Health inspection·May 30, 2024

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 record review, review of the facility's policy and procedure, and staff interview, the facility failed to ensure 5 (Resident #75, #76, #77, #78, and #79) of 5 residents sampled who were admitted during the 2023 to 2024 influenza season received education regarding the benefits and potential side effect of the influenza immunization and were offered the influenza immunization. The failure to offer and provide influenza immunization education puts the residents at risk of developing influenza. Residents Affected - Some The findings included: Review of the facility Influenza Vaccination policy and procedure created 9/16/15 and reviewed on 10/22/23, stated during the annual influenza season, patients, staff member, and volunteer workers would be offered an influenza vaccination unless such immunization is medically contraindicated, or the individual had already been immunized during this time period. Prior to the administration of the influenza's vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of Center for Disease Control (CDC) current vaccine information statement relative to the influenza vaccination. Vaccine information statements (VIS) would as appropriate, be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding the benefits and potential side effects of the influenza vaccine. Individuals being offered the influenza vaccine, or their legal representative, would be required to sign a consent form or declination form prior to the administration or refusal of the vaccine. The completed, signed, and dated record would be filed in the resident's medical record. 1. On 5/30/24 review of Resident #75's medical record revealed the resident was admitted to the facility on [DATE]. The medical record lacked documentation Resident #75 had received a copy of the CDC's current vaccine information related to the influenza immunization vaccination to include the benefits and potential side effect of the influenza vaccination and the required signed consent form or declination form to the administration or refusal of the vaccine. 2. On 5/30/24 review of Resident #76's medical record revealed the resident was admitted to the facility on [DATE]. The medical record lacked documentation Resident #75 had received a copy of the CDC's current vaccine information related to the influenza immunization vaccination to include the benefits and potential side effect of the influenza vaccination and the required signed consent form or declination form to the administration or refusal of the vaccine. 3. On 5/30/24 review of Resident #77's medical record revealed the resident was admitted to the facility on [DATE]. The medical record lacked documentation Resident #75 had received a copy of the CDC's current vaccine information related to the influenza immunization vaccination to include the benefits and potential side effect of the influenza vaccination and the required signed consent form or (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 106129 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 106129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Terracina Health & Rehabilitation 6869 Davis Boulevard Naples, FL 34104 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)