Health inspection·December 10, 2020

F 0550 Function Status of the MDS revealed the resident requires one-person extensive assistance for eating. Level of Harm - Minimal harm or potential for actual harm A review of Resident #3's care plan, initiated on 8/17/20, revealed, . The Resident has a problem with communication: Rarely or Never Understood- unable to express ideas or want. Rarely/Never understands. Residents Affected - Few A review of Resident #3's Nutritional Evaluation Quarterly, dated 11/21/20, Section D: Meals/Dining revealed a requirement for full assistance with meals inside her room. A review of Resident #39's admission Record, revealed an admission date of 7/22/19 with medical diagnoses of cerebral infraction, unspecified protein-calorie malnutrition, muscle wasting and atrophy, and transient cerebral ischemic attack. Resident #39's MDS, dated [DATE], Section C: Cognitive Patterns revealed the resident has difficulty focusing, and disorganized thinking. Section G: Functional Status of the MDS revealed the resident requires one-person extensive assistance for eating. A review of Resident #39's Care Plan, initiated on 7/23/19, revealed, . The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] Moderately Impaired . Short term memory loss. A review of Resident #39's Nutrition Evaluation Quarterly, dated 9/30/20, Section D: Meals/Dining revealed a requirement for full assistance with meals inside her room. An interview conducted on 12/09/20 at 1:34 p.m. with Staff C, CNA revealed the process for assisting residents with eating includes sanitizing hands and making sure the resident is sitting upright. Staff C said, We are supposed to be sitting down when assisting a resident with eating, but I didn't have a chair. I asked the [Social Services Director] for a chair but she said she couldn't find one, so I had no choice but to stand up. An interview conducted on 12/09/20 at 1:39 p.m. with Staff A, LPN revealed she does not normally help with passing meal trays or assisting residents with eating. She stated she is not completely sure about policies [related to assisted eating] and would need to double check what the facility requirements are. Staff A confirmed she assisted Resident #39 with eating on 12/08/20 and remained standing while assisting the resident with eating. She stated normally there are metal chairs inside of the rooms because staff are no longer allowed to use cloth chairs due to infection control issues. She stated that she has not personally received education regarding assisting residents with eating but is unsure if CNAs were provided with education. An interview conducted on 12/09/20 at 1:46 p.m. with the Director of Nursing (DON) revealed the Nursing Home Administrator recently purchased additional metal chairs that are placed throughout the building for staff to use when assisting residents with eating. The DON stated the expectation for staff members when assisting residents with eating is to be seated. She stated there is no specific policy related to staff members and assisted eating procedures, however, it is part of the CNA's competencies that they must complete upon hire. A record review of the Competency Review Certified Nursing Assistant form, undated, revealed required competencies of preparing the resident for dining, properly preparing a tray for residents who can feed themselves, assist with eating and drinking, feeding those residents who require total assistance, providing a dignified environment and privacy, being able to explain resident rights, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105271 If continuation sheet Page 2 of 9 Printed: 05/28/2026 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 105271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Ciega Center 1414 59th St S Gulfport, FL 33707 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 0550 ensuring resident dignity, respect, and recognition. 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: 105271 If continuation sheet Page 3 of 9 Printed: 05/28/2026 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 105271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Ciega Center 1414 59th St S Gulfport, FL 33707 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure appropriate and timely completion of grievance reporting, documentation, and resolution for three residents (#2, #51, and #63) of three residents related to maintenance, repair, and replacing of electric wheelchairs and missing personalized wheelchair equipment and an assistive walking device. Findings included: 1. An observation on 12/09/20 at 11:04 a.m. revealed two electric wheelchairs in the [Unit Number] hallway with blue tarps covering them. An interview with Staff A, Licensed Practical Nurse (LPN) revealed the wheelchair on the left belonged to a resident who was recently discharged to the hospital. Staff A was unable to identify who the second electric wheelchair belonged to and stated she would need to speak with someone to find out. Staff A walked away and returned a moment later with the Social Services Director (SSD). The SSD stated she knew the electric wheelchair on the left belonged to a resident