Every finding on record at Mountain Ridge Hospice, LLC

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. This standard was not met as evidenced by document review and interview. A review of the Emergency Preparedness documentation revealed the hospice did not ensure to complete an annual all hazard vulnerability assessment. There was no documented evidence that a Hazard Vulnerability Risk assessment was completed in 2023, 2024, or 2025 year to date. DOCUMENT 1: The Emergency Preparedness Policy on Risk Assessment stated in part, "The Hospice does an annual all hazard vulnerability assessment, based on risk assessment." During a joint review of the Emergency Preparedness documentation and interview on 08/01/2025, the Administrator agreed there was no documented evidence that a Hazard Vulnerability Risk assessment was completed in 2023, 2024, or 2025 year to date. Additionally, the Administrator stated, "I have not been able to locate a hazard vulnerability risk assessment at all." A review of the Emergency Preparedness documentation revealed the hospice did not ensure to complete an annual all hazard vulnerability assessment. There was no documented evidence that a Hazard Vulnerability Risk assessment was completed in 2023, 2024, or 2025 year to date.

It is required that each patient’s individualized written plan of care reflects patient and family goals, includes all services necessary for the palliation and management of the terminal illness, including the following measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed the hospice did not ensure the plan of care included measurable outcomes for patient and family goals. CLINICAL RECORD 2: The patient elected the hospice benefit on 10/15/2024. The plan of care was reviewed for 10/15/2024-08/01/2025. Pain was identified as a problem on 12/23/2024 with the goal, "manageable pain." The patient's manageable level of pain was not identified. Edema was identified as a problem on 12/02/2024 with the goal, "lasix, compression stockings." A measurable goal for the patient and family was not identified. CLINICAL RECORD 4: The patient elected the hospice benefit on 04/05/2024. The plan of care was reviewed for 04/05/2024-08/01/2025. Chronic pain was identified as a problem on 04/05/2024 with the goal, "to keep the patient as comfortable as possible with proper pain medications." The Registered Nurse (RN) assessment on 04/04/2025 and 06/27/2025 documented 8/10 pain. The RN assessment on 06/06/2025 documented 9/10 pain, Fentanyl patch, Methadone, and Dilaudid for pain control. The patient's comfortable level of pain was not identified. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/22/2024. The plan of care was reviewed for 04/22/2024-08/01/2025. Poor appetite was identified as a problem on 04/22/2024 with the goal, "optimize nutrition." The patient's optimal nutrition level was not identified. During a joint review of the record and interview on 08/01/2025, the Director of Nursing agreed there was no documented evidence that the plans of care identified patient goals with measurable outcomes.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene; Use of gloves, mask, eye protection, or face shield depending on anticipated exposure; Safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; Safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations, the hospice did not ensure that the staff followed the hand hygiene policy. DOCUMENT 3: Agency policy, Hand Hygiene, stated in part, "Hand washing with liquid soap and a paper towel or freshly laundered cloth towel is required before and after all patient contact. It is required to perform hand hygiene before and after touching the patient's skin and items in the patient's vicinity." HOME VISIT 2: During the home visit with the Registered Nurse (RN) [Personnel Record 8] on 07/31/2025, The RN donned gloves, removed the dirty wound dressing from the left shin, cleaned with NS and gauze, applied moistened collagen, covered with a foam dressing, and compression stockings. Using the same gloves, the RN proceeded to the next wound and removed the dirty soiled dressing from the right shin, cleaned with NS and gauze, removed the phone from her pocket and took a picture of the wound, applied moistened collagen, covered with a foam dressing, and compression stockings. With the same gloves, the RN reached into the bag and removed bleach wipes and began to clean the vital sign equipment. The RN did not wash her hands or change gloves between dirty and clean wound care to two sites. The RN removed her gloves at the end of the visit, packed away the used wound supplies and placed the unused wound supplies on the patient's bathroom counter before exiting the patient's room at the facility. The RN did not wash her hands after removing her gloves or before exiting the patient's room in the Assisted Living Facility. During a review of the home visit findings with the Director of Nursing on 08/01/2025, the Director of Nursing agreed that the RN did not follow the Hand Hygiene policy.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed in which the patient revoked or was discharged for no longer being terminally ill revealed the hospice did not ensure the discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 11: The patient elected the hospice benefit on 08/26/2024. The patient was discharged, leaving service area-hospitalized, on 10/27/2024. There was no documented evidence the discharge summary was provided to the attending physician. CLINICAL RECORD 12: The patient elected the hospice benefit on 05/17/2025. The patient was discharged, revocation, on 05/19/2025. There was no documented evidence the discharge summary was provided to the attending physician. During a joint review of the record and interview on 08/01/2025, the Director of Nursing agreed there was no documented evidence the discharge summary was completed or sent to the attending physician. Additionally, the Director of Nursing stated, "We did not know where to document the discharge summary but now we do. We had been sending the records only if requested. We will be updating our process."

