Health inspection·March 13, 2024

F 0641 Ensure each resident receives an accurate assessment. 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 accurately code a Minimum Data Set for one of 12 residents (R11) reviewed for restraints on the sample list of 12. Residents Affected - Few Findings Include: R11's MDS (Minimum Data Set) dated 1/2/24 documents R11 is alert and oriented, uses bed rails as a restraint daily and is independent with rolling side to side. On 3/11/24 at 9:35 AM, R11 was sitting up in the recliner in R11's room. R11 stated R11 does not use any restraints explaining, I'm able to walk independent down the hall and that R11 uses upper side rails so I (R11) can turn myself in bed. I (R11) want/need them so I (R11) don't have to ask for help. R11's Side Rail assessment dated [DATE] documents R11 uses 1/4 upper rails bilaterally per request to enable in repositioning. R11's Care Plan dated 1/15/24 documents R11 can change positions in bed with assist of one and prefers to use side rails on a daily basis to help with positioning. This care plan also documents R11 has signed the bed rail agreement and understands the risks of having them in place. On 3/11/24 at 3:04 PM, V3 MDS/Care Plan Coordinator stated R11 does not use any restraints, only side rails to aid in repositioning. V3 explained V3 coded them as a restraint on the MDS because V3 thought they had to be coded that way due to R11's use of side rails. Page 1 of 11 145979 145979 03/13/2024 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review the facility failed to develop a comprehensive care plan for Urinary Tract Infections (UTI) for one (R1) of twelve residents reviewed for care plans in the sample list of 12. Residents Affected - Few Findings include: On 3/11/24 at 1:08 PM R1 stated R1 gets frequent bladder infections and is not sure what the facility does to prevent them. R1 stated R1 has burning with urination all the time which is a long term problem for R1, and staff assist R1 with toileting. R1's Nursing Notes dated 9/28/23-10/2/23 document R1 was on an antibiotic for a UTI. R1's urine Culture resulted on 1/10/24 documents Escherichia coli (bacteria found in colon) greater than 100,000 colony forming units (CFU), indicating an infection. R1's Urine Culture resulted on 12/30/23 documents Klebsiella pneumoniae greater than 100,000 CFU, indicating an infection. R1's Care Plan revised 2/28/24 does not have a problem, goal, and interventions to address R1's UTIs. On 3/12/24 at 12:00 PM V3 Minimum Data Set Coordinator stated V3 does not care plan for a history of or frequent UTIs, and information such as antibiotic use, encouraging fluids, and monitoring would be documented in the nursing notes. V3 confirmed R1 does not have a care plan for UTIs or prevention. 145979 Page 2 of 11 145979 03/13/2024 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Base on observation, interview and record review, the facility failed to complete a fall risk assessment quarterly and failed to ensure safety equipment was in use during a transfer for one of one residents (R5) reviewed for falls on the sample list of 12. This failure resulted in R5 falling and sustaining a four centimeter laceration requiring seven sutures to the forehead and a fractured humerus. Findings Include: R5's Fall Risk Assessments dated 8/16/23 and 1/29/24 document R5 is a high risk for falls. On 3/12/24 at 10:40 AM, V3 MDS (Minimum Data Set)/CP (Care Plan) Coordinator stated fall risk assessments are to be completed upon admission, with significant changes and quarterly. V3 confirmed R5 only has an August and January assessment completed. V3 is unsure why one was not completed in November stating, that was before my time, but one should have been completed in November 2023. R5's MDS dated [DATE] documents R5 is alert and oriented, and requires substantial/maximal assistance when transferring from a sit to stand position and for chair/bed to chair transfers. On 3/11/24 at 9:41 AM, R5 was sitting up in a recliner with R5's right arm in sling. R5 stated R5 fell when transferring from the chair and sustained a fractured shoulder. R5's CP dated 1/29/24 documents R5 needs extensive assistance of one for transfers using a gait belt and walker and up to extensive assist of two using a gait belt (changed from assistance of 1 which was on the original care plan dated 8/17/23) and walker to ambulate and transfer. R5 