Inspection·March 4, 2022

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to ensure a pharmacist completed a monthly Medication Regimen Review (MRR, a review of all ordered medications for administration safety and medication compatibility) for 10 of 10 sampled residents (Resident 1, 2, 3, 6, 10, 11, 16, 19, 20 and 24) during the months of December 2021 and January 2022. This failure had the potential to result in the administration of unnecessary or incompatible medications for the ten residents during December 2021 and January 2022. Findings: A review of Resident 1's admission Record, undated, indicated Resident 1 was admitted to the facility in 2015 with a diagnosis of iron deficiency anemia (inadequate amounts of blood levels of iron, resulting in low numbers of red blood cells which are needed for adequate blood circulation and all body functions). A review of Resident 2's admission Record, undated, indicated Resident 2 was admitted to the facility in 2018 with a diagnosis of hyperlipidemia (an abnormally high concentration of fats or lipids in the blood, associated with heart disease). A review of Resident 3's admission Record, undated, indicated Resident 3 was admitted to the facility in 2016 with a diagnosis of vitamin D deficiency (inadequate amounts of blood levels of vitamin D, a vitamin necessary for bone health). A review of Resident 6's admission Record, undated, indicated Resident 6 was admitted to the facility in 2015 with a diagnosis of diabetes mellitus (the body's inadequate production of the hormone insulin results in high blood sugar levels causing excessive urination and damage to body organs). During a review of Resident 10's admission Record, undated, indicated Resident 10 was admitted to the facility in 2015 with a diagnosis of diabetes mellitus. A review of Resident 11's admission Record, undated, indicated Resident 11 was admitted to the facility in 2016 with a diagnosis of chronic pain. A review of Resident 16's admission Record, undated, indicated Resident 16 was admitted to the facility in 2018 with a diagnosis of hypothyroidism (abnormally low activity of the thyroid gland, which makes hormones that regulate many body activities, including how the body uses energy). A review of Resident 19's admission Record, undated, indicated Resident 19 was admitted to the facility in 2018 with a diagnosis of acute kidney failure (a sudden failure of the kidney's ability to produce urine). A review of Resident 20's admission Record, undated, indicated Resident 20 was admitted to the facility in March 2021 with a diagnosis of traumatic brain injury (an injury due to external force). A review of Resident 24's admission Record undated, indicated Resident 24 was admitted to the facility in 2017 with a diagnosis of diabetes mellitus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056463 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emmanuel Post Acute Care - Hayward 26660 Patrick Avenue Hayward, CA 94544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview and concurrent record review on 3/2/22, at 3:30 p.m., with the Director of Nursing (DON), the pharmacy records for resident MRR's were reviewed. The DON was unable to provide documentation to show Residents 1, 2, 3, 6, 10, 11, 16, 19, 20, and 24 had a pharmacist complete a MRR during the months of December 2021 and January 2022. The DON stated the facility's pharmacy services provider had gone out of business and the resident's MRR were not completed for December 2021 or January 2022. The DON stated it was important for residents to have a pharmacist complete a monthly MRR to ensure residents had appropriate actions taken to avoid unnecessary medications, potential adverse side effects, and negative medication interactions. During an interview on 3/3/22, at 9:15 a.m., with the Administrator (ADM), the ADM stated the facility's previous pharmacy services provider had gone out of business before the Administrator had started working at the facility in January. The ADM stated the facility had contracted with a new provider for pharmacy services in January 2022. During an interview on 03/03/22, at 10:22 a.m., with the Pharmacist Consultant (PC), the PC stated he came to the facility for the first time on 2/20/22, and he completed a MRR for all the residents at that time. The PC stated a pharmacist should complete a resident MRR every 30 days to avoid negative medication issues. A review of the facility's policy and procedure titled, Medication Regimen Reviews, undated, indicated . Routine review will be done monthly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056463 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emmanuel Post Acute Care - Hayward 26660 Patrick Avenue Hayward, CA 94544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure: Residents Affected - Few 1. Expired drugs were removed from the medication cart for two of ten sampled residents (Resident 10 and Resident 5). 