Health inspection·May 23, 2023

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of facility policy, and review of the Centers for Disease Control (CDC) recommendations, the facility failed to ensure residents were offered all recommended doses of the pneumococcal vaccine and failed to ensure the medical record indicated education was provided on the benefits, potential side effects, and the resident's or representative's acceptance or refusal of the vaccination. This affected four (#3, #8, #32, and #45) of five residents reviewed for vaccination status. The facility census was 54. Residents Affected - Some Findings include: 1. Review of Resident #3's medical record revealed an admission date of 12/23/22. Diagnoses included diabetes mellitus type II, repeated falls, arthritis, bipolar disorder, schizoaffective disorder, cerebral infarction, chronic obstructive pulmonary disease (COPD), and chronic hepatitis Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact and the pneumococcal vaccine was not offered. Further review of Resident #3's medical record revealed no information related to Resident #3 being offered or receiving a pneumococcal vaccine, and no documentation the facility provided education on the benefits and potential side effects, or refusal of the pneumococcal vaccine. 2. Review of Resident #8's medical record revealed an admission date of 07/21/21. Diagnoses included schizophrenia, diabetes mellitus type II, epilepsy, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #8 was moderately cognitively impaired and the pneumococcal vaccine was not offered. Further review of Resident #8's medical record revealed the resident received a pneumococcal polysaccharide vaccine (PPSV23) on 10/07/19. The medical record contained no evidence Resident #8 was offered, received, provided education on the benefits and potential side effects, or refusal of a 15-valent pneumococcal conjugate vaccine (PCV15) or 20-valent pneumococcal conjugate vaccine (PCV20) pneumococcal vaccine. 3. Review of Resident #32's medical record revealed an admission date of 08/07/19. Diagnoses included Wernicke's encephalopathy, bipolar disorder, hypertension, nicotine dependence, COPD, and vascular dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #32 was severely cognitively Page 1 of 3 365488 365488 05/23/2023 Continuing Healthcare of Toledo 4420 South Avenue Toledo, OH 43615

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 365488 Page 2 of 3 365488 05/23/2023 Continuing Healthcare of Toledo 4420 South Avenue Toledo, OH 43615

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 365488 Page 3 of 3