is to be encouraged to walk during the day, and staff are to bring a wheelchair behind R5 for long distances so that R5 can take a break if needed. R5 has a history of knees buckling so please be cautious of this during ambulation and transfers. R5's Progress Notes dated 2/16/24 by V9 LPN (Licensed Practical Nurse) documents at 1750 on 2/16/24, the CNA (Certified Nursing Assistant) notified the nurse that R5 had fallen in R5's room. The CNA stated she was assisting R5 and turned to unlocked R5's wheel chair to move it out of R5's way when resident fell forward. Upon entering room, R5 was noted to be lying with the right side with R5's face down on the floor with blood coming from a laceration to the right side of the head and R5's right arm was tucked up under R5's body. 911 called and transferred to the ER (Emergency Room). R5 returned to the facility with a diagnosis of a Fractured right humerus and has an immobilizer in place. Per the ER nurse, R5 has 7 sutures to the right forehead. R5 has a pressure dressing to the forehead. Bruising is noted to the right forehead under the dressing pooling down to R5's right eye and back behind the right ear. R5 also has a skin tear with bruising to the right wrist. R5 is alert and able to answer questions appropriately. An undated and untitled summary into R5's fall by V2 DON (Director of Nursing) documents on 2/15/24 R5 was ambulating with the walker in R5's room and experienced a fall. R5 had painful ROM (Range of Motion) to the right upper extremity as well as a laceration to the right forehead. An x-ray of the right arm revealed a fracture of the proximal right humerus and the laceration was repaired with sutures. This summary also contained a witness statement from V10 CNA that documents V10 went into R5's room to let R5 know that the facility needed to collect a urine sample. V10 then set up the 145979 Page 3 of 11 145979 03/13/2024 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0689 Level of Harm - Actual harm Residents Affected - Few equipment in the bathroom. R5 had stood up out of the wheelchair and was beginning to ambulate to the bathroom. V10 unlocked the wheelchair to move it out of the way and as V10 turned back from moving the wheelchair, R5 was falling. The Hospital ED (Emergency Department) Summary Report dated 2/15/24 documents R5 had a fall at the nursing home due to R5's legs giving out and sustained a 4 cm (centimeter) jagged laceration above the right eyebrow and pain to the right upper extremity. R5's X-ray report dated 2/15/24 documents an impacted fracture of the proximal right humerus extending through the humeral neck and greater tuberosity. On 3/12/24 at 10:35 AM, V7 CNA stated prior to R5's fall, R5 was a one or two assist with gait belt, depending on the day, for transfers and a one assist with walker and gait belt for ambulation. V7 explained R5 would hold onto the walker and staff were to hold onto the gait belt. On 3/12/24 at 10:45 AM, V2 DON stated V10 did not have a gait belt on R5 at the time of the fall. V2 confirmed R5 has a history of falls but wants to be independent. On 3/13/24 at 1:45 pm R5 stated, staff normally use a gait belt with R5 during transfers but at the time of R5's fall, R5 did not have a gait belt in place. R5 stated at the time of the fall, R5 didn't realize staff had not placed a gait belt onto R5 and also did not realize that staff was not next to and holding onto R5 when R5 began to walk to the bathroom. The facility's Gait Belt Use Policy dated March 2023 documents gait belts are provided to secure a grasping surface to aid with resident transfer and ambulation and to prevent injury during transfer and ambulation and to prevent injury during transfer and ambulation of the resident. A gait belt must be used, if there are no contraindications, every time a resident is transferred or ambulated with assistance. When a gait belt is used, staff must have at least one hand on the gait belt supporting the resident at all times. 