who was discharged to the hospital but was unsure who the second wheelchair belonged to and she would need to consult with a unit assigned Certified Nursing Assistant (CNA) to determine its owner. The SSD called over Staff B, CNA. Staff B, CNA stated she thinks the second electric wheelchair (one on the right) may belong to [Resident #51]. An interview on 12/09/20 at 11:10 a.m. with Resident #51 revealed the second electric wheelchair in the hallway belonged to him. He stated he has not used the wheelchair for a while since coming back from the hospital. Resident #51 said the wheelchair was . broken and acting weird. He stated he told the SSD during a care plan meeting but could not remember the date of the meeting. He stated the meeting was a while ago and after he reported the wheelchair was not functioning correctly . nothing came of it. A review of Resident #51's admission Record revealed an initial admission date of 10/03/08 with a readmission date of 7/17/20 and with medical diagnoses of paraplegia, immobility syndrome, chronic pain syndrome, and major depressive disorder. His Quarterly Minimum Data Set (MDS) assessment, dated 10/15/20, Section C: Cognitive Patterns revealed Resident #51 had no behaviors of inattention, disorganized thinking, or altered level of consciousness and had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #51 was cognitively intact. Section G: Functional Status revealed Resident #51 requires supervision with one-person assistance for location on and off the unit with a mobility device of a wheelchair. A review of Resident #51's progress notes, dated 10/19/20, revealed . Resident is alert able to make needs know . During an interview on 12/09/20 at 11:23 a.m. the Program Manager of Rehabilitation (PMR) stated Resident #51 does not ambulate and has an electric wheelchair for mobility. She stated that she has not performed the 6-month safety assessment on him (Resident #51) yet. She stated Resident #51 has not been up very much and has not been very motivated to get out of bed, so she has not seen him use his electric wheelchair recently. During an interview on 12/09/20 at 11:50 a.m. the SSD stated Resident #51 has not reported any grievances to her. The SSD went into Resident #51's room and asked him if he needed to speak with her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105271 If continuation sheet Page 4 of 9 Printed: 05/28/2026 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 105271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Ciega Center 1414 59th St S Gulfport, FL 33707 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #51 immediately stated that the only issue he is having is that the front motor on his wheelchair is not working. The SSD stated she would file a grievance on his behalf. Resident #51 stated that he mentioned the problem before in a care plan meeting where . A bunch of people were present. During an interview on 12/09/20 at 11:55 a.m. with the SSD and the MDS Coordinator, the MDS Coordinator stated she documents any complaints during care plan meetings. She stated Resident #51 has never had any complaints. During an interview on 12/09/20 at 1:15 p.m., Staff F, CNA stated Resident #51 does not ambulate by himself and used to have an electric wheelchair. She stated he has not been using it for a while because he said it has not been working. Staff F stated Resident #51 told her about a month ago that the wheelchair was not functioning properly, and he reported it in a care plan meeting which the SSD attends. Staff F stated she did not follow-up regarding the malfunctioning wheelchair because the resident told her he already reported it to the SSD, and she oversees filing and resolving grievances. A review of the medical record revealed a care plan/IDT note dated 10/22/20 at 16::32 (4:32 p.m.) which indicated, The resident's care plan meeting was held for the quarterly review. The resident was invited and attended. The plan of care was reviewed by the IDT and the resident. The current plan of care will continue at this time. 2. During an interview on 12/07/20 at 10:40 a.m., Resident #63 stated he has an electric wheelchair. He stated he returned from the hospital a few months ago and was placed under quarantine for COVID-19. Once he was moved off COVID-19 precautions, the facility told him they lost his wheelchair charger. He spoke with the SSD regarding the issues with his wheelchair. Resident #63 stated he misses being able to move independently to the outside area to, . Feel the sun on my face . I have some memory problems but I'm not a liar. A follow-up interview on 12/09/20 at 12:20 p.m. with Resident #63 revealed he feels that the facility does not follow through on grievances and he really need his electric wheelchair. A review of Resident #63's admission Record revealed an initial admission date of 8/13/18 with medical diagnoses of quadriplegia, personal history of traumatic brain injury, contracture of the left wrist and hand, major depressive disorder, and suicidal ideations. His MDS, dated [DATE], revealed no behaviors of inattention, disorganized thinking, or altered level of consciousness and a BIMS score of 