It is required that all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the hospice did not ensure that interdisciplinary team members provided care and services as ordered on the plan of care. Clinical Record 2: The patient was admitted to hospice on 3/13/2023 with a diagnosis of atherosclerotic heart disease. The Chaplain documented patient visits completed on 3/14/2023, 4/13/2023, and 4/20/2023. The plan of care dated 3/13/2023 did not include orders for Chaplain services. Additionally, the plan of care ordered Medical Social Worker (MSW) services two (2) times per month. The MSW documented patient visits completed on 3/17/2023, 3/30/2023, 4/25/2023, and 5/3/2023; the actual frequency was two (2) times a month for one month and one time a month for two months. There was no evidence of communication with the physician or physician's order changing the frequency of MSW visits. During an interview and a joint review of the clinical record, the Director of Nursing and the Administrator agreed that there were no orders for the Chaplain visits on the plan of care, and the MSW visits did not follow the plan of care.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes physician orders. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed, the hospice did not ensure that the patient's record included all physician orders. Clinical Record 2: The patient was admitted to hospice on 3/13/2023 with a diagnosis of atherosclerotic heart disease. The patient's daughter and the hospice Registered Nurse (RN) provided the patient with wound care. A joint review of clinical records and an interview with the Director of Nursing (DON) and Administrator revealed no documented evidence of a physician's order for wound care. Clinical Record 3: The patient was admitted to hospice services on 3/27/2023 with a diagnosis of Heart Failure. The RN documented the patient fell on 4/24/2023 and sustained a skin tear on the right shin. The RN visit notes dated 4/27/2023, 5/1/2023, 5/4/2023, and 5/8/2023 documented wound care provided, "cleansed with wound cleanser, applied TAO and covered with foam dressing." A joint clinical record review and an interview with the DON and the Administrator revealed no documented evidence of a physician's order for wound care. Clinical Record 5: The patient was admitted to hospice services on 4/18/2023 with a diagnosis of Alzheimer's disease. The plan of care ordered aide services two (2) times a week. The aide services were documented as discontinued on 5/18/2023. A joint clinical record review and an interview with the DON and the Administrator revealed no documented evidence of a physician's order to discontinue aide services.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 7 (14%) clinical records reviewed, the hospice did not ensure the social worker completed visits as ordered on the plan of care. Record 1: This patient was admitted to hospice on 4/23/2022. The plan of care on 5/23/2022 and 6/7/2022 included orders for a social work visit frequency of once weekly. During the weeks of 6/5/2022 - 6/11/2022 and 6/12/2022 - 6/18/2022 there was no documented evidence of a social work visit completed during those weeks or documentation that described the reasons the visits were missed. The Director of Nursing was interviewed on 8/24/2022 and agreed the social worker did not follow the plan of care for visits as ordered. Record 1: This patient was admitted to hospice on 4/23/2022. The plan of care on 5/23/2022 and 6/7/2022 assigned a social worker visit frequency once weekly. During the weeks 6/5/2022-6/11/2022 and 6/12/2022-6/18/2022 there were no documented evidence of a social worker visit or documented reasons for the missed visits. The Director of Nursing was interviewed on 8/24/2022 and agreed, the social worker did not follow the plan of care as ordered.