145979 Page 4 of 11 145979 03/13/2024 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to complete psychotropic medication assessments prior to starting a psychotropic medication and failed to ensure as needed psychotropic medications were limited to 14 days or less for residents. This failure affects three of four residents (R7, R11 and R65) reviewed for unnecessary medications on the sample list of 12. Findings Include: The facility's Psychotropic Medication Policy dated 11/28/17 documents psychotropic medication is any drug that affects brain activity associated with mental processes and behavior. These medications include but are not limited to: antianxiety, antidepressant, antipsychotic and hypnotic. These medications are to be given to treat a specific condition/medical symptom that is diagnoses and documented in the clinical record. Specific condition/medical symptoms alone are not enough to justify pharmacological use. An evaluation must be done to determine other possible physical, mental, behavioral, psychosocial needs. Residents that are admitted with a psychotropic medication need an evaluation by the physician and consultant pharmacist for the use of the medication and whether a reduction or discontinuation can occur. Quarterly evaluation or more frequent if needed to determine if a reduction is warranted. Initial PRN (as needed) psychotropic medications should not exceed 14 days, unless the attending physician or prescribing practitioner believes that to extend beyond 14 days and has documented the rational and indicated the duration. 1. R11's Physician Order List dated 3/11/24 documents the following orders: Duloxetine {Antidepressant} 60 mg (milligrams) - one tablet daily ordered on 12/27/23 Hydroxyzine {Antihistamine} 50 mg - one tablet every 6 hours as needed for anxiety or itching ordered on 12/27/23 and discontinued on 1/30/24 (34 days later). R11's Psychotropic Medication Assessments for the above listed medications were completed on 1/9/24 (13 days after initiated). On 3/11/24 at 3:28 PM, V3 MDS (Minimum Data Set)/CP (Care Plan) Coordinator stated V3 is the one that completes psych med assessments and completes them quarterly when all of the assessments and MDS's are completed. V3 also stated V3 does not do assessments between times, even if a new medication is started. On 3/11/24 at 3:38 PM, V2 DON (Director of Nursing) confirmed R11 did not have any other psychotropic medication assessments completed other than the one in R11's medical record. On 3/12/24 at 9:21 AM, V2 DON stated typically PRN (as needed) psychotropic medications are ordered for 14 days however since R11's Hydroxyzine isn't your typical psychotropic medicine, that is why it did not have a 14 day time frame. It went unnoticed until pharmacy told us that because it was being used to treat R11's anxiety, that we needed to limit it to 14 days. That is why it was discontinued. 2. R65's ongoing diagnoses listing documents diagnoses of Anxiety and Major Depressive Disorder. 145979 Page 5 of 11 145979 03/13/2024 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0758 R65's March 2024 Physician Order Sheet dated 3/7/24 documents the following orders: Level of Harm - Minimal harm or potential for actual harm Clonazepam {Benzodiazepine} 0.5 mg (milligrams) - 1 tablet BID (twice a day) for anxiety Escitalopram {Antidepressant} 20 mg - one tablet daily for depression Residents Affected - Few Trazodone {Antidepressant} 100 mg - one tablet at night for insomnia R65's medical record does not contain any psychotropic medication assessment. On 3/12/24 at 9:15 AM, V2 DON (Director of Nursing) confirmed R65 has not had a psychotropic medication assessment completed and stated R65 is a new admission. V2 explained, the facility typically does not do medication assessments when residents are admitted on psychotropic medications, only when they are started on them after admission to the facility. 3.) R7's New Prescription Request dated 2/12/24 documents R7's order for Lorazepam (antianxiety) 2 milligrams/milliliter (mg/ml) give 0.25 ml by mouth/sublingual every four hours as needed (PRN) for agitation/anxiety/restlessness and includes a stop date of 5/10/24. This stop date is not transcribed to R7's Lorazepam order in R7's electronic medical record prior to 3/12/24. R7's February and March 2024 Medication Administration Records document R7 received Lorazepam as needed 16 times between 2/10/24 and 3/8/24. On 3/12/24 at 9:16 AM V2 Director of Nursing stated antianxiety PRN orders are ordered for 14 days and then re-evaluated for continued use with a new stop date, unless otherwise ordered. V2 stated V2 has hospice provide documentation to extend the order past the 14 days, and has been struggling with hospice to provide this documentation for R7's PRN Lorazepam. V2 stated R7's PRN Lorazepam order is good through R7's next hospice certification date. V2 reviewed R7's PRN Lorazepam order and confirmed the order does not document a stop date. V2 stated V2 puts the stop date on V2's calendar when the order is due to be re-evaluated. At 9:29 AM V2 provided pharmacy documentation that R7's PRN Lorazepam order stop date is 5/10/24. V2 stated hospice has been faxing the prescription with the stop dates to the pharmacy and not to the facility. At 9:40 AM V2 stated V2 will add the May stop date to R7's PRN Lorazepam order. 