Health inspection·September 1, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 4 (Resident #12, #20, #42, and #55) of 5 sampled residents received care and services with respect and dignity. The finding included: 1. Resident #12 was admitted to the facility on [DATE] with a history of coronary artery disease, heart failure, peripheral vascular disease, renal insufficiency, chronic pain, anxiety disorder, and depression. The Quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #12's cognition was mildly impaired with a Brief Interview for Mental Status score of 12. The MDS noted Resident #12 required supervision with transferring, ambulation, eating, and toileting and extensive assistance with dressing. On 8/29/23 at 9:07 a.m., Resident #12 said staff did not treat her respectfully. Resident #12 said staff have an attitude when they care for her. On 8/29/23 at 9:37 a.m., Resident #12 said staff will sometimes open her bathroom door without knocking when she is using the bathroom and it makes her feel indecent when it happens. While conducting the interview with Resident #12 in her room, Certified Nursing Assistant (CNA) Staff M was observed opening Resident #12's closed bedroom door without knocking and waiting for the resident's permission to enter the room. On 8/31/23 at approximately 11:00 a.m., Resident #12 said she walked out of her room in the morning and staff in the hallway told her to go to her room. Resident #12 could not identify the staff who told her to go to her room but said staff treat her as though she was a child. 2. Resident #20 was admitted to the facility on [DATE] with a history of anemia, coronary artery disease, hypertension, and depression. The Quarterly MDS dated [DATE] showed she had moderate cognitive impairment with a Brief Interview for Mental Status BIMS score of 7. The MDS showed Resident #20 required extensive assistance with transferring, bed mobility, dressing, toileting, and personal hygiene. On 8/29/23 at 10:48 a.m., Resident #20 was observed fully dressed and lying in bed. Resident #20 was asked if staff treated her with respect and dignity. Resident #20 said when staff at the facility speak with her they have an attitude and make her feel demeaned. Resident #20 said she had asked for the TV (television) remote control six times this morning and staff ignored her. Resident #20's Page 1 of 12 105421 105421 09/01/2023 Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some call light was observed pinned to the left side of the bed, out of the resident's reach. Resident #20 said she could not reach the call light to request assistance. With the resident's permission the call light was engaged. CNA Staff M responded to the call light 10 minutes later and came in the room. Resident #20 asked CNA Staff M for her remote control. CNA Staff M looked for the remote control, was not able to find it and proceeded to provide incontinent care without addressing the resident's concern about the television remote control. 3. Resident #42 was admitted to the facility on [DATE] with a history of anxiety disorder and Schizophrenia. The Quarterly MDS dated [DATE] noted the resident's cognition was intact with a BIMS score of 15. Resident #42 required extensive assistance with transferring, dressing, toileting, and personal hygiene. On 8/29/23 at 12:00 p.m., during a resident council meeting Resident #42 said staff do not treat her with respect and dignity. Resident #42 said staff speak in a different language while they are providing her care and it offends her. Resident #42 said, I don't know if they're talking about me or not. Resident #42 said staff will act like they don't hear you, they pass right by you, and ignore you. On 9/1/23 2:09 p.m., Resident #42 said staff do not respond to call lights at night. Resident #42 said the majority of the staff have an attitude and disrespect her. They use their phone when they are giving her care. 4. Resident #55 was admitted to the facility on [DATE] with a history of hypertension, Multiple Sclerosis, Arthritis, and depression. The Annual MDS dated [DATE] showed Resident #55 has a BIMS of 15. Section G of the MDS shows Resident #55 needs extensive assistance from staff with mobility, transferring, toileting, and grooming. The Quarterly MDS dated [DATE] noted the resident's cognition was moderately impaired with a BIMS score of 10. On 8/28/23 at 9:55 a.m., Resident #55 was asked if staff treat her with respect and dignity. Resident #55 said, They treat me like a pile of [excrement]. I have been known to sit in my feces three to four hours at night. On the 25th of this month I called for help at 2:00 a.m., and did not get assistance until 6:45 a.m. The resident said when she reported it to the staff, they called her a liar. On 9/1/23 at approximately 2:30 p.m., the Social Service Director said residents had complained about staff using their phones while providing care and not speaking English. She verified the facility had identified residents were identified who felt staff were not treating them with respect. The Social Service Director said the facility started a performance improvement plan on 8/25/23 related to treating residents with dignity. 