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. (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 2 Event ID: 146184 Printed: 05/15/2026 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 146184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luther Oaks 601 Lutz Road Bloomington, IL 61704 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)