Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that COVID-19 vaccinations were offered and properly documented for both residents and staff, as evidenced by the lack of vaccination status or documentation for one resident and one staff member. Specifically, a resident admitted with cerebral palsy and severe cognitive impairment had no record of being offered the COVID-19 vaccine, no documentation of vaccination, refusal, or contraindication, and no evidence that the required education or consent process occurred. The resident's care plan indicated COVID-19 isolation precautions following a positive test, but the clinical record did not reflect any action regarding vaccination upon admission. The Infection Preventionist confirmed that there was no monitoring system in place for resident COVID-19 vaccinations and acknowledged the omission. Similarly, a certified nursing assistant's employee health file lacked any documentation of COVID-19 vaccination status, offer, or refusal. Interviews with the Infection Preventionist, Director of Staff Development, and Director of Nursing confirmed that the facility's expectation was to offer and document COVID-19 vaccination for all staff upon hire and annually, but this was not done for the staff member in question. Review of facility policies indicated requirements for offering and documenting COVID-19 vaccination for both residents and staff, but these procedures were not followed in the cited cases.