2. Expired antimicrobial (Silvadene gel) and antiseptic (Betadine) solutions were not accessible for stock use. 3. Pill cutters were cleaned after use. For Resident 10, Veltassa Oral Suspension (a medication used to treat increased potassium level in the blood) was one month past the expiration date. This had the potential to result in Resident 10 having increased blood potassium levels due to administration of expired and less effective medication. For Resident 5, Clearlax Oral Powder (medication used to treat occasional constipation) was one month past the expiration date. This failure had the potential for Resident 5 to be constipated after administration of expired and less effective medication. The failure to remove the expired antimicrobial and antiseptic solutions from stock supplies for five months after the expiration date had the potential to result in infection. The failure to remove medication residue from pill cutters after use, had the potential for administration of unordered medications or incompatible medications due to the mixing of different medications used in the pill cutter. Findings: 1. A review of Resident 10's admission Record, undated, indicated he was admitted in 2015. The admission Record indicated Resident 10 had end stage renal disease (a permanent condition of kidney failure, which can lead to a rise in potassium levels in the blood and impair the heart's ability to function). A review of Resident 10's order Summary Report dated 3/4/22, indicated Resident 10 had an order for one packet of Veltassa to be given in the evening every Wednesday and Saturday for hyperkalemia (elevated blood level of potassium). During a concurrent observation and interview on 3/2/22, at 11:37 a.m., with the Director of Nursing (DON), inside the Medication Room Storage, was an opened box, stored at room temperature. The DON confirmed the box was labeled Veltassa for oral suspension and had Resident 10's name and dispensing directions, with a dispensing date of 10/27/21, and a handwritten expiration date of 12/23/21. The label indicated, Keep in Refrigerator. Do Not Freeze. During a telephone interview on 3/4/22, at 11 a.m., with the Pharmacy Consultant (PC), the PC stated Veltassa Oral Suspension needed to be used within three months of dispensing if stored at room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056463 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emmanuel Post Acute Care - Hayward 26660 Patrick Avenue Hayward, CA 94544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 temperature and not refrigerated. Level of Harm - Minimal harm or potential for actual harm A review of the National Library of Medicine website, DailyMed, drug label for Veltassa, indicated Veltassa must be used within three months of being taken out of the refrigerator. Residents Affected - Few A review of Resident 5's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 1/30/22, indicated Resident 5 was admitted to the facility in 2020. The MDS indicated Resident 1 had paralysis of one side (both upper and lower extremities) and used a wheelchair for locomotion. The MDS indicated Resident 1 was incontinent of bowel and bladder and required extensive assistance from two or more people for toilet use. During a concurrent observation and interview on 3/2/22, at 11 a.m., with Licensed Vocational Nurse 1 (LVN 1), of Medication Cart 2, the medication cart drawer had an unsealed bottle of Clearlax Oral Powder labeled with Resident 5's name, directions for daily use, and an expiration date of 1/2022. LVN 1 confirmed the Clearlax was for Resident 5, and the expiration date had passed. 2. During a concurrent observations and interview on 3/2/22, at 11:37 a.m., with the DON, in the Central Supply Room was one sealed bottle of Betadine solution (an antiseptic to prevent wound infection) with an expiration date of 10/2021, and three tubes of Silvadene Gel (an antimicrobial to prevent wound infection) with an expiration date of 10/2021. The DON stated nurses should check for expired medications and supplies and discard any medications or supplies that were past their expiration date. During a telephone interview on 3/3/22, at 10:30 a.m., with the Pharmacy Consultant (PC), the PC stated expired medications and biologicals should be discarded and/or replaced and not be used past their expiration dates. Further review of the facility's undated P&P titled, Discontinued/Expired Medications/Supplies, the P&P indicated, Staff shall destroy discontinued, and expired medications/supplies or shall return them to the dispensing pharmacy in accordance with facility policy. 