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interviews. In 5 of 7 (71%) clinical records reviewed revealed the hospice did not ensure the plans of care included documentation of all the planned interventions for problems identified in the initial and updated comprehensive assessments completed by hospice clinicians. Record 1: This patient was admitted to hospice on 4/23/2022 with a diagnosis of Mantle Cell Lymphoma. The plan of care orders for the period dated 4/23/2022 - 8/1/2022 were reviewed. The chaplain assessment on 4/26/2022 revealed the patient needed assistance with getting the local priest from the parish to provide spiritual support and planned to provide assist to the family in making arrangements. Also, the medical social worker (MSW) completed an assessment on 4/25/2022. The plan of care dated 4/25/2022 included orders for MSW visits to be made "1xwk". There was no documented evidence on the plan of care of specific interventions or goals related to the services to be provided by the chaplain and MSW based on their completed assessments. Record 2: This patient was admitted to hospice on 7/20/2022 with a diagnosis of Emphysema. The plan of care dated 8/1/2022 was reviewed. The chaplain assessment on 7/22/22 stated the patient would like prayer as he is close to death once the time comes, and the patient's friend requested prayer towards the end of life but did not need weekly visits from chaplain. The plan of care dated 8/1/2022 ordered chaplain visits to be provided as "1x mo and 3 prn spiritual/emotional support". The social work assessment on 7/22/2022 revealed the patient acknowledged depression and was open to weekly visits with the MSW for support. There was no documented evidence on the plan of care of specific interventions or goals related to the services to be provided by the chaplain and MSW based on their completed assessments. Record 3: This patient was admitted to hospice on 6/20/2022 with a diagnosis of Parkinson’s disease. The plan of care dated for the period of 6/20/2022 - 8/1/2022 was reviewed. The chaplain's assessment on 6/24/2022 revealed the patient and son expressed the need for the chaplain to provide a continued ministry presence and asked for weekly visits from the chaplain. The plan of care dated 6/21/2022 ordered chaplain visits to be provided as "1x mo and 3 prn spiritual/emotional support". There was no documented evidence on the plan of care of specific interventions or goals related to the services to be provided by the chaplain based on their completed assessment. Record 4: This patient was admitted to hospice on 6/21/2022 with a diagnosis of Protein Calorie Malnutrition. The plan of care dated 6/22/2022 was reviewed. The Registered Nurse assessment on 6/21/2022 revealed the patient had an oxygen saturation level of 88% and the patient stated that he felt short of breath (SOB). Documentation stated the patient did stand up and walked approximately 10 feet and he appeared fatigued and SOB after that distance. The plan of care did not include documented evidence of interventions and goals to manage the patient's dyspnea. Record 7: This patient was admitted to hospice on 5/26/2022 with a diagnosis of Heart Disease. The plan of care dated for the period of 5/26/2022 - 7/7/2022 were reviewed. The Registered Nurse assessment on 5/26/2022 revealed patient had a 16Fr, 10CC Foley catheter in place. The Registered Nurse assessment on 6/29/2022 revealed the Foley catheter was changed and flushed with 60 ml normal saline. The plan of care did not include interventions and goals to address the care to be provided related to the Foley catheter. The owner was interviewed on 8/23/2022 and stated they did not understand this was required for the disciplines of social work and chaplain.” The Director of Nursing was interviewed on 8/25/2022 and agreed that the plans of care did not include documented evidence of planned interventions for all problems identified in the comprehensive assessments for the records identified. Record 1: This patient was admitted to hospice on 4/23/2022. Mantle cell lymphoma. The plans of care dated 4/23/2022-8/1/2022 were reviewed. The chaplain assessment on 4/26/2022 revealed patient will need