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F0887
F

Delayed COVID-19 Vaccination and Notification During Outbreak

Barre, Vermont Survey Completed on 11-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement effective policies and procedures to ensure that all eligible residents and staff were offered the COVID-19 vaccine in a timely manner, as required. Although the facility's infection prevention and control policy referenced encouraging vaccination, it did not ensure that the vaccine was actually offered and administered to those who consented. Documentation showed that 16 residents tested positive for COVID-19 during a specified period, and interviews revealed that the Medical Director was not notified of the outbreak until several days after the initial cases were identified. The first cases were detected 11 days prior to the survey, but the Medical Director was only informed on the day of the survey, indicating a breakdown in communication and timely response. Record review indicated that, of 10 residents sampled who tested positive for COVID-19, 8 had provided consent to receive the vaccine but did not receive it before becoming infected. The facility only began vaccinating residents 10 days after the initial infection was identified, despite having documentation from a prior Quality Assurance Performance Improvement meeting that the vaccine would be received. This delay in offering and administering the vaccine to consenting residents contributed to the deficiency, as the facility did not follow through with timely vaccination despite having the necessary consents and advance notice of vaccine availability.

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