F0887

F

Failure to Offer and Document COVID-19 Vaccination for Residents and Staff

Henderson, North Carolina Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to assess residents for eligibility, educate them on COVID-19 vaccination, offer the vaccine, and document vaccination status as required by its own policies. The facility’s Infection Prevention and Control Program policy assigned oversight of infection prevention to the Infection Preventionist (IP), and the COVID-19 Vaccination policy required the facility to educate and offer the vaccine to residents, resident representatives, and staff, and to maintain documentation. Despite these policies, surveyors found that residents’ records lacked evidence that COVID-19 vaccines or additional doses had been offered, administered, or refused, and that staff vaccination status was not documented.

For five residents reviewed for immunizations, records and interviews showed missing or incomplete COVID-19 vaccination documentation. One resident with diabetes, chronic kidney disease, and COPD had received a COVID-19 vaccine dose in the facility, but there was no documentation of any subsequent offer, administration, or refusal of additional doses, and the MDS coded the resident as not up to date. Another cognitively intact resident with diabetes and COPD had last refused the vaccine in 2023, with no documentation of any further offers or refusals. A resident with severe cognitive impairment and vascular dementia had last refused the vaccine in 2023, again with no record of additional offers or refusals. Two cognitively intact residents with COPD, hypertension, diabetes, chronic kidney disease, and obstructive sleep apnea had no documentation at all that the COVID-19 vaccine had been offered, given, or refused, and both reported they were unsure if the vaccine had been offered in the past year. The Unit Manager confirmed she could not provide any documentation of COVID-19 vaccination status for these residents.

Interviews with facility leadership and staff further demonstrated a lack of clear responsibility and tracking for COVID-19 vaccination activities. The IP, in the role for about one and a half years, stated she had offered the COVID-19 vaccine to residents and believed none wanted it, but she was unable to locate any documentation of offers or signed declination forms. The DON, in the position for about four months, stated she had not focused on resident COVID-19 vaccinations and confirmed the facility had not offered the vaccine to residents during her tenure, with no documentation that residents were offered the vaccine in the prior year. Regarding staff, the facility was unable to provide any documentation of staff COVID-19 vaccination status. The IP stated she was not responsible for maintaining staff vaccination records and did not know who was; the DON similarly did not manage staff vaccination logs and was unsure who did. The Administrator stated that she and the nursing management team, including the IP, Unit Manager, and DON, were working together to track staff vaccinations and that information was sent to corporate, but she was unable to provide any documentation of staff COVID-19 vaccination status.