assistance with getting local priest from parish to provide spiritual practices. Will help provide this for the family. The social worker completed an assessment on 4/25/2022. The plan of care dated 4/25/2022 ordered MSW (medical social worker) visits 1xwk. There was no documented evidence of any problems, interventions or goals based on the completed assessments by the chaplain and medical social worker. Record 2: This patient was admitted to hospice on 7/20/2022. Diagnosis Emphysema. The plan of care dated 8/1/2022 was reviewed. The chaplain assessment on 7/22 revealed patient would like prayer as he is close to death once the time comes; patients friend requests prayer towards the end of life but doesn’t need weekly visits from chaplain. The plan of care dated 8/1/2022 ordered chaplain 1x mo and 3 prn spiritual/emotional support. The social worker assessment on 7/22/2022 revealed patient acknowledged depression. Patient is open to weekly visits with MSW for support. There was no documented evidence of any problems, interventions or goals based on the completed assessments by the chaplain and medical social worker. Record 3: This patient was admitted to hospice on 6/20/2022. Diagnosis Parkinson’s disease. The plans of care dated 6/20/2022-8/1/2022 were reviewed. The chaplain assessment on 6/24/2022 revealed patient and son expressed the need for chaplain to provide continue ministry of presence. Son and patient asked for weekly visits from chaplain for a spirit of presence. The plan of care dated 6/21/2022 ordered chaplain 1x mo and 3 prn spiritual/emotional support. There was no documented evidence of any problems, interventions or goals based on the completed assessments by the chaplain. Record 4: This patient was admitted to hospice on 6/21/2022. Diagnosis Protein calorie malnutrition. The plan of care dated 6/22/2022 was reviewed. The Registered Nurse assessment on 6/21/2022 revealed O2 sat 88%, patient stated he felt SOB (short of breath), pt did stand up and walk approximately 10 feet and he did appear fatigued and SOB after that distance. The plan of care did not include interventions and goals to manage the dyspnea. Record 7: This patient was admitted to hospice on 5/26/2022. Diagnosis Heart disease. Plan of cares dated 5/26/2022-7/7/2022 were reviewed. The Registered Nurse assessment on 5/26/2022 revealed patient had a 16Fr 10CC foley catheter in place. The Registered Nurse assessment on 6/29/2022 revealed the foley catheter was changed and flushed with 60ml normal saline. The plan of care did not include interventions and goals for the foley catheter. The owner was interviewed on 8/23/2022 and stated, “I was under the impression this isn’t required for the social worker or chaplain.” The Director of Nursing was interviewed on 8/25/2022 and agreed, the plans of care did not include documented evidence of planned interventions based on problems identified in the comprehensive assessments for the records identified.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: Measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 7 (14%) clinical records reviewed the plan of care was missing documentation of patient and family goals with outcomes that were defined and measurable. Record 1: This patient was admitted to hospice on 4/23/2022 with a diagnosis of Mantle Cell Lymphoma. The plan of care dated 8/1/2022 was reviewed and included a problem statement of "Urinary spasms" with a goal to "decrease spasms". The goal statement did not define how the desired outcome of decreased spasms would be specifically measured. The Director of Nursing was interviewed on 8/25/2022 and agreed the goal did not include an outcome that was defined and measurable. Record 1: This patient was admitted to hospice on 4/23/2022. Diagnosis Mantle cell lymphoma. The plan of care dated 8/1/2022 was reviewed. Problem: Urinary spasms. Goal: decrease spasms. The Director of Nursing was interviewed on 8/25/2022 and agreed, the goal did not include an outcome that was defined and measurable.

