Failure to Educate, Offer, and Document Staff COVID-19 Vaccination
Penalty
Summary
The facility failed to provide COVID-19 vaccination education, offer the COVID-19 vaccine, and document vaccination status for its employees, contrary to its own policy and CMS regulations. The CMS-671 dated 1/5/26 showed a facility census of 81 residents. During an interview, the Infection Prevention Nurse stated that the facility does not offer the COVID-19 vaccine to employees and does not keep records of which employees have or have not received the vaccine. The facility’s written policy, reviewed in 10/25, states that employees will be offered CDC-recommended vaccines annually, including COVID-19, that staff will be provided information and education regarding the vaccine, that declination forms will be completed and filed for those who refuse, and that a list of vaccinated employees will be maintained by the Infection Prevention Nurse designee. The policy also states that CMS regulations require staff to receive education on COVID-19 and be offered the vaccine, with staff completing a COVID-19 staff education form as proof. Staff interviews confirmed that the facility was not implementing these requirements. A restorative CNA who had worked at the facility for 13 years reported that the facility was not currently offering COVID-19 vaccines to employees, that no one had asked about her current COVID-19 vaccination status, and that she had not received any education regarding the current COVID-19 vaccine. An RN and an LPN both reported that they work throughout the building without designated areas, indicating that staff who move across all units were not being tracked or documented for COVID-19 vaccination status. These observations and interviews demonstrate that the facility was not following its own policy or CMS requirements to educate staff on COVID-19 vaccination, offer the vaccine, and maintain documentation of each employee’s vaccination status.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.