Health inspection·August 2, 2023

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to administer Pneumococcal Conjugate Vaccine (PCV) 13, PCV 15, PCV 20 and/or Pneumococcal Polysaccharide Vaccine (PPSV) 23 to four (R1, R3, R4, R8) residents out of five residents reviewed for vaccinations in a sample list of 16 residents. Residents Affected - Some Findings include: 1.) R1's undated Face Sheet documents R1's admission date of 6/25/2020. R1's Electronic Medical Record (EMR) documents R1's medical diagnoses of Vascular Dementia, Diabetes Mellitus, Severe Protein-Calorie Malnutrition and Peripheral Vascular Disease (PVD). This same EMR does not document R1's refusal nor administration of Pneumococcal Conjugate Vaccine (PCV) 13, PCV 15, PCV 20 and/or Pneumococcal Polysaccharide Vaccine (PPSV) 23. 2.) R3's undated Face Sheet documents R3's admission date of 11/25/17. R3's Electronic Medical Record (EMR) documents medical diagnoses of Alzheimer's Disease, Stage 3 Chronic Kidney Disease, Protein Calorie Malnutrition and Asthma. This same EMR documents R1 had received PPSV 23 on 7/8/2014. This same EMR does not document any further administrations nor refusals of PCV 13, PCV 15, PCV 20 and/or PPSV 23. 3.) R4's undated Face Sheet documents R4's admission date of 9/1/2017. R4's Electronic Medical Record (EMR) documents R4's medical diagnoses of Alzheimer's Disease, Allergic Rhinitis, Protein Calorie Malnutrition and Atrial Fibrillation. This same EMR documents R1 had received PPSV 23 on 9/1/2017. This same EMR does not document any further administrations nor refusals of PCV 13, PCV 15, PCV 20 and/or PPSV 23. 4.) R8's undated Face Sheet documents R8's admission date of 7/28/21. R8's Electronic Medical Record (EMR) documents R8's medical diagnoses. This same EMR documents R8 had received PPSV 23 on 10/4/2014 and PCV 13 on 11/3/2015. This same EMR does not document any further administrations nor refusals of PCV 13, PCV 15, PCV 20 and/or PPSV 23. On 8/2/23 at 12:30 PM V2 Director of Nurses stated the facility is not able to provide any further documentation on resident Pneumococcal Vaccinations. V2 stated the program was monitored by another employee who has since left. V2 stated, We (facility) are working on getting this all together for the future. I have already spoken with pharmacy to get doses on hand. I have already begun to get this program organized. It is too bad it wasn't already but I am working on it. Page 1 of 2 146184 146184 08/02/2023 Luther Oaks 601 Lutz Road Bloomington, IL 61704

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The undated facility policy titled 'Pneumococcal Vaccine Program Policy and Procedure' documents it is the policy of this facility that each resident will be offered immunization(s) against Pneumococcal disease in accordance with current standards of practice and the Advisory Committee on Immunization Practices (ACIP) recommendations, unless contraindicated or already immunized. For residents 65 years or older: 1 dose of PCV 20 or 1 dose of PCV 15 followed by a dose of PPSV 23 greater than or equal to one year later. A physician's order for the Pneumococcal vaccination must be obtained for PCV 20, PCV 15 and/or PPSV 23. Residents and/or representatives will be provided with education on the benefits and potential risks of receiving the Pneumococcal vaccine. Documentation will include education provided and resident/resident representative decision to accept or refuse vaccination. If the resident did not receive the influenza vaccine and the reason of medical contraindication and /or refusal after education provided. 146184 Page 2 of 2