Deficiency in COVID-19 Vaccination Documentation for Staff
Summary
The facility failed to maintain infection control prevention practices, specifically regarding COVID-19 vaccinations for staff. During a recertification survey, it was found that the facility did not provide documentation of screening, administration, or declination of the COVID-19 vaccine for two staff members, a Certified Nurse Aide and a Laundry Aide. The facility's COVID-19 policy required that all employees and contracted staff be screened and educated about the vaccine, with documentation maintained to reflect this process. However, the facility was unable to provide such documentation for the two staff members in question. Interviews conducted during the survey revealed that the Licensed Practical Nurse responsible for collecting employee immunization data did not have completed forms for the two staff members, indicating a lack of awareness that the COVID-19 vaccine needed to be offered to staff. The Director of Nursing stated that the responsibility for ensuring forms were signed was delegated to the Licensed Practical Nurse, but they were unsure why the documentation was not completed. This oversight led to a deficiency in the facility's infection control practices as per the regulatory requirements.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 Staff #15 and #16 were both offered and declined COVID vaccinations for the year. Consent form was signed on (MONTH) 12, 2025. Staff #17 has been educated on the importance of completion of vaccination forms in its entirety. That Covid vaccinations are available in the facility throughout the year. A full house audit of all staff vaccination status will be conducted by DON/designee. All staff will be offered the Covid vaccines with education and eligibility information. Education provided to Staff #17 all staff can accept or decline all vaccinations throughout the year. Covid vaccinations are available at any time in the facility. Upon request. Covid vaccinations are offered at time of hire and, throughout the year. All vaccinations are available at any time. House wide audit of vaccinations records will be completed by ADON/designee monthly until 100% compliance is attained for 3 consecutive months. Any abnormal findings will be reported to the DON. These findings will be corrected immediately with education provided. The DON/ADON will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported to QAPI monthly meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not provide required education on the benefits and risks of the COVID-19 vaccine or offer the vaccine to its staff, despite having a policy stating that such education and vaccination would be provided unless medically contraindicated or already immunized. An MDS nurse and a nurse consultant both reported that neither COVID-19 education nor vaccination had been offered to them or other staff. Administration reported that approximately 99 staff members, including therapy staff, were employed at the time, and this failure had the potential to affect all residents in the facility.
Failure to Offer COVID-19 Vaccination: A resident with HTN, HLD, and malnutrition was documented as overdue for a COVID-19 vaccine, but the medical record had no evidence the vaccine was offered or given. The IP and DON both confirmed the resident had not been offered or received the vaccine, despite expectations that it would have been completed shortly after admission.
Failure to Offer COVID-19 Vaccine to Residents: The facility did not offer the COVID-19 vaccine to residents because staff believed repeated refusals meant it no longer needed to be offered. The ICPN, DON, MD, and administrator each stated they were unaware residents should still be offered the vaccine and allowed to accept or refuse it. The facility policy required residents and staff to be offered the vaccine, screened for contraindications, and educated before it was offered.
Facility staff did not maintain required documentation of staff COVID-19 vaccination education, offers, or vaccination status. When surveyors requested Infection Control information for staff, the IP reported she had not been directed to track staff COVID-19 vaccination status and had no records showing that staff were educated on COVID-19 vaccine benefits and risks, offered the vaccine, or given information on how to obtain it. In a subsequent interview, facility leadership, including the Administrator and DON, did not provide any additional information regarding staff COVID-19 vaccination data.
The facility failed to document COVID-19 vaccine education for two residents reviewed for vaccination status. EHR review showed no evidence that either resident received education on the risks and benefits of the vaccine, and there was no documented consent or declination form. A QA leader stated residents were expected to be offered the vaccine on admission with education and a completed consent/declination form, but this was not done for the two residents.
Failure to Document COVID-19 Vaccine Refusal: A resident with dementia, diabetes, and HTN had severely impaired decision-making and lacked capacity to make decisions. The IPN stated she offered the COVID-19 vaccine to the resident’s RP, who refused, but the refusal was not documented in the health record. The DON stated the declination should have been signed and the refusal documented with the risks and benefits explained and a timeline for reoffering the vaccine.
Failure to Educate and Offer COVID-19 Vaccination to Facility Staff
Penalty
Summary
The facility failed to provide education on the benefits and risks of the COVID-19 vaccine and failed to offer the COVID-19 vaccine to its employees, contrary to its own COVID-19 policy dated 11/25/25, which required education and vaccine offering unless medically contraindicated or already immunized. During an interview on 4/30/26, the MDS nurse reported that COVID-19 education and vaccination had not been offered to her. In a separate interview on 5/1/26, the Nurse Consultant also stated that COVID-19 education and the vaccine had not been offered to the staff. On 5/6/26, Administration indicated there were 99 staff members, including therapy staff, employed by the facility. The surveyors determined that the failure to provide COVID-19 vaccine education and to offer vaccination to staff had the potential to affect all residents residing in the facility.