It is required that a hospice aide provides services are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 4 (25%) records reviewed with a hospice aide ordered, the hospice did not ensure the hospice aide followed the plan of care as ordered. Record 3: This patient was admitted to hospice on 6/20/2022. The hospice aide plan of care dated 6/20/2022 assigned the aide to complete the following duties: Assist to dress; comb hair; foot care; skin care; back rub/massage; oral hygiene denture care; check pressure areas; nail care; change linen; light housekeeping; make bed; and, incontinence care. The hospice aide documentation on the visit note dated 6/27/2022 stated: “Today the patient only needed shaving so I assisted him with that helped him out.” There was no documented evidence that the hospice aide notified the registered nurse that the other assigned duties were not completed or received direction to amend the assigned duties during the visit. The Director of Nursing was interviewed on 8/24/2022 and agreed, stating the hospice aide did not follow the plan of care as assigned. Record 3: This patient was admitted to hospice on 6/20/2022. The hospice aide plan of care dated 6/20/2022 ordered assist to dress, comb hair, foot care, skin care, back rub/massage, oral hygiene denture care, check pressure areas, nail care, change linen, light housekeeping, make bed, incontinence care. The hospice aide documentation on 6/27/2022 stated, “today the patient only needed shaving so I assisted him with that helped him out.” There was no documented evidence that the hospice aide notified the registered nurse. The Director of Nursing was interviewed on 8/24/2022 and agreed, the hospice aide did not follow the plan of care as ordered.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 4 (50%) records reviewed with a hospice aide ordered, the hospice did not ensure the hospice aide reported and documented changes noted in the patients' condition to the registered nurse. Record 1: This patient was admitted to hospice on 4/23/2022. The hospice aide documentation on the aide visit note dated 7/11/2022 stated: “Still complaining about the burning while she urinates.” There was no documented evidence that the hospice aide notified the registered nurse of the patient's complaint. Record 3: This patient was admitted to hospice on 6/20/2022. The hospice aide documentation on the aide visit note dated 8/18/2022 stated: “Does have pretty large red mark on his left forearm, he stated not sure how he got it.” There was no documented evidence that the hospice aide notified the registered nurse of the observation. The Director of Nursing was interviewed on 8/24/2022 and agreed that there was no documented evidence the hospice aide notified the registered nurse with the changes in the patients' condition. Record 1: This patient was admitted to hospice on 4/23/2022. The hospice aide documentation on 7/11/2022 stated, “still complaining about the burning while she urinates.” There was no documented evidence that the hospice aide notified the registered nurse. Record 3: This patient was admitted to hospice on 6/20/2022. The hospice aide documentation on 8/18/2022 stated, “does have pretty large red mark on his left forearm, he stated not sure how he got it.” There was no documented evidence that the hospice aide notified the registered nurse. The Director of Nursing was interviewed on 8/24/2022 and agreed, there was no documented evidence the hospice aide notified the registered nurse with the change in condition.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 2 (100%) clinical records reviewed of patients receiving treatment for a wound, the hospice did not ensure the clinical record included orders for the wound care provided. Record 5: This patient was admitted to hospice on 4/17/2022. The Registered Nurse assessment during visits on 6/28/2022 and 6/30/2022 described a skin tear to left wrist that was treated with the application of Bacitracin ointment and a wrapped dressing. There was no documented evidence of a physican's order obtained for the wound treatment. Record 7: This patient was admitted to hospice on 5/26/2022. The Registered Nurse assessment on 6/27/2022 revealed a left heel wound that was treated with the application of Bacitracin ointment, elevation and wrap. Documentation also stated, “Advised daughter to apply Bacitracin on wound and wrap". There was no documented evidence of a physican's order obtained for the wound treatment. The Director of Nursing was interviewed on 8/25/2022 and agreed with the finding that there were no physician orders present for the wound care. Record 5: This patient was admitted to hospice on 4/17/2022. The Registered Nurse assessment on 6/28/2022 revealed a skin tear to left wrist with treatment: bacitracin and wrapped in bandage. The Registered Nurse assessment on 6/30/2022 revealed a skin tear treated with bacitracin and wrapped. There was no documented evidence of a physican’s order for the wound. Record 7: This patient was admitted to hospice on 5/26/2022. The Registered Nurse assessment on 6/27/2022 revealed a left heel wound with treatment bacitracin, elevation and wrap, “advised daughter to apply bacitracin on wound and wrap. There was no documented evidence of a physican’s order for the wound. The Director of Nursing was interviewed on 8/25/2022 and agreed, there were no physician orders for the wound care.