105421 Page 2 of 12 105421 09/01/2023 Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on staff interviews, record review, facility policy review and reportable events review the facility failed to have documentation of a thorough investigation of an allegation of neglect for 1 (Resident #230) of 2 residents reviewed. Residents Affected - Few The findings included: The facility's policy and procedure titled, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and injury of Unknown Origin (ANEMMI) revised 10/2022 noted, Identification . Any resident event that is reported to any staff by resident, family, other staff or any other person will be considered as possible ANEMMI if it meets any of the following criteria: . Any complaint of deprivation by an individual caregiver of goods and services necessary to attain or maintain physical, mental, and psychological well-being to include toileting issues . Any report to Adult Protective Services will trigger an internal investigation . Review of the clinical record for Resident #230 revealed documentation on 2/7/23 at 9:15 p.m., a police officer came to the facility to visit Resident #230. The resident told the police officer that she put the light on and nobody came. The nurse documented in the progress note two Certified Nursing Assistants had changed the resident at 8:45 p.m. Paramedics arrived at the facility and took the resident to the hospital. Review of the hospital records revealed documentation on 2/7/23 the resident presented to the Emergency Department with altered mental status and concerns for neglect. Review of the facility's Nursing Homes Federal Reporting to the Florida Agency for Health Care Administration revealed on 2/9/23 the facility submitted a report for an allegation of neglect. The report noted an investigator from the Department of Children and Families (DCF) came to the facility and spoke with the Administrator regarding Resident #230. The Administrator documented in the report, DCF arrived on 2/9/23 and it is still unclear why. DCF stated that they may have had facts misconstrued and that she would come back to the center. The center has not heard from her since that day. The Nursing Homes Federal Reporting noted the allegation of neglect was not substantiated. On 8/31/23 at 3:52 p.m., interviewed Facility Administrator about reported event alleging neglect involving Resident #230. The administrator said the facility was unable to provide information about the investigation. The Administrator said, If the event had occurred now we would submit the event as a reportable, interviewed staff and residents, keep the witness statements. I would have documented the DCF person who came to investigate and called back to obtain the DCF report. I know this investigation in the 5-day report is not complete. On 9/01/23 at 2:21 p.m., interviewed the administrator who confirmed that they have no documentation of a full investigation. The administrator could not explain how the allegation of neglect was unsubstantiated. Administrator confirmed the investigation process was outlined in the abuse and neglect policy and should have been followed. 105421 Page 3 of 12 105421 09/01/2023 Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure 2 (Residents #58 and #60) of 2 residents reviewed with newly evident or possible serious mental disorder, intellectual disability (ID) or related condition were referred to the appropriate state-designated mental health or intellectual disability authority for review for newly diagnosed mental illnesses. The findings included: 1. Resident #60 was admitted to the facility on [DATE] with a Level I Preadmission Screening and Resident Review (PASRR). On 5/5/22 the diagnosis of schizoaffective disorder, bipolar type was added to Resident #60's diagnosis list, and she began receiving Risperidone 1 mg (antipsychotic medication), 1 tablet by mouth two times per day related to schizoaffective disorder, bipolar type. Record review of Resident #60's chart on 8/30/23 revealed the PASRR had never been updated and sent for review for the newly diagnosed condition. On 8/31/23 at 2:37 p.m., the Social Services Director (SSD) said with the new diagnosis of schizoaffective disorder, bipolar type, the PASRR should have been updated and sent for review. 2. Review of the clinical record for Resident #58 revealed an admission date of 12/22/21 with a PASRR level I dated 12/17/21. The PASRR Level I noted the resident had no mental illness or suspected mental illness, there was no mental illness or suspected mental illness or ID for Resident #58. There was no PASRR Level II in the resident's chart. Review of physician's orders revealed psychiatric consults were ordered for the resident on 2/22/21, 10/13/21, 1/5/22, 1/28/23 (diagnoses: increase in psychosis and aggression), and 4/13/23. Review of the Annual Minimum Data Set (MDS) with assessment reference date of 3/31/23 revealed diagnoses of anxiety, depression, and psychotic disorder. Review of the physician's orders for Resident #58 revealed active orders for Mirtazapine 15 milligrams at bedtime on 4/25/23 for depression; Buspirone 5 mg three times a day on 8/10/23 for anxiety and agitation; and Zyprexa 5 mg at bedtime on 8/10/23 for bipolar disorder. On 8/31/23 at 5:02 p.m., Licensed Practical Nurse (LPN) Staff K said Resident #58 is being treated