Failure to Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure COVID-19 vaccinations were offered to 1 of 5 residents reviewed for COVID-19 vaccination status. Resident R6’s quarterly MDS showed the resident was admitted to the facility and had diagnoses of high blood pressure, hyperlipidemia, and malnutrition. R6’s undated client information vaccination record indicated the resident was overdue for a COVID-19 vaccination, but the medical record contained no evidence that the vaccine was offered or provided. The Infection Preventionist stated R6 had been on a list from the previous IP to be completed, but no supportive documentation could be found showing the vaccine was ever offered or completed, and stated it should have been completed within a few days of admission. The DON also confirmed R6 had not been offered or received the COVID-19 vaccination and stated the expectation was that it would have been completed within a week of admission.
Failure to Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to ensure each resident was offered the COVID-19 vaccine unless the immunization was medically contraindicated or the resident had already been immunized. During interviews, the ICPN stated the facility did not offer COVID vaccines to residents because residents and their representatives always declined the vaccination, so the facility stopped offering it. She stated she was unaware the facility should have continued to offer the vaccine and allow residents to accept or refuse it, and she did not recall when the facility stopped offering it. The DON, MD, and administrator each stated they were unaware the facility should have offered the COVID vaccine to residents and allow them to accept or refuse it, and each did not recall when the facility stopped offering the vaccine. Record review of the facility’s Infection Control Policy dated 05/13/2023 showed residents and staff were to be offered the COVID-19 vaccine when supplies were available, screened for prior immunization and contraindications, and given education about the vaccine before it was offered. CDC ACIP recommendations dated October 2024 stated adults aged 65 years and older should receive 2 doses of the 2024-2025 COVID-19 vaccine, and CDC COVID recommendations dated 11/19/2025 stated the vaccine helps protect against severe illness, hospitalization, and death and is especially important for persons ages 65 and older.
Failure to Document Staff COVID-19 Vaccination Education, Offers, and Status
Penalty
Summary
Facility staff failed to document COVID-19 vaccination information for staff members, including education, offers of vaccination, and vaccination status. During the Infection Control task on 4/23/26 at approximately 1:05 PM, surveyors requested the facility’s Infection Control information for staff. At 3:38 PM, the Infection Preventionist (IP) reported that she had not been directed to maintain staff COVID-19 vaccination status and therefore had no records of staff vaccination information. The IP further stated she had no documentation that any staff had been provided education on the benefits and potential risks of the COVID-19 vaccine, nor that staff had been offered the vaccine or given information on how to obtain it, because she had not been instructed to perform these activities. On 4/28/26 at 3:30 PM, during a final interview with the Administrator, Assistant Administrator, DON, Regional Nurse Consultant, and Regional MDS Consultant, the facility’s leadership team did not provide comments or additional information regarding staff COVID-19 data. No specific residents or their medical histories were mentioned in relation to this deficiency, and the report focuses solely on the lack of staff COVID-19 vaccination documentation and associated education and offering processes.
Failure to Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to ensure COVID-19 vaccination education was documented in the medical record for 2 of 5 sampled residents, Residents 10 and 7, who were reviewed for COVID-19 vaccinations. Review of Resident 10's electronic health record showed an admission date of 01/10/2026, but there was no documentation that the facility provided education on the risks and benefits of the COVID-19 vaccine. Review of Resident 7's electronic health record showed an admission date of 02/11/2026, and there was also no documentation that the resident was provided education on the risks and benefits of the COVID-19 vaccine. During an interview on 04/24/2026 at 11:39 AM, Staff C, Regional Director of Quality Assurance, stated it was the facility's expectation that all residents be offered the COVID-19 vaccine on admission with education on risks and benefits and a consent/declination form completed, and stated this was not done for Residents 7 and 10.
Failure to Document COVID-19 Vaccine Refusal
Penalty
Summary
The facility failed to document the responsible party’s refusal of the COVID-19 vaccine for one sampled resident. Resident 52 was admitted and later readmitted to the facility and had diagnoses including type 2 diabetes mellitus, dementia, and hypertension. The resident’s MDS showed severely impaired cognitive skills for daily decision making, and the H&P stated the resident did not have the capacity to understand and make decisions. RP 3 was the assigned responsible party for vaccine decisions. The Infection Preventionist Nurse stated she reviewed residents’ vaccines on admission and offered vaccines to the resident or responsible party within five days of admission. She reported that she spoke with RP 3 and offered the COVID-19 vaccine, and RP 3 refused, but this refusal was not documented in the resident’s health record. The DON stated the licensed nurse was responsible for asking about vaccines on admission and that the refusal should have been documented with the risks and benefits explained and a timeline for reoffering the vaccine. The resident’s immunization report showed the last COVID-19 vaccine was received on 12/22/2023, and the MDS was not updated on the resident’s COVID-19 vaccine status.
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