Health inspection·February 8, 2024

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, review of immunization records, staff interview, review of policy, and review of the Centers of Disease Control and Prevention (CDC) guidance, the facility failed to ensure residents were offered influenza and pneumococcal vaccinations per CDC recommendations. This affected four (Residents #9, #17, #22, and #48) of five reviewed for influenza and pneumococcal vaccination. The facility census was 40. Residents Affected - Some Findings include: 1. Review of the closed medical record revealed Resident #9 was admitted on [DATE] and discharged on 11/27/23. Diagnoses included alcoholic cirrhosis of liver with ascites, COVID-19, thrombocytopenia, muscle weakness, alcohol induced acute pancreatitis without necrosis or infection. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the Patient Vaccination Informed Consent/Declination form signed 09/22/23 revealed Resident #9 consented to the influenza vaccine. Review of the vaccination record revealed Resident #9 did not receive the influenza vaccine. 2. Review of the medical record revealed Resident #17 was admitted on [DATE]. Diagnoses included rhabdomyolysis, type two diabetes mellitus without complications, dysphagia oropharyngeal, atherosclerotic heart disease of native coronary arterly without angina pectoris, hypothyroidism. Review of the MDS assessment 11/08/23 revealed the resident was cognitively intact. Review of the current immunization record located in the electronic medical record (EMR) revealed no documentation the resident had been offered or received the influenza or pneumococcal vaccines. 3. Review of the medical record revealed Resident #22 was initially admitted on [DATE] with re-entry on 4/30/22. Diagnoses included acute chronic diastolic (congestive) heart failure, type two diabetes mellitus with diabetic neuropathy, muscle weakness, lymphedema, and chronic kidney disease stage 3. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. In addition, Resident #22 was not up to date on the pneumococcal vaccine and it had not been offered. Page 1 of 4 365600 365600 02/08/2024 Lost Creek Rehabilitation and Nursing Center 804 South Mumaugh Road Lima, OH 45804

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Review of the medical record revealed Resident #48 was admitted on [DATE]. Diagnoses included primary generalized osteo(arthritis), unspecified dementia with agitation, atherosclerotic heart disease of native coronary artery. Review of the MDS assessment dated [DATE] revealed the resident was severely cognitively impaired. In addition, Resident #48 was not up to date on the Influenza vaccine. Interview on 02/08/24 at 2:45 P.M. with Director of Clinical Services #300 verified Resident #9 was offered the Influenza vaccine and did not receive the vaccine, Resident #48 was not offered the influenza vaccine, and Resident #17 and #22 were not offered the pneumococcal vaccine. Review of the policy, Influenza Vaccine, dated August 2016 verified all residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annual to encourage and promote the benefits associated with the vaccinations against influenza. Review of the policy, Pneumococcal Vaccine, dated August 2016, revealed all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated will be offered the vaccine series within 30 days of admission to the family unless medically contraindicated or the resident has already been vaccinated. Review of CDC guidance titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, reviewed 09/22/23 and located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html, revealed the CDC recommended pneumococcal vaccination for all adults over 65. For adults over 65 who had not previously received any pneumococcal vaccine, the CDC recommended one dose of PCV15 or PCV20. If PCV15 was used, follow up with one dose of PPSV23 at least one year later. For adults 65 or older who previously received a dose of PPSV23, the CDC recommended a follow up dose of PCV15 or PCV20 at least one year after the most recent dose of PPSV23. Lastly, for adults 65 or older who previously received a dose of PCV13, the CDC recommended a follow up dose of PCV20 or PPSV23 at least one year after receiving PCV13. 365600 Page 2 of 4 365600 02/08/2024 Lost Creek Rehabilitation and Nursing Center 804 South Mumaugh Road Lima, OH 45804

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of immunization records, staff interview, review of policy, and review of the Centers of Disease Control and Prevention (CDC) guidance, the facility failed to ensure residents received or were offered the COVID-19 vaccination. This affected four (Residents #9, #17, #22, and #48) of five reviewed for COVID-19 vaccinations. The facility census was 40. Findings include: 1. Review of the closed medical record revealed Resident #9 was admitted on [DATE] and discharged on 11/27/23. Diagnoses included alcoholic cirrhosis of liver with ascites, COVID-19 (11/9/23), thrombocytopenia, muscle weakness, alcohol induced acute pancreatitis without necrosis or infection. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the Patient Vaccination Informed Consent/Declination form, signed 09/22/23, revealed Resident #9 consented to the COVID-19 vaccine. Review of the vaccination record revealed Resident #9 did not receive the COVID-19 vaccine. 2. Review of the medical record revealed Resident #17 was admitted on [DATE]. Diagnoses included rhabdomyolysis, type two diabetes mellitus without complications, dysphagia oropharyngeal, atherosclerotic heart disease of native coronary artery without angina pectoris, hypothyroidism. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of the current immunization record located in the electronic medical record (EMR) revealed no documentation the resident had been offered or received the COVID-19 vaccine. 3. Review of the medical record revealed Resident #22 was initially admitted on [DATE] with re-entry on 4/30/22. Diagnoses included acute chronic diastolic (congestive) heart failure, type two diabetes mellitus with diabetic neuropathy, muscle weakness, lymphedema, and chronic kidney disease stage 3. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of the current immunization record located in the EMR revealed no documentation the resident had been offered or received the COVID-19 vaccine. 4. Review of the medical record revealed Resident #48 was admitted on [DATE]. Diagnoses included primary generalized osteo(arthritis), unspecified dementia with agitation, atherosclerotic heart disease of native coronary artery. Review of the MDS assessment dated [DATE] revealed the resident is severely cognitively impaired. 365600 Page 3 of 4 365600 02/08/2024 Lost Creek Rehabilitation and Nursing Center 804 South Mumaugh Road Lima, OH 45804

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the current immunization record located in the EMR revealed no documentation the resident had been offered or received the COVID-19 vaccine. Interview on 02/08/24 at 2:45 P.M. with Director of Clinical Services #300 verified Resident #9 consented to the COVID-19 vaccine and did not receive the vaccine and Resident #17, #22, and #48 were not offered or received the COVID-19 vaccine. Review of policy, COVID-19 Vaccine Policies and Procedures, dated 06/27/23, verified COVID-19 vaccinations will be offered to all staff and residents. Review of CDC guidance titled Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States, updated 02/12/24 and located at https://www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.html, revealed the CDC recommended people six months of age and older be vaccinated for COVID-19. 365600 Page 4 of 4