4. During a concurrent observation and interview on 3/2/22, at 11:35 a.m., with the DON, the Medication Room Storage had a pill cutter with a white powder residue inside the cutter. DON stated the pill cutter must be cleaned after each use to prevent cross contamination (material from one substance mixes with another substance). During a concurrent observation and interview on 3/2/22, at 11:45 a.m., with LVN 1 at Medication Cart 2, LVN 1 removed the pill cutter from the drawer of Medication Cart 2: the pill cutter had a white powder residue inside the cutter. LVN 1 confirmed the pill cutter needed to be cleaned and should be cleaned each time after use. During a review of the facility's undated policy and procedure (P&P) titled, Storage of Medications, the P&P indicated, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . During a review of the facility's undated P&P titled, Cleaning Nursing Equipment, the P&P indicated, The purpose of this procedure is to prevent cross contamination when using equipment i.e .pill cutter, pill crusher, others between residents and/or when an equipment is used by multiple staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056463 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emmanuel Post Acute Care - Hayward 26660 Patrick Avenue Hayward, CA 94544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 members . the P & P indicated the equipment should be inspected for damage and cleaned between residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056463 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emmanuel Post Acute Care - Hayward 26660 Patrick Avenue Hayward, CA 94544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 15 sampled residents (Resident 178) had implementation of national standards designed to prevent and control the spread of the contagious infection of Clostridia difficile. (C. diff, a bacterial infection which causes severe diarrhea and can lead to serious health problems. C. diff bacteria shed spores, a single cell organism capable of growing into the bacteria C. diff, in the feces of infected individuals. The spores can be transferred to the environment or the hands of healthcare personnel who have touched a contaminated surface or item.) Residents Affected - Few The failure of Registered Nurse Consultant (RNC) to wear a gown and gloves during direct contact with Resident 178, a resident diagnosed with a C. diff infection, and the failure to perform handwashing and sanitizing of shared equipment (a writing pen) upon exiting from Resident 178's room had the potential to result in spread of C. diff infection to other residents. Findings: During a review of Resident 178's admission record, the admission record indicated Resident 178 was admitted to the facility on [DATE], with a diagnosis of C. diff infection. During a review of Resident 178's Order Summary Report dated 2/25/22, the Order Summary Report indicated Resident 178 was to be in contact isolation (contact isolation precautions are measures intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) for the C. diff infection. During an observation on 2/28/22, at 10:03 a.m., Resident 178's room had a sign posted on the outside wall adjacent to the right side of the room entrance; the sign indicated, Contact Precautions, please see the nurse before entering the room. During an observation on 3/1/22, at 10:15 a.m., Registered Nurse Consultant (RNC) was inside Resident 178's room, without gown or gloves. RNC leaned against Resident 178's bed, and RNC placed her left hand on Resident 178's bedrail. Resident 178 handed a pen and paper to RNC, who took the pen and paper with her bare hands. RNC exited the room, handed the paper to another employee to hold while she performed hand hygiene with an alcohol-based hand sanitizer, while still holding the pen in her hand. RNC took back the paper and left the area holding the pen and paper. During an interview on 3/1/22, at 10:17 a.m., with RNC, RNC stated she had not worn a gown or gloves when she entered Resident 178's room, given Resident 178 a pen and a paper to sign, and received the pen and paper back from Resident 178. During an interview on 3/2/22, at 11:15 a.m., with Infection Preventionist (IP), IP confirmed gown and gloves should be worn when having direct contact with Resident 178. During an interview on 3/2/22 at 2:16 p.m., with the Director of Nursing (DON), the DON stated Resident 178 was on contact precaution for an infectious disease which required gown and gloves be worn when in direct contact with the resident or the resident's environment. A review of the Centers for Disease Control (CDC) article, Transmission-Based Precautions, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056463 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emmanuel Post Acute Care - Hayward 26660 Patrick Avenue Hayward, CA 94544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1/7/16, indicated, Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient. A review of the CDC article, FAQs for Clinicians about C. diff, dated 7/20/21, indicated C. diff was a spore-forming bacteria, shed in feces, which could be transferred to the environment or the hands of healthcare personnel who had touched a contaminated surface or item. The article indicated, Wear gloves and a gown when treating patients with C. diff, even during short visits. Gloves are important because hand sanitizer doesn't kill C. diff and handwashing might not be sufficient alone to eliminate all C. diff spores. A review of the facility's policy and procedure (P&P), Contact Precautions, undated, indicated, .implement contact precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces . Examples of infections requiring contact precautions include, but are not limited to: . Diarrhea associated with Clostridium difficile wear gloves when entering the room Wear a disposable gown upon entering the Contact Precautions room or cubicle. If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056463 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emmanuel Post Acute Care - Hayward 26660 Patrick Avenue Hayward, CA 94544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document: Residents Affected - Few 1. The vaccination status of one (Resident 176) of five sampled residents at the time of admission for pneumococcal pneumonia (PNA, a respiratory infection causing difficulty breathing) and influenza (the flu, a contagious respiratory illness caused by influenza viruses). 