14, which indicated the resident was cognitively intact. Section G: Functional Status revealed Resident #63 requires extensive assistance with two-person assistance for locomotion on the unit, and one-person assistance for location off the unit with a mobility device of a wheelchair. A review of Resident #63's care plan, initiated on 11/07/18, revealed a Focus of . The Resident has an ADL [Activities of Daily Living] Self Care Performance Deficit As Evidence by: Cannot complete ADL tasks independently . This focus included interventions of . LOCOMOTION: Electronic Wheelchair . During an interview on 12/09/20 at 11:23 a.m., the PMR stated Resident #63 does not ambulate and has splints to address his contractures. She stated the resident has an electric wheelchair and the facility has been attempting to replace some of the broken parts. She was told the entire electric wheelchair would need to be replaced, this has been an ongoing process for a couple of months. Resident #63 is not able to self-ambulate and declined a high-back manual wheelchair until his mechanical one is fixed. She stated Resident #63 does have some monetary funds in his account so perhaps they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105271 If continuation sheet Page 5 of 9 Printed: 05/28/2026 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 105271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Ciega Center 1414 59th St S Gulfport, FL 33707 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 0585 Level of Harm - Minimal harm or potential for actual harm could get him a used electric wheelchair to replace his broken one as it would not be an easy task to get Resident #63 into a manual one. During an interview on 12/09/20 at 11:50 a.m., the SSD stated that she was aware of Resident #63's wheelchair problems, but she did not feel that he reported it as a grievance. Residents Affected - Few During an interview on 12/09/20 at 12:30 p.m., the PMR stated she did not have any written notes about attempting to repair Resident #63's electric wheelchair and she would need to check with maintenance to see if they had any documentation. The PMR returned a few moments later saying that maintenance did not have any documentation related to Resident #63's wheelchair repair attempts. 3. During an interview on 12/08/20 at 9:06 a.m., Resident #2 stated he went to the hospital about four months ago. Before he went to the hospital, he had a personalized wheelchair with a cupholder, that his [family member] gave him, and a brown seat cover that a friend gave him. Resident #2 stated he also had a walker that he used. When he went out to the hospital, the facility staff told him they would store his wheelchair and walker until he returned. When he was re-admitted (8/12/20), he spoke to the Social Services Director (SSD) to get his wheelchair and walker back. He said, But nothing came of it. When Resident #2 followed up about his assistive devices with the SSD, he had the Activities Director with him, and the SSD said they never had the conversation about his assistive devices. Resident #2 said, I have my mind about me. I have some troubles on my left side, but my mind is fine. Resident #2 stated the Activities Director told him to always make sure these types of conversations are documented. During a follow-up interview on 12/09/20 at 12:11 p.m., Resident #2 stated when he returned to the facility after the hospital . I went to social services like I was supposed to if there are problems, and she said she would write up a form. That never happened. So, then I went with the Activities Director to see the SSD and she said we never had that conversation. This really upset me . Resident #2 stated no one has seen him to complete or sign any documentation related to his concern. A review of Resident #2's admission Record revealed an initial admission date of 3/28/19 and a readmission date of 8/12/20 with medical diagnoses of epilepsy, peripheral vascular disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, and COVID-19. His Minimum Data Set [MDS] assessment, dated 11/18/20, Section C: Cognitive Patterns revealed a BIMS score of 14; indicating an intact cognition with no behaviors of inattention, disorganized thinking, or altered level of consciousness. Section G: Functional Status revealed Resident #2 requires supervision with one-person assistance for locomotion on and off the unit with a mobility device of a wheelchair. A review of Resident #2's progress notes, dated 11/27/20, revealed . Resident is able to make needs known . During an interview on 12/09/20 at 11:23 a.m., with the PMR and Staff K, Restorative CNA, the PMR stated that Rehabilitation (department) screens all residents and determines their needs. She stated that Resident #2 was discharged from therapy services and primarily uses a wheelchair for location. In the past, the restorative program was working with him with a walker for assistance to increase strength. The Restorative CNA stated that prior to Resident #2 going to the hospital with COVID-19, he was on an ambulation program and . was doing really well. The PMR stated upon his readmission to the facility, he was screened. Resident #2 did report to her that his old wheelchair and walker were missing but the facility has been unable to find them. The PMR stated she found out about his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105271 If continuation sheet Page 6 of 9 Printed: 05/28/2026 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 105271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Ciega Center 1414 59th St S Gulfport, FL 33707 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 0585 missing walker on Friday of last week, 12/04/20. