Failure to Document COVID-19 Vaccination Status for Residents and Staff
Penalty
Summary
The facility failed to maintain proper documentation of COVID-19 vaccination status for both residents and staff, as identified during a recertification and complaint survey. For two residents, one admitted in May 2025 and another in August 2023, there was either no documentation of COVID-19 vaccination status in the medical record or missing information regarding primary vaccination, despite a recorded refusal of a booster dose. The absence of this documentation was confirmed through medical record review and interviews with the DON, who acknowledged the gaps when questioned by the surveyor. Additionally, a review of employee health files revealed that one staff member hired in December 2024 for direct resident care did not have documentation of COVID-19 vaccination status at the time of hire. Although a declination form was later provided, it was signed only after the surveyor's inquiry, indicating the facility did not have this information on file as required. These findings demonstrate lapses in the facility's process for tracking and recording COVID-19 vaccination status for both residents and staff.