The facility failed to educate and offer annual COVID-19 vaccination to eligible residents. Record review showed several residents had prior COVID-19 immunizations, but there was no documentation that they were educated, offered the vaccine, or that the vaccine was refused during the review period. The DON confirmed the facility offers immunizations annually and acknowledged the residents should have been offered COVID-19 vaccination.
The facility failed to offer and document COVID-19 vaccination for residents and staff. Several residents had no evidence of being offered the vaccine for months, and a newly admitted resident had no documented offer at all. Staff records for multiple employees showed only old COVID vaccine dates or an incomplete declination form, with no evidence of screening, education, offering, or current vaccination documentation. The ICP and ADON confirmed there was no active process in place during the transition period.
Missing COVID-19 Vaccine Documentation for Two Residents: The facility failed to offer and administer COVID-19 immunization to two residents reviewed. One resident had a phone consent on file, but the vaccine administration section was left blank with no other proof the vaccine was given. For another resident, staff recalled a discussion with the RP and a declination, but there was no declination form or other documentation showing the resident or RP received information to decline the vaccine.
Failure to Educate and Offer COVID-19 Vaccination: The facility did not document education or offer of the COVID-19 vaccine for multiple staff and residents. An RN infection preventionist stated that residents received vaccine education in the admission packet and that vaccines were ordered for consenting residents, but she had no evidence that staff were educated or offered the COVID-19 vaccine, and the NHA acknowledged there was no evidence the vaccine was offered to staff or residents.
The facility failed to monitor and document an employee’s COVID-19 vaccination status. During review of employee health files, a Dietary Aide hired in October 2024 was found to lack documentation of COVID-19 vaccination status. The IP stated that vaccination records are collected on hire and should include COVID-19, but the employee’s file did not contain this information.
The facility failed to consistently offer COVID-19 vaccine education and document vaccination status for residents and staff. Record review found missing immunization records for several staff members and no evidence that the vaccine had been offered or that education on benefits, risks, and side effects had been provided. For multiple residents, the chart lacked documentation of vaccine offer or education, and consents or declinations were only signed after surveyor intervention.
The facility failed to document COVID-19 vaccine education, offer, and refusal for 4 of 5 residents reviewed. Record review showed no 2025 documentation of vaccine administration or refusal for several residents, and the IP stated that while the vaccine is offered annually and education is provided, refusals are not documented when a resident declines after education.
Delayed Documentation of COVID-19 Vaccination Status: A resident's COVID-19 immunization status remained documented as pending consent for more than 50 days after admission. The IP stated staff review vaccination status on admission and offer vaccines to eligible residents, but the EMR still showed the status as pending consent during survey review, and the updated consent had not been documented at that time.
A facility failed to ensure education was provided to a resident's representative regarding the benefits and potential side effects of the COVID-19 vaccine. EHR review showed one vaccine refusal without documented education, while the hard chart showed declination forms signed by the resident even though two providers had certified the resident as incapable of understanding and making medical decisions.
The facility failed to document COVID-19 vaccine education and vaccination status for three residents and one employee. Records showed no documentation that the residents or the employee were offered education on the benefits, risks, and potential side effects of the vaccine, or that they received or declined it. The DON and Administrator confirmed the missing documentation during interview.
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