for mental illness, takes medication for mental illness, and sees the psychiatrist. On 8/31/23 at 6:22 p.m., the Social Service Director confirmed depression, anxiety, psychosis, and bipolar disorder were serious mental illness that required referral to the state-designated authority, but had not been done in the past. 105421 Page 4 of 12 105421 09/01/2023 Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #7 was an [AGE] year-old female who was readmitted to the facility on [DATE] after a being hospitalized with a history of Dementia, Malnutrition, and Respiratory failure. Residents Affected - Few On 6/23/23 Resident #7's weight prior to hospitalization was documented as 141.4lbs. on 7/6/23 upon readmission Resident #7's was documented as being 121lbs. A physician's order dated 7/6/23 reads, Every day shift for 3 Days Enter Weight in Weights and Vitals Section of PCC [Point Click Care] THEN every day shift every 7 day(s) for 4 Weeks Enter Weight in Weights and Vitals Section of PCC THEN every day shift every 30 day(s) Enter Weight in Weights and Vitals Section of PCC. The next documented weight in PCC was on 8/14/23 (38 days later) and Resident #7's weight was documented as 115.4lbs. On 8/31/23 at 1:30 p.m. the Registered Dietitian verified Resident #7's weights had not been obtained as ordered by the physician and the resident continued to lose weight. Based on observation, record review, and interview, the facility failed to provide nutritional interventions in a timely manner to prevent weight loss for 2 (Residents #30, and #7) of 5 residents reviewed for nutrition and hydration. The findings included: 1. On 8/28/23 at 11:13 a.m., observed Resident #30 in bed. His face was gaunt, his arms and legs were bony. He said he does not get a supplement. kilograms (kg) (145.2 lbs.) on 7/20/23 when discharged from the hospital. Review of the clinical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including pneumonia, chronic obstructive pulmonary disease, sepsis, and moderate protein-calorie malnutrition. Review of the physician's orders dated 7/21/23 revealed the resident was receiving a regular diet with a pureed texture, nectar/mildly thick consistency. Review of the facility Nutrition assessment dated [DATE] revealed Resident #30's weight was 143.0 pounds (lbs.), height 68 inches. The nutritional evaluation recommended an oral nutritional supplement for oral intake less than 75%. Review of the Plan of Care (POC) Response History for Amount Eaten by Resident #30 from 8/3/23 to 8/31/23 revealed fluctuating meal intake ranging from 50%, 75%, and 100%. Review of the facility weights revealed Resident #30 weighed 143 lbs. on 7/24/23; 171.8 lbs. on 8/11/23 and 171.8 lbs. on 8/14/23. 105421 Page 5 of 12 105421 09/01/2023 Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the active orders, progress notes, and care plans for Resident #30 revealed no weight or nutrition concerns were identified for the 28.8 lb. documented weight increase the facility documented for Resident #30 from 7/24/23 to 8/11/23. On 8/31/23 at 5:27 p.m., the Registered Ditetitian (RD) said he worked at the facility one day a week but was not familiar with Resident #30 since he started employment at the facility at the beginning of August 2023. He said he did not review the record or meet with Resident #30. He said when nutrition or weight issues are identified by staff, they should let him know so he can make necessary recommendations. He said otherwise, a nutritional assessment is completed every 90 days. The RD confirmed the facility-documented weight gain for Resident #30 that required attention from the facility. The RD confirmed the nutrition evaluation for Resident #30 completed on 7/26/23 recommended an oral nutritional supplement, but the supplement was never added to the physician's orders. Observation with the RD revealed Resident #30 was in bed. The RD confirmed Resident #30's face was gaunt, and limbs were bony. On 8/31/23 at 5:51 p.m., the Dietary Services Manager went to Resident #30's room, observed the dinner tray and meal ticket, and confirmed Resident #30 was not receiving an oral nutritional supplement. On 8/31/23 the RD documented a nutritional evaluation which noted Resident #30's current weight was 114.4 lbs. On 9/1/23 at 9:00 a.m., the Interim Director of Nursing confirmed Resident #30's weight on 8/31/23 was 114.4 lbs. On 9/1/23 at 12:48 p.m., the RD said Resident #30 would have benefited from the nutritional supplement when the nutritional evaluation was completed on 7/26/23, but the supplement was never added to the physician's orders. The RD verified the resident suffered a significant wieght loss over 38 days. 105421 Page 6 of 12 105421 09/01/2023 Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident, and staff interviews, the facility failed to ensure the availability of sufficient nursing staffing to meet the needs of 5 (Residents #55, #12, #47, #330 and #383 ) of 31 sampled residents. The failure to ensure sufficient nursing staffing to provide timely care and services could prevent residents from attaining, or maintaining their highest practicable physical, mental, and psychosocial well-being. The findings included: The facility's assessment with a date reviewed by the Quality Assurance and Performance Improvement committee on July 20, 2023, noted Registered Nurses and the Licensed Practical Nurses were based on 1.0 per person per day state mandated requirements. Certified Nursing Assistants direct care staff is based on Day shift: (7a-3p): 8-9 CNA's Evening Shift:(3p-11p) 8-9 CNA's Night Shift:(11p-7p) 5-6 CNA's The hours were based upon the state mandatory requirement of 2 hours per person per day. The Facility Assessment showed 77 residents required the assistance of one to two staff members for toileting. 