145979 Page 6 of 11 145979 03/13/2024 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to maintain complete and current resident and staff infection control logs, analyze infection data to identify trends, restrict staff from working while ill, and test symptomatic staff for COVID-19 (Human Coronavirus Infection). These failures affect eight (R1, R2, R4, R5, R6, R7, R11, R65) of eight residents reviewed for infection control and has the potential to affect all 12 residents in the facility Residents Affected - Many Findings include: 1.) The Employee Illness Reports document the following: On 1/14/24 V20 Certified Nursing Assistant (CNA) called in sick due to sore throat, cough, and muscle aches. On 1/29/24 V12 CNA called in sick due to headache, runny/stuffy nose, body aches, and vomiting. On 2/5/24 and 2/7/24 V18 CNA called in due to headache and vomiting. On 2/6/24 V7 CNA called in sick due to diarrhea and vomiting. On 2/9/24 V9 Licensed Practical Nurse was sent home due to diarrhea and nausea. On 2/16/24 and 2/17/24 V9 called in due to asthma and V9 is taking an antibiotic and steroid. On 2/20/24 V17 CNA called in sick due to vomiting. On 2/21/24 V18 CNA called in sick due to vomiting. On 2/22/24 V10 CNA called in sick due to vomiting. On 3/1/24 V12 CNA called in sick due to vomiting. On 3/7/24 V17 CNA called in sick due to fever of 100.1 degrees Fahrenheit (F), headache, and muscle aches. The employee infection logs with a date range of 6/13/23-1/23/24 do not document illnesses after 1/23/24. V20's call in on 1/14/24 is not listed on this log. 03/12/24 at 12:06 PM V15 Infection Preventionist stated V15 relies on a collaborative process with V2 Director of Nursing (DON) for infection control. V15 stated V15 receives reports on employee illnesses which are tracked/logged by the human resources department and V2. On 3/12/24 at 3:15 PM V2 DON confirmed the employee illness log is not up to date. V2 stated V2 reviews the employee illness reports daily when they come in, and then V2 tries to keep an eye out for other similar illnesses in residents and staff. V2 stated residents with GI (gastrointestinal) symptoms (nausea/vomiting) are not logged on the resident infection logs, we just keep an eye out as it happens. On 3/13/24 at 10:32 AM V2 confirmed the CNAs work on both halls of the facility. 2.) The January 2024-March 2024 Monthly Infection Logs document resident infections, and there is 145979 Page 7 of 11 145979 03/13/2024 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many no documentation that these infections were tracked to identify any trends or patterns. These infection logs do not document organisms identified from cultures for resident infections. R1, R2, and R6 had Urinary Tract Infections (UTIs) in January. In February R4, R5, R6, and R7 had UTIs; and R4 had a lower respiratory tract infection. R65 had a UTI in March. On 3/12/24 at 11:35 AM V3 Minimum Data Set/Care Plan Coordinator was completing the March infection control log which was incomplete and not up to date. V3 stated V3 has notes of infections, but has not yet transcribed them onto the log. V3 confirmed V3 is responsible for logging the resident infections on the monthly logs. V3 stated V3 took over for logging infections as of January 2024, and both V2 DON and V15 Infection Preventionist are notified verbally of infections as they occur. V3 stated V3 has not provided the infection logs to V15. V3 confirmed the infection logs do not identify patterns/trends of infections or organisms. V3 stated V3 does not do that and was unsure if V15 is documenting infection trends. On 3/12/24 at 12:06 PM V15 stated infections are reported to V15 by V3 and V15 is also informed of infections verbally and through a daily written report. V15 stated the infection trends/patterns are identified and documented on the quarterly infection reports, and this is not done on a monthly basis. 