It is required that for those individuals eligible to be fully vaccinated for COVID-19, Organization policy and procedure define: The process for tracking and documenting each individual’s receipt, at a minimum, of a single dose COVID-19 vaccine, or the first dose of a COVID-19 primary vaccination series of a multi-dose vaccine prior to providing any care, treatment or other services for the hospice and/or its patients; The process for tracking and documenting an individual’s completion of a COVID-19 primary vaccination series; The process for tracking and documenting an individual’s receipt of COVID-19 booster doses, per CDC guidelines; What vaccination documentation is accepted; Who receives the vaccination documentation, reviews it, and accepts or rejects it; and How each individual’s vaccination information is securely maintained. This standard was not met as evidenced by document reviews and interviews. Review of the agency's COVID-19 policies revealed the hospice did not ensure policies and procedures were developed that defined: What vaccination documentation would be accepted; Who receives the vaccination documentation, reviews it, and accepts or rejects it; and How each individual’s vaccination information is securely maintained. Review of agency policy, "COVID-19 Infection Control and Precautions Policy" stated, in part: "Staff members are required to notify the Director of Nursing or Administrator of their current COVID-19 vaccination status, including whether they have received or declined the vaccine and accompanying boosters, or are unable to receive the vaccine due to qualifying exemption. Staff members who have received the vaccine and/or booster vaccines should notify the Director of Nursing or the Administrator of the dates(s) they received their COVID-19 vaccines and boosters.” Review of the following additional agency policies revealed they also did not define a process for tracking and documenting COVID-19 vaccines and boosters: "Positive COVID-19 Testing Result Policy; Staff COVID-19 Testing Policy; Possible SARS-COV-2 Exposure Policy; COVID-19 Screening; and COVID-19 Control and Prevention and Reporting Requirements". During interview with the Owner and Administrator on 8/23/2022 they confirmed that agency policy did not include specific verbiage that described the tracking and documentation process for vaccines. Review of agency policy "COVID-19 Infection Control and Precautions Policy" stated, in part: "Staff members are required to notify the Director of Nursing or Administrator of their current COVID-19 vaccination status, including whether they have received or declined the vaccine and accompanying boosters, or are unable to receive the vaccine due to qualifying exemption. Staff members who have received the vaccine and/or booster vaccines should notify the Director of Nursing or the Administrator of the dates(s) they received their COVID-19 vaccines and boosters.” Review of agency policies: COVID-19 Infection Control and Precautions Policy, Positive COVID-19 Testing Result Policy, Staff COVID-19 Testing Policy, Possible SARS-COV-2 Exposure Policy, COVID-19 Screening, COVID-19 Control and Prevention and Reporting Requirements revealed there was no evidence that the policies included a process for tracking and documenting vaccination and booster doses, what vaccination documentation is accepted, who reviews it and accepts or rejects it and how each individual’s vaccination information is securely maintained. The owner was interviewed on 8/23/2022 and stated, “we don’t track or have a policy, we just put what they give us in the personnel file.” The administrator was interviewed on 8/23/2022 and stated, “we don’t have a separate vaccination policy” and “we thought the covid policies we already had in place would cover the vaccination mandate.” The administrator was interviewed on 8/23/2022 and agreed, the policies did not include a process for tracking and documenting all vaccination and booster doses, what vaccination documentation is accepted, who reviews it and accepts or rejects it and how each individual’s vaccination information is securely maintained.