28 residents required one to two staff members for eating and 66 residents required one to two staff members for transferring, and eight residents were dependent on staff for transfers. 1. Resident #55 was admitted to the facility on [DATE] with a history of hypertension, Multiple Sclerosis, Arthritis, and depression. The Quarterly Minimum Data Set (MDS) showed Resident #55's cognition was intact with a Brief Interview for Mental Status score of 15. has a BIMS of 15. Resident #55 required extensive physical assistance from staff with mobility, transferring, toileting, and grooming. On 8/28/23 at 9:55 a.m., Resident #55 said she had to sit in her feces 3 to 4 hours at night. Resident #55 said, On the 25th of this month I called for help at 2:00 a.m., and did not get assistance until 6:45 a.m. When asked if she reported this to nursing staff she stated she was called a liar. Resident #55 said she uses a mechanical lift (total body lift) to transfer to her wheelchair and she always has to wait 30 minutes to an hour for the mechanical lift to be available. 3. Resident #12 was admitted to the facility on [DATE] with a history of coronary artery disease, heart failure, peripheral vascular disease, renal insufficiency, Diabetes Mellitus, chronic pain, anxiety disorder, and depression. The Quarterly MDS dated [DATE] showed Resident #12 required supervision with transferring, ambulation, eating, and toileting and extensive physical assistance with dressing. On 8/29/23 at 9:15 a.m., Resident #12 said staff do not respond to her call light at night. She said she complains but the staff ignore her. 4. On 8/28/23 at 4:22 p.m., Resident #47 said, Without a doubt they need more staff, both days and nights. At times it can take 45 minutes other times within minutes. Most of the time you wait a while. Sometimes you hear buzzers all night. 5. On 8/29/23 at 11:19 a.m., Resident #330 said he often has to wait thirty minutes to an hour for staff to respond to his call light. He stated that this happens often day and night. 105421 Page 7 of 12 105421 09/01/2023 Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6. On 8/28/23 at 3:54 p.m., Resident #383 said sometimes it can take up to two hours for someone to answer the call light. Resident #383 said it occurred more during the day. On 9/1/23 at approximately 2:30 p.m., the Social Service Director verified she had had complaints from several residents regarding call light response time. She said the facility had recently started a performance improvement plan due to call light response time. 105421 Page 8 of 12 105421 09/01/2023 Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, records review and facility policy review the facility failed to ensure medication error rate was not greater than 5%. Three nurses were observed administering a total of 25 medications to three residents. Two medication errors were observed resulting in a medication error rate of 8%. Residents Affected - Few The findings included: Review of facility policy titled Administering medications revised [DATE] which stated, Policy statement: Medications are administered in a safe and timely manner, and as prescribed . 8. The individual administering the medications verifies the resident's identity before giving the resident his/ her medications . 11. The expiration/ beyond use date on the medication label is checked prior to administering. On [DATE] at 9:30 a.m., during medication administration Licensed Practical Nurse (LPN) Staff A was observed preparing medications to administer to Resident #44. LPN Staff A removed Fluticasone 50 micrograms nasal spray from the medication cart. The Fluticasone spray was labeled for Resident #3. LPN Staff A proceeded to Resident #44 room to administer the Fluticasone spray. The surveyor stopped the nurse from administering the Fluticasone nasal spray to resident #44. LPN Staff A verified the Fluticasone nasal spray belonged to Resident #3, and said, Oh my, I can't believe I did that. LPN Staff A said she could not find the nasal spray for Resident #44 and will have to order it from the pharmacy. On [DATE] at 9:00 a.m., LPN Staff F was observed preparing medications to administer to Resident #231. The physician's orders included Lactobacillus Capsule one capsule by mouth twice daily for probiotic. Observation of the Lactobacillus capsule container showed an expiration date of 7/2023. Photographic evidence obtained LPN Staff F poured the Lactobacillus capsule into a cup and prepared to administer the medication to Resident #231. Upon surveyor intervention, LPN Staff F verified the Lactobacillus's expiration date was 7/2023. LPN Staff F verified she did not check the expiration date on the medication and would have administered the expired medication to Resident #231 without the surveyor's intervention. On [DATE] at 4:00 p.m., the Director of Nursing (DON) was informed of the medication errors observed during observation of medication administration and the error rate of 8%. 