Inspection·May 23, 2023

F 0883 impaired and was up to date on pneumococcal vaccination. Level of Harm - Minimal harm or potential for actual harm Further review of Resident #32's medical record revealed the resident received Pneumovac 23 pneumococcal vaccine on 10/29/20. The medical record contained no evidence Resident #32 was offered, received, was provided education on the benefits and potential side effects, or refusal of a PCV15 or PCV20 pneumococcal vaccine. Residents Affected - Some 4. Review of Resident #45's medical record revealed an admission date of 12/12/19. Diagnoses included diabetes mellitus type II, personal history of traumatic brain injury, hypertension, vascular dementia, and schizoaffective disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #45 was moderately cognitively impaired and was up to date on pneumococcal vaccination. Further review of Resident #45's medical record revealed the resident received a Pneumovac 23 pneumococcal vaccine on 10/27/20. The medical record contained no evidence Resident #45 was offered, received, was provided education on the benefits and potential side effects, or refusal of a PCV15 or PCV20 pneumococcal vaccine. Interview on 05/23/23 at 2:40 P.M. with the Administrator stated she received education today from the corporate office related to recommended pneumococcal vaccination doses and was unaware there were four different pneumococcal vaccines. The Administrator verified the medical records for Resident #3, Resident #8, Resident #32, and Resident #45 contained no information that the residents or their representatives were offered and educated on the benefits and potential side effects of immunization, or documentation the residents received or refused immunization. Additionally, the Administrator verified each of the residents were under [AGE] years of age and had chronic medical conditions. The Administrator was unaware if nursing staff reviewed the resident's pneumococcal vaccination status following admission to determine if additional doses were needed. Review of CDC guidance titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, reviewed 02/13/23 and located at, https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html#adults-19-64, revealed the CDC recommended pneumococcal vaccination for adults 19 to [AGE] years old who have certain chronic medical conditions, including, but not limited to, COPD, cigarette smoking, and diabetes mellitus. Further review revealed those adults who had never received a vaccination should receive one dose of PCV15 or PCV20 and, if PCV15 is given, an additional dose of PPSV23 administered at least one year later. For those adults who received a dose of PPSV23 only, the CDC recommended a dose of PCV15 or PCV20 at least one year after receiving the dose of PPSV23. Review of facility policy titled, Pneumococcal Vaccine (Series), dated August 2022, revealed each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization. In addition, for adults 19 to [AGE] years old who have certain chronic medical conditions including, but not limited to, chronic lung disease (COPD, emphysema and asthma), cigarette smoking, and diabetes mellitus, a pneumococcal vaccination was recommended. For those adults 19 to [AGE] years old who had not previously received any pneumococcal vaccine, give one dose of PCV15 or PCV20, followed by one dose of PPSV23 at least one year later if PCV15 is used. If an adult 19 to [AGE] years old only received a dose of PPSV23, give one dose of PCV15 or PCV20 at least one year after the most recent PPSV23 vaccination. Lastly, the resident's medical record shall include documentation that indicates, at a minimum, the following: the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365488 If continuation sheet Page 2 of 3 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 365488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Continuing Healthcare of Toledo 4420 South Avenue Toledo, OH 43615 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)

F 0883 immunization and the resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365488 If continuation sheet Page 3 of 3