3.) The facility's undated COVID-19 outbreak log documents the outbreak began on 1/14/24 when V12 CNA tested positive. This log documents R5 and R11 tested positive on 1/15/24, and R6 tested positive on 1/16/24. The employee illness logs with date range 6/12/23-1/23/24 document V13 CNA URI (Upper Respiratory Infection) on 1/12/24 and 1/15/24; and V12 CNA URI on 1/13/24 and returned to work on 1/14/24. There is no documentation that these CNAs were tested for COVID-19 after symptoms began and prior to returning to work. V12's Rapid COVID-19 test dated as collected on 1/14/24 at 4:06 PM and resulted at 4:30 PM documents V12 tested positive. V12's Time Card dated 1/7/24-1/20/24 documents V12 worked on 1/14/24 from 6:09 AM until 4:30 PM. V13's Time Card dated 1/7/24-1/20/24 documents V13 worked on 1/10/24 from 6:08 AM until 6:09 PM. On 3/12/24 at 12:00 PM V12 CNA stated V12 had symptoms of headache, cough, and runny nose that began on 1/13/24. V12 stated V12 reported V12's symptoms to the nurse that day when V12 called off. V12 stated V12 did not test for COVID-19 on 1/13/24, but tested the following day while V12 was at work. V12 stated V12 waited for V12's test results and then was sent home once V12 test resulted positive. V12 stated V12 thought V12 was ok to work on 1/14/24 since V12 was feeling better, but V12 decided to test later that day when V12 had symptoms while at work. On 3/12/24 at 2:45 PM V13 CNA stated V13 recalled calling off from work in January 2024 with URI symptoms of green mucus, fever of 101.8 F., headache, coughing, and sneezing. V13 stated V13 had symptoms of body aches, shortness of breath, and feeling tired when V13 was working on 1/10/24, but V13 thought it was just a cold. V13 stated V13 took cold medication that day, worked from 6:00 AM until 6:00 PM, and did not report V13's symptoms. On 3/12/24 at 3:15 PM V1 Administrator stated we were not requiring surgical masks to be worn in the facility prior to the COVID-19 outbreak that began on 1/14/24. V2 DON stated V2 can't prove that V13 was not COVID-19 positive since V13 was not tested. V2 confirmed there is no documentation that V13 was tested in January 2024 prior to 1/17/24. V2 stated the staff should tell V2 or the nurses 145979 Page 8 of 11 145979 03/13/2024 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many when they are having symptoms so that they can be tested. V2 confirmed V12 should have tested for COVID-19 prior to working on 1/14/24. V2 stated V12 was sent home from work on 1/14/24 after testing positive and that was when the facility identified the outbreak. V2 stated staff who are COVID-19 positive are restricted from work for five days, and if they are negative and symptomatic they can return to work once fever free without medication use for 24 hours. On 3/13/24 at 10:32 AM V2 confirmed the CNAs work on both halls of the facility. The facility's Long-Term Care Facility Application For Medicare and Medicaid dated 3/11/24 documents 12 residents reside in the facility. The Centers for Disease Control and Prevention Symptoms of COVID-19 dated October 26, 2022 documents COVID-19 symptoms include fever/chills, cough, shortness of breath, difficulty breathing, fatigue, body/muscle aches, headache, new loss of taste/smell, sore throat, congestion, runny nose, nausea, vomiting and diarrhea; and recommends testing if you are symptomatic. The facility's Infection Prevention policy revised June 2021 documents the infection prevention program incorporates surveillance and prevention of infections, which includes monitoring and investigating exposures and infectious disease outbreaks. This policy documents that actions taken and recommendations to address opportunities for improvement will be documented, and performance improvement and infection prevention activities is determined through information gathering and clinical analysis. This policy documents that positive cultures are investigated to identify clusters of pathogens, location, and staff involved. The facility's COVID-19 Testing Policy and Response Strategy revised September 2023 documents healthcare workers are educated on reporting positive COVID-19 tests, symptoms of COVID-19, and/or exposure to COVID-19 to their direct supervisor. This policy documents testing is required for symptomatic healthcare workers. 