Health inspection·January 8, 2025

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 interviews and review of the Influenza Vaccine Report, the facility failed to offer the annual influenza vaccines to residents. This affected three (#47, #14 and #39) out of three residents reviewed for influenza vaccines and had the potential to affected 80 out of 82 residents residing in the facility, the facility identified two (#16 and #79) residents who were not eligible for the influenza vaccine. The facility census was 82. Residents Affected - Some Findings include: 1. Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic obstructive pulmonary disease, spondylosis without myelopathy or radiculopathy, lumbosacral region, and unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Further review of Resident #47's medical record revealed there was no documentation the resident was not offered or administered the influenza vaccine for the 2024-2025 influenza season. 2. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include pressure ulcer of sacral region, stage 3, malignant neoplasm of middle lobe, bronchus or lung, and type 2 diabetes mellitus with diabetic neuropathy. Further review of Resident #14's medical record revealed there was no documentation the resident was not offered or administered the influenza vaccine for the 2024-2025 influenza season. 3. Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include cerebral atherosclerosis, pressure ulcer of sacral region, stage 4, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Further review of Resident #39's medical record revealed there was no documentation the resident was not offered or administered the influenza vaccine for the 2024-2025 influenza season. Interview on 01/08/25 at 11:46 A.M. with Assistant Director of Nursing (ADON) #3 confirmed the facility has not offered the residents the annual 2024-2025 influenza vaccine due to losing the infection control nurse approximately six weeks ago and reorganizing the position. Interview with ADON #3 also confirmed the floor nurses were given consent paperwork on 12/30/24 to review with the resident and get their consent for the vaccine. Interview with ADON #3 also confirmed on 01/03/25 pharmacy was notified of the need of 60 additional flu vaccines. ADON #3 confirmed there were some residents not Page 1 of 2 365819 365819 01/08/2025 Siena Woods Care Center 6125 N Main Street Dayton, OH 45415

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some eligible for the annual influenza vaccine as they were newly admitted and received it outside the facility or there are some residents who have refused it. ADON #3 confirmed there was no documentation that Resident #47, #14 and #39 were offered the annual influenza vaccine. Interview on 01/08/25 at 12:10 P.M. with Pharmacy Technician #101 confirmed 20 doses of Afluria and 30 doses of Fluzone were sent to the facility on [DATE], and 50 doses of Afluria were sent to the facility on [DATE]. Review of the Influenza Vaccine report revealed Resident #16 was not eligible for the to receive the influenza vaccine as the resident received the vaccine on 11/06/24. Additionally, Resident #79 refused the influenza vaccine. There was no other documentation that residents were offered the influenza vaccine for the 2024-2025 influenza season. This deficiency represents non-compliance investigated under Complaint Number OH00160725. 365819 Page 2 of 2