105421 Page 9 of 12 105421 09/01/2023 Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, staff and resident interview, the facility failed to comprehensively assess food preferences for 1 (Resident #131) of 2 residents reviewed for food choices. The findings included: The facility's policy titled, Standards and Guidelines: Food Preference revised July 2023 noted, The food likes and dislikes of each resident are determined through a dietary food preference assessment. 1. Upon the resident's admission, the Food Service Manager will interview the resident to determine the resident's food likes and dislikes. a. Time frame of 7-10 days after admission. 2. Facility shall maintain the resident's likes and dislikes. This will also include diet order, which indicates any dietary restrictions . On 8/28/23 at 11:17 a.m., Resident #131 stated she likes to eat healthy with lots of fruits, vegetables, and salads. The resident said she did not want pasta and heavy food. She said since her admission at the facility, no one has talked to her about her food preferences. Review of the admission Record revealed Resident #131 was admitted to the facility on [DATE]. Diagnoses included Multiple Sclerosis, iron deficiency anemia, and gastro-esophageal reflux disease. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #131's cognition was intact with a brief Interview for Mental Status (BIMS) score of 15. There was no documentation in the clinical record Resident #131's food preferences were assessed and documented. On 8/31/23 at 4:53 p.m., Dietary Director Staff H said, To be honest I have not talked with the resident yet about her preferences. He verified the lack of assessment of the resident's food preferences. On 8/31/23 at 5:19 p.m., the Registered Dietitian (RD) acknowledged the resident has been in the facility since 8/2/23 without food preferences being assessed. He said he completed a nutritional assessment but could not recall if the assessment was done remotely. 105421 Page 10 of 12 105421 09/01/2023 Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

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, review of facility's policy and procedure, and record review, the facility failed to administer the pneumonia vaccine as requested for 1 (Resident #20) of 5 residents reviewed for immunizations. Residents Affected - Few The findings included: Review of the facility policy for pneumonia immunizations revised 12/2022 noted upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. On 8/29/23 at 11:59 a.m., Resident #20 said she could not remember the facility offering her the pneumonia vaccine. Review of the admission record for Resident #20 revealed Resident #20 admitted to the facility on [DATE] with diagnosis of senile degeneration of the brain, heart disease, weakness, and unsteadiness on feet. Review of Resident #20's medical record revealed a consent for the pneumonia vaccine signed on 8/1/23. Review of the physician's orders for Resident #20 did not include a physician's order for pneumonia vaccine. Review of Resident #20's Medication Administration Records (MARs) and Treatment Administration Records (TARS) failed to reveal documentation the facility Resident #20 received the pneumonia vaccine. On 9/1/23 at 2:29 p.m., the Infection Preventionist said on 8/25/23 the facility initiated a Performance Improvement Plan related to administration of vaccines but could not locate documentation Resident #20 received the pneumonia vaccine. 105421 Page 11 of 12 105421 09/01/2023 Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

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 record review and interview, the facility failed to ensure 1 (Resident #20) of 5 residents reviewed for immunization received the COVID-19 vaccine as requested. The findings included: Review of the facility policy for COVID-19 revised on 7/12/23 page 8 of 10 indicated COVID-19 vaccines are offered to residents and staff in accordance with the Center for Diseases Control (CDC) guidance. On 8/29/23 at 11:59 a.m., Resident #20 said she did not remember being offered the COVID-19 vaccine from the facility. Review of the admission record for Resident #20 revealed Resident #20 admitted to the facility on [DATE] with diagnosis of senile degeneration of the brain, heart disease, weakness, and unsteadiness on feet. Review of Resident #20's clinical record revealed a consent for the COVID-19 vaccine dated 8/1/23. Review of the physician's orders for Resident #20 did not include a physician's order for COVID-19 vaccine. Review of Resident #20's Medication Administration Records (MARs) and Treatment Administration Records failed to reveal documentation Resident #20 received the vaccine as requested. On 9/1/23 at 2:29 p.m., the Infection Preventionist said the facility started a Performance Improvement Plan (PIP) on 8/25/23 to address identified problems with vaccinations. She said she could not find documentation Resident #20 received the COVID-19 vaccine as requested. 105421 Page 12 of 12