145979 Page 9 of 11 145979 03/13/2024 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow their antimicrobial stewardship policy by failing to accurately document the status of obtaining residents urine cultures and identify/document organisms results. This failure affects five (R1, R2, R4, R5, R6) of eight residents reviewed for infection control in the sample list of 12. Residents Affected - Some Findings include: The facility's Antimicrobial Stewardship policy with reviewed date May 2023 documents the purpose of this program is to ensure appropriate use of antimicrobials which includes selecting the appropriate antibiotic, dose, duration and route to decrease toxicity and antimicrobial resistance. This policy documents to collect, track, and analyze antibiotic use and resistance patterns. This policy documents laboratory personnel will guide the proper use of tests/results and assist in ensuring that laboratory reports will be used to support optimal antibiotic use; and infection control personnel will develop/implement and document facility wide infection surveillance, prevention, and control activities. The January 2024-March 2024 Monthly Infection Logs do not document organisms from culture results as instructed on the form. R1, R2, and R6 had Urinary Tract Infections (UTIs) in January, and no cultures were obtained for R2 and R6. These logs do not document if R1 had urine cultures or the organism identified for UTIs on 1/10/24 and 12/31/23. R4, R5, and R6 had UTIs in February. These logs do not document cultures were obtained for R4 and does not document the organism from R5's urine culture. R1's urine Culture resulted on 1/10/24 documents Escherichia coli greater than 100,000 colony forming units (CFU), indicating an infection. R1's Urine Culture resulted on 12/30/23 documents Klebsiella pneumoniae greater than 100,000 CFU, indicating an infection. On 3/12/24 at 11:35 AM V3 Minimum Data Set/Care Plan Coordinator was completing the March infection control log, which was incomplete and not up to date. V3 stated V3 has notes of infections, but has not yet transcribed them onto the log. V3 confirmed V3 is responsible for logging the resident infections on the monthly logs. V3 stated V3 has not provided infection logs to V15 since V3 started in January. V3 confirmed the infection logs do not identify organisms from culture results. On 3/12/24 at 12:06 PM V15 confirmed the infection logs are incomplete and do not document if cultures were completed or the organisms from completed cultures. V15 stated culture results are reviewed and followed up on with the physician as part of the antibiotic stewardship. 145979 Page 10 of 11 145979 03/13/2024 Gibson Community Hsp Annex 430 East 19th Gibson City, IL 60936

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 administer a COVID-19 (Human Coronavirus) booster vaccine for one (R2) of five residents reviewed for immunizations in the sample list of 12. Findings include: The facility's COVID-19 Immunization Policy & Procedure - Residents with reviewed date June 2023 documents residents will be offered the vaccine unless it is medically contraindicated or the resident has already been vaccinated. The Centers for Disease Control and Prevention Updated (2023–2024 Formula) COVID-19 Vaccine Interim 2023-2024 COVID-19 Immunization Schedule for Persons 6 Months of Age and Older dated 9/22/23 documents for persons age [AGE] and older administer one does of the 2023-2024 vaccine at least eight weeks after the prior COVID-19 vaccine. R2's undated profile documents R2 is over the age of 65. R2's COVID-19 2023 Vaccine Consent Form dated 1/29/24 documents R2's last COVID-19 booster vaccine was given on 10/20/21, R2 has not had COVID-19 in the last 90 days, and R2 consented to receive the 2023 booster vaccine. There is no documentation in R2's medical record that R2 was given this booster vaccine. On 3/12/24 at 4:05 PM V2 Director of Nursing confirmed R2 consented to receive the 2023 COVID-19 booster and it was not administered. On 3/12/24 at 4:40 PM V2 stated the facility didn't order the vaccine since the pharmacy required a minimum purchase of three vials, which is 30 doses. V2 stated they didn't have enough residents to support purchasing that amount since the facility had been in COVID-19 outbreak status in November and January, and the pharmacy recommended waiting 90 days after being COVID-19 positive before administering the booster vaccine. 145979 Page 11 of 11