2. The refusal of one (Resident 177) of five sampled residents to be vaccinated for PNA and the flu. The failure to verify and document the vaccination status of Resident 176 had the potential to result in unnecessary repeated vaccination or no offer of vaccination and subsequent infection. The failure to document the vaccine education and vaccine refusal of Resident 177 had the potential to result an increased risk of infection due to an uninformed choice from inadequate education. Findings: 1. During a review of Resident 176's admission Record, undated, the admission record indicated Resident 176 was admitted to the facility on [DATE] with a diagnosis of pneumonia. During a concurrent interview and record review on 3/2/22, at 11:15 a.m., with the Infection Preventionist (IP), the IP was unable to provide documentation of Resident 176's PNA and flu vaccination status. 2. During a review of Resident 177's admission Record, undated, the admission record indicated Resident 177 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus (the body's inadequate production of the hormone insulin results in high blood sugar levels causing excessive urination and damage to body organs). During a concurrent interview and record review on 3/3/22, at 12:54 p.m., with the IP, the IP stated she had offered both the PNA and flu vaccines to Resident 177, but he had refused both vaccines. The IP further stated, she did not recall what education had been provided to Resident 177 before his refusal, and she had not documented the education or Resident 177's refusal in the resident's medical records. During a review of facility Policy and Procedure (P&P) titled Influenza and Pneumococcal Vaccine, undated, the P&P indicated, Influenza and pneumococcal vaccine will be available to nursing facility residents, unless medically contraindicated or refused. At the time of admission, the attending physician will determine whether the resident meets the criteria for receiving influenza and/or pneumococcal pneumonia vaccine. If indicated, the attending physician will write or verbally authorize an order to administer the vaccine(s). Document previous vaccination for influenza and/or pneumococcal pneumonia vaccine on the Resident's Immunization Record The attending physician and nursing staff will collaborate in informing the resident or their decision-maker of the advisability of the vaccine(s) and obtain consent if not obtained at the time of admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056463 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emmanuel Post Acute Care - Hayward 26660 Patrick Avenue Hayward, CA 94544 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document one (Resident 177) of five residents received education about Covid-19 vaccination (COVID-19, a respiratory infection which can result in breathing difficulty and other complications, including death.) and refused vaccination. This failure had the potential to result in Resident 177 not receiving adequate education to make an informed choice about Covid-19 vaccination, and increased risk of Covid-19 infection. Findings: During a review of Resident 177's admission Record, undated, the admission record indicated Resident 177 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus (the body's inadequate production of the hormone insulin results in high blood sugar levels causing excessive urination and damage to body organs). During a concurrent interview and record review, on 3/2/22, at 11:15 a.m., with the Infection Preventionist (IP). Resident 177's immunization records were reviewed. The IP stated she did not recall if she had provided Covid-19 vaccine education to Resident 177. The IP stated Resident 177 had refused the Covid-19 vaccine, but the IP had not documented the refusal in his medical record. During a review of facility's Policy and Procedure (P&P) titled Covid-19 Vaccination of Residents and Staff, undated, the P&P indicated, All newly admitted residents .will be offered COVID-19 vaccine that aid in preventing the spread of the virus unless the vaccine is medically contra-indicated or the resident .have already been fully vaccinated. Prior to receiving the COVID-19 vaccine, the resident or legal representative and staff will be provided information and education regarding the benefits and potential side effects of the COVID-19 vaccine Provision of such education shall be documented in the resident's medical record If vaccines are refused, the refusal shall be documented in the resident's medical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056463 If continuation sheet Page 10 of 10