Failure to Administer or Document 2025–2026 COVID-19 Vaccination for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that when COVID-19 vaccine was available, each resident was offered and either administered or documented as declining the 2025–2026 COVID-19 vaccine, in accordance with facility policy and CDC/FDA guidance. The facility’s COVID-19 Vaccination policy, implemented 11/10/25, states that residents and staff are to be educated and offered the COVID-19 vaccine, and that vaccinations will be offered when supplies are available unless medically contraindicated, already administered during the time period, or refused. For adults 65 years and older who were previously vaccinated, the policy references a schedule requiring administration of two doses of the 2025–2026 vaccine. One resident, R3, over the age of 65 with severe unspecified dementia with agitation, primary hypertension, atherosclerotic heart disease, and supraventricular tachycardia, was admitted on hospice with an activated POA. R3 had prior COVID-19 vaccinations in 2021 and 2023. A progress note dated 9/29/25 documented that the resident’s daughter/POA agreed to both COVID-19 and influenza vaccines, and that hospice would be contacted for approval. The resident subsequently received the influenza vaccine on 10/27/25, but there was no documentation that the 2025–2026 COVID-19 vaccine was administered or declined. During an interview on 3/24/26, the DON stated she was unable to find any information indicating that the COVID-19 vaccine had been given to or refused by this resident and stated she would have expected the resident to receive the vaccine after verbal consent from the POA, confirming the lack of documentation and follow-through on the COVID-19 vaccination for R3.
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