emergency fire safety supplies were available at the designated smoking area and staff was educated regarding smoking emergency procedures. failed to ensure education was provided regarding the emergency procedure.

Inspectors wroteBased on clinical record review, observations, policy review and staff interviews for 1 of 1 resident (Resident #10) reviewed for indwelling urinary catheter, the facility failed to ensure the resident's urinary drainage bag was properly placed during a transfer.

Inspectors wroteBased on clinical record reviews, facility policy and interviews for 1 sampled resident (Resident # 7) reviewed for nutrition, the facility failed to consistently monitor the resident's weights according to policy and plan of care.

Inspectors wroteBased on observations, clinical record review, review of facility policy, and interviews for the only sampled resident (Resident #55) reviewed for respiratory care, the facility failed to ensure a physicians order for a sleep apnea device and failed to ensure appropriate storage of a sleep apnea device mask.

Inspectors wroteBased on observation, and interviews for 2 of 4 medication carts reviewed for bimonthly narcotic audits, the facility failed to ensure a systematic, routine reconciliation of narcotics in use and conduct bimonthly narcotic cart audits.

Inspectors wroteBased on environmental observations, resident screening during the initial tour, review of clinical records, review of facility policy, and interviews, the facility failed to ensure safe storage of over the counter medications on the North Star Unit closet, failed to discard an expired medication in the North Star/South Center medication room, failed to discard an expired medication on the South Center medication cart and for Resident #32 and Resident #55, the facility failed to ensure safe storage and evaluation of bedside medication use.

Inspectors wroteBased on observations, record reviews, staff interviews and facility policy for 2 of 2 Residents (Resident #32 and Resident #65) reviewed for dental services, the facility failed to ensure that residents received timely dental care.

Inspectors wroteBased on initial screening interviews, review of policy and staff interviews for 1 of 9 residents (Resident # 32), the facility failed to ensure the residents were offered snacks.

Inspectors wroteBased on observations and interview, the facility failed to maintain annual electrical service checks on Outpatient Patient Physical Therapy (OPPT) equipment.

Inspectors wroteBased on observations, clinical record reviews, review of facility policy and interviews for 5 of 8 residents, (Residents # 1, 32, 50, 51 and 55), the facility failed to ensure resident equipment and supplies were maintained in a clean homelike manner.

Inspectors wroteBased on observations,interviews, review of clinical records and facility policy for 5 residents observed for respiratory equipment (Resident #1, Resident #18, Resident #20, Resident #43 and Resident #57), the facility failed to ensure nasal cannulas were changed weekly.

Inspectors wroteBased on observations in the Dietary department, staff interviews and review of facility policy, the facility failed to ensure Dietary staff performed hand hygiene according to infection control standards and failed to ensure food contact surfaces were sanitized with the appropriate solution.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #214) reviewed for accidents, the facility failed to assess Resident #214 to safely self-administer prescribed eye drops and topical medications.

Inspectors wroteBased on review of the clinical record, review of the facility documentation, and interviews for one of one sampled residents reviewed for a specific care request (Resident #314), the facility failed to honor Resident #314's request to have only female staff provide personal and incontinent care.

Inspectors wroteBased on review of the clinical record, review of the facility documentation, interviews, and review of policy and procedures for one of three residents reviewed for mistreatment (Resident #314), the facility failed to develop an initial comprehensive baseline care plan for a resident who requested to have only female staff provide personal/incontinent care.

Inspectors wroteBased on observations, review of the clinical record, facility policy and staff interviews for 1 of 3 residents (Resident #26) reviewed for pressure ulcers, the facility failed to ensure there was consistent offloading of Resident #26's heels. Resident #26 was admitted with diagnoses that included dementia with behavioral disturbance, fibromyalgia, bipolar depression, hypertension, atherosclerosis, osteoarthritis and contractures. A Resident Care Plan (RCP) dated 10/7/20 identified a problem of being dependent on staff for activities of daily living. Interventions included to transfer Resident #26 with assistance of 2 staff using a mechanical lift. The quarterly Braden Scale at Risk assessment dated [DATE] identified a significant risk for pressure ulcers. [...]

Inspectors wroteBased on observation, review of the clinical record, facility policy, and interviews for 1 of 5 sampled residents (Resident #28) reviewed for nutrition, the facility failed to complete weekly weights and failed to ensure the Dietician reassessed Resident #28 when he/she developed a significant weight loss.

Inspectors wroteBased on observations, clinical record review, facility policies, and staff interviews for 1 of 3 residents observed during medication administration (Resident #46) the facility failed to ensure the correct dose of a medication was received from the pharmacy according to the physician's order.

Inspectors wroteBased on observation, interview and review of facility policy, the facility failed ensure IntraVenous (IV) solutions stored in the Emergency Box (E-box) were not expired.

Inspectors wroteBased on staff interview and record review for 1 of 3 sampled residents (Resident #40) reviewed for pressure ulcers, the facility failed to ensure interventions to prevent a pressure ulcer were documented as completed.

Inspectors wroteBased on observations, interviews, review of facility documentation and policy for 2 of 4 residents (Resident #9 and Resident #44) reviewed for transmission based precautions, the facility failed to ensure Personal Protective Equipment was removed before exiting a resident room and failed to ensure hand hygiene was performed. Resident #9's diagnoses included COVID-19 exposure and dementia. A Resident Care Plan dated 2/4/21 identified a problem of being potentially exposed to COVID-19. Interventions included to observe Resident #9 for signs and symptoms of COVID-19 and directed a 14 day quarantine to include droplet precautions and staff were required to use full PPE. Resident #44 diagnoses included dementia and Parkinson's disease. A Resident Care Plan dated 2/4/21 identified a problem of being potentially exposed to COVID-19. [...]