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/09/20 at 11:50 a.m., the SSD stated she is the facility's designated Grievance Officer. She stated that Resident #2 reported his wheelchair missing to the activities department, who then reported it to therapy first. Therapy provided him with another wheelchair until they figured out how to get him another one with his personalized items. She stated it was reported late afternoon on 12/04/20 and she was waiting on the PMR to complete her portion of the grievance form. Residents Affected - Few During an interview on 12/09/20 at 12:16 p.m. with the Activities Director it was revealed Resident #2 reported to her that his wheelchair and walker were missing. She then went to speak with the PMR and the PMR stated she was already aware of the situation. The Activities Director stated the PMR looked for the wheelchair with Resident #2, and Resident #2 did not identify his wheelchair. After this conversation, she stated Resident #2 and herself went to the SSD. At this point, the SSD stated there had never been a conversation about Resident #2's missing assistive devices and a grievance would be filed. The Activities Director stated she has filed grievances on the behalf of residents before. She usually does it immediately and passes the information to the SSD. During an interview on 12/9/20 at 12:30 p.m. with the PMR it was revealed that she assisted Resident #2 with finding his personalized wheelchair sometime during the middle of last week and was unsuccessful but did not find out about the missing walker until 12/4/20. She stated she completed her portion of the grievance form related to Resident #2's missing items today. During an interview on 12/09/20 at 1:46 p.m., the Director of Nursing (DON) stated the process at the facility is to review and talk about grievances as an Interdisciplinary Team during the morning meetings. Usually, the SSD will even call her over the weekend if any issues or concerns arise. The DON reviewed the facility's Grievance/Concern Management policy and stated that a grievance is anything that impedes on the resident's rights. She stated a grievance can also be if a resident feels like they need something and are not getting it. She reminds staff that even if a resident states a problem that seems small, write it on the grievance log and complete the grievance form. The DON stated she educates staff to immediately write up a grievance form. A review of the policy titled, Grievance/Concern Management, dated August 2017, page 1 revealed, Residents/representatives has the right to present concerns on behalf of themselves, and/or others to the staff and/or administrator of the facility, to governmental officials, or to any other person. The concern may be filed verbally or in writing, and the reporter may request to remain anonymous . These rights also include the right to prompt efforts by the facility to resolve resident concerns, including concerns/grievances with respect to the behavior of other residents . Page 2 of the Grievance/Concern Management revealed, . 3. Residents/resident representative who are unable to complete a written concern will be assisted by staff to prepare and submit the form. 4. The NHA is responsible for oversight of the concern process. 5. The Social Services Representatives/Grievance Official in collaboration with the NHA will be responsible for assigning the concern to the appropriate department for investigation. Social Services will monitor and document resident/family satisfaction upon completion of the investigation and the summary of findings/conclusion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105271 If continuation sheet Page 7 of 9 Printed: 05/28/2026 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 105271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Ciega Center 1414 59th St S Gulfport, FL 33707 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 Residents Affected - Few 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 observations, record review, and interviews, the facility did not ensure that four vials of a Schedule IV medication, Ativan, were stored in a locked, permanently affixed compartment for one medication storage room (300/400 hall) of two medication storage rooms sampled during the performance of the facility task of Medication Storage and Labeling. Findings included: On 12/9/2020 at 3:55 p.m. Staff G, Registered Nurse (RN), and Staff H, RN accommodated the observation of the locked medication storage room located behind the nurse's station between the 300 hall and 400 hall. The refrigerator in the room was not