Inspection·May 22, 2024

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. Based on record review, review of immunization records, and facility policy the facility failed to provide education and offer COVID 19 vaccines in a timely manner for 4 of 5 sampled residents. (Residents #15, #28, #39, #64) The findings included: On 5/20/24, a review of the immunization record of Resident #15 was conducted. The record had an influenza vaccine dated 10/5/2023. There was no COVID vaccine in the record at the time. On 5/21/24, the Infection Control nurse was asked to provide proof any additional COVID vaccines not included in the electronic immunization record along with COVID vaccine consent forms and or declination forms. On 5/22/24, the Director of Nursing (DON) provided proof of COVID vaccines given on 1/4/21, 2/4/21, 3/8/21, and 6/22/22. The facility did not provide proof of approval or refusal of COVID vaccines after 6/22/22. On 5/20/24, a review of the immunization record of Resident #28 was conducted. The record had documentation of the administration of the COVID vaccine dated 1/14/21, 2/14/21, 11/5/21, and 8/1/22. On 5/21/24, the Infection Control nurse was asked to provide proof any additional COVID vaccines not included in the electronic immunization record along with COVID vaccine consent forms and/or declination forms. The facility did not provide proof of any of these forms after 8/1/22. On 5/20/24, a review of the immunization record of Resident #39 was conducted. The record had documentation of the COVID vaccine on 1/14/21, 2/4/21, and 11/14/21. The facility did not provide proof of approval or refusal of the COVID vaccine after 11/14/2021. On 5/20/24, a review of the immunization record of Resident #64 was conducted. The record had documentation of an influenza vaccine dated 10/5/2023. There was no proof of offering the COVID vaccine in the record at the time. On 5/21/23, the Infection Control nurse was asked to provide proof any additional COVID vaccines not included in the electronic immunization record along with COVID vaccine consent forms and or declination forms. On 5/22/24, the Director of Nursing provided proof of a COVID vaccine given on 11/1/21. The facility did not provide proof of any acceptance or refusal of a COVID vaccine after 11/12/21. On 5/22/24 at approximately 1:00 PM, the DON provided COVID 2023 Booser Immunization Consent Forms dated 5/22/24 for Residents #15, #28, #39, #64. Resident #15's family had been contacted verbally and the resident and his family refused the vaccine. Resident #28's guardian had been contacted verbally. The guardian wished for the resident to continue the Pfizer booster but refused the Moderna vaccine. Resident #39's guardian had been contacted verbally. The guardian wished for the resident to continue the Pfizer booster. Resident #64's guardian had been contacted verbally. The guardian wished for the resident to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105854 If continuation sheet Page 2 of 3 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 105854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Oaks 4449 Meandering Way Tallahassee, FL 32308 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 continue the Pfizer booster but refuses the Moderna vaccine. Level of Harm - Minimal harm or potential for actual harm On 5/22/24 at approximately 2:30 PM an interview was conducted with the DON. She was asked when the COVID 2023 Boosters Immunization Consent forms for the residents were completed. The DON acknowledged that they contacted the residents and their families earlier in the day. She mentioned that several residents preferred to receive the covid vaccine from Pfizer. She explained that the facility had a binder for tracking the immunizations. The binder had been lost the past November when all of the medical records were being uploaded into the electronic record. The DON was asked who was responsible for tracking, ordering, providing vaccinations at the facility. She explained that there are three Assistant Directors of Nursing (ADON) and each ADON is responsible for tracking, ordering providing and following up on immunizations for residents in their area. Residents Affected - Few The Facility Administrator indicated that a performance improvement plan (PIP) was initiated that am to track and update immunizations. A copy of the PIP was provided indicating that the facility had started an audit of all in house residents covid vaccines and consent forms had been initiated on 5/22/24. On 5/22/24 a review of the infection prevention and control policy, dated July 2023, was conducted. Page 2 of the policy indicated that residents would be offered the vaccine. Residents and resident representatives will have the opportunity to accept of refuse a COVID-19 vaccine and changed their decision based on current guidance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105854 If continuation sheet Page 3 of 3