locked and contained a locked plastic box that contained four vials of Ativan 2mg/ml (milligram/milliliter), a Schedule IV medication. (photographic evidence obtained). The plastic box was not permanently affixed and was easily removed from the refrigerator. Staff G, RN, and Staff H, RN were then asked if they were aware that Schedule II-V medications stored in the refrigerator were to be stored in a locked, permanently affixed compartment. Staff G, RN replied that she was aware, but did not realize that the Ativan in the refrigerator was not stored in a locked permanently affixed compartment. Staff H, RN did not reply. On 12/9/2020 at 4:10 p.m. an interview with the Director of Nursing (DON) revealed that she was aware that Schedule II-V medications stored in the refrigerator were to be stored in a locked, permanently affixed compartment. On 12/9/2020 at 4:20 p.m. a telephone interview with the Consulting Pharmacist revealed that she was aware that controlled substances need to be stored in a locked, permanently affixed compartment in the medication storage room and has informed the facility of such in the past. On 12/10/2020 at 4:15 p.m. a review of the facility's policy titled, 4.2 Medication Storage Controlled Medication Storage, page 1 of 3 and dated 11/17, showed in section 4, Controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105271 If continuation sheet Page 8 of 9 Printed: 05/28/2026 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 105271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Boca Ciega Center 1414 59th St S Gulfport, FL 33707 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 Based on interview and record review the facility failed to ensure that annual influenza vaccine was offered to one (Resident #73) out of five sampled residents. Residents Affected - Few Findings included: Record review of Resident #73's medical record revealed no documentation regarding influenza vaccination. There were no orders or administration record for vaccination, no documentation that the vaccination was offered, and no documentation that the vaccination was declined. The admission Record revealed an admission date of 10/26/20 and a readmission date of 11/5/2020. On 12/10/20 at 10:48 a.m. the facility Director of Nursing (DON) was interviewed about the facility influenza vaccination program. She confirmed that attempts were made to offer the vaccine to all residents starting at the end of September 2020 and the beginning of October 2020. She stated that the corporation had required for all residents to be offered the vaccine by the beginning of November 2020, that the facility had met that goal, and that currently efforts were ongoing to re-offer the vaccine to anyone who had refused it. The DON was requested to produce records that the influenza vaccine had been offered/administered/declined for Resident #73 and she confirmed that there was nothing on record. On 12/10/20 at 2:25 p.m. the DON, facility Administrator, and Corporate Regional Nurse consultant (RNC) were interviewed. They reported that the consent to influenza vaccine form was part of the admission packet for any resident admitted to the facility and agreed that influenza vaccine had not been offered to Resident #73. The RNC described that the process for influenza vaccination for residents was to offer the vaccine and associated consent form, if resident consented then the vaccine was ordered and administered and if a resident declined then they would sign the declination form. She confirmed that the vaccination process started in the facility in September 2020 and included a mass mailing and mass calling to responsible family and resident representatives. She confirmed that the corporate expectation was to offer the influenza vaccine to all residents by November (2020) and that the facility had achieved that goal. She stated that typically the facility infection control nurse would have close follow-up regarding influenza vaccination and that the facility had identified that more help was needed in this area, although no formal quality assurance process had been started. Review of the facility policy and procedure titled, Immunizations - Pneumococcal & Annual Influenza, dated May 2020 revealed the following: The influenza vaccine will be administered during the optimal time for immunization, which is usually October to March, Immunization will be offered from October to March. The Infection Prevention Coordinator/DON will coordinate the influenza and pneumococcal immunizations. The facility will continue to offer vaccine to unvaccinated personal and newly admitted residents all throughout the influenza season as recommended (usually October 1 through March 31). Procedure .1. Screen the resident on admission to determine if they are current on the following adult immunizations: a. Influenza .2. Obtain consent for immunization or immunization declination on the Pneumococcal and Annual Influenza Vaccination Information and Request form. The influenza vaccination will be offered annually, and a new request form will be signed annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105271 If continuation sheet Page 9 of 9