**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of a facility policy, the facility failed to ensure residents were offered pneumococcal vaccines. This affected two residents (#02 and #18) out of the five residents reviewed for immunizations. The facility census was 43. Findings include: 1. Review of the Resident #02's chart revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, cerebral palsy, muscle weakness, hyperlipidemia, hypertension, chronic obstructive pulmonary disease (COPD) and anemia. Review of Resident #02's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired. Review of immunization history for Resident #02, revealed the resident received a Pneumovax 23 vaccine on 12/27/07. Resident #02 had no education on pneumococcal vaccines, no consents on file, and there was no documented evidence Resident #02 was offered or received an updated pneumococcal vaccine since 12/27/07. Interview on 06/21/23 at 9:36 A.M. with Registered Nurse (RN) #27 verified Resident #02 received a Pneumovax 23 vaccine on 12/27/07 and Resident #02 did not have any updated consents offering Resident #02 an updated pneumococcal vaccine. 2. Review of the Resident #18's chart revealed Resident #18 admitted to the facility on [DATE] with diagnoses including, but not limited to, unspecified dementia, pain in the right hand, muscle weakness, anxiety disorder, anemia, hypothyroidism, other symbolic dysfunctions, and mixed hyperlipidemia. Review of Resident #18's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired. Review of the immunization history for Resident #18, revealed the resident received a Pneumovax 23 vaccine on 01/01/16. Resident #18 had no education on pneumococcal vaccines, no consents on file and there was no documented evidence Resident #18 was offered or received an updated pneumococcal vaccine since 01/01/16. Interview on 06/21/23 at 9:36 A.M. with RN #27 verified Resident #18 last received a pneumococcal vaccine on 01/01/16 and Resident #18 did not have any updated consents offering Resident #18 an updated pneumococcal vaccine. Review of the facility's pneumococcal vaccine policy dated 10/26/15 revealed all residents will be offered pneumococcal vaccines to aid in preventing pneumococcal infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was offered a Coronavirus (COVID-19) vaccine. This affected one resident (#17) out of five residents reviewed for immunizations. The facility census was 43. Findings include: Review of the Resident #17's chart revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, hyperlipidemia, type two diabetes mellitus, malignant neoplasm of prostate, major depressive disorder, and abnormal posture. Review of Resident #17's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired. Review of Resident #17's COVID-19 vaccine consents revealed Resident #17 did not have a COVID-19 vaccine consent on file declining or accepting the vaccine. Review of Resident #17's COVID-19 vaccine history revealed Resident #17 did not have a history of receiving a COVID-19 vaccine. Interview on 06/21/23 at 9:36 A.M. with Registered Nurse (RN) #27 verified Resident #17 did not have a consent declining or accepting the COVID-19 vaccine and Resident #17 did not have any documentation that he received a COVID-19 vaccine prior to admission to the facility. Review of the facility's undated offering residents COVID-19 immunizations policy revealed the facility will notify all residents that the vaccination is available to them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to convey a resident's funds within 30 days of death. This affected one (Resident #403) of one resident reviewed who had expired. This had the potential to affect twenty-four residents with personal funds accounts. The facility census was 54. Findings include: Review of Resident #403's progress notes revealed the resident expired in the facility on [DATE]. Review of the facility's personal funds documentation revealed an undated letter to the Ohio Attorney General advising of the resident's death on [DATE]. The resident had a balance of $3153.00. The check was issued on [DATE], 16 months after the resident died. Interview on [DATE] with Administrator confirmed the facility had not timely refunded Resident #403's personal funds balance to the State Attorney General's office.

Based on record review, interview and policy review, the facility failed to test for Legionella in the hot water sources from the facility kitchen, shower room, and shower room for the rehabilitation unit. This had the potential to affect all residents who resided in the facility. The census was 54. Findings include: Review of the Legionnaire's Disease Testing documentation revealed no weekly testing of the hot water system for the kitchen sinks, main shower room, and the rehabilitation shower room. Interview on 08/26/21 at 1:55 P.M. Maintenance Director #85 verified the temperature checks had not been performed weekly. Review of the facility policy titled Monitoring Waterborne Organisms Legionnaires Disease, revised date 01/09/21 revealed water control measures: 1) Legionella testing on the water system will be done on an annual basis, 2) daily temperature check of mix valve for Extended Care Facility (ECF), 3) weekly visual inspection on the 6 inch water main, and 4) weekly temperature check of the hot water system for kitchen sinks, room sinks, shower room, and room shower (Rehabilitation).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, personal funds account review, facility policy review, family and staff interview, the facility failed to promptly notify the resident's representative when the resident's account reached $200 less than the maximum amount permitted a recipient for Medicaid. This affected one (Resident #32) of four residents reviewed for personal funds. This had the potential to affect twenty-eight residents with personal funds accounts. The facility census was 61. Findings include: Review of medical record for Resident #32 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's Disease, malignant neoplasm of the frontal lobe and hemiplegia following a cerebral vascular infarction. Review of the resident's Minimum Data Set (MDS) assessment, dated 02/06/19, revealed the resident had impaired cognition. Review of Resident #32's account balances from 04/10/18 through 04/01/19 revealed the following amounts: 04/23/18 $1,926.47 04/30/18 $1,926.63 05/31/18 $2,248.79 06/15/18 $2,570.79 07/31/18 $2,892.97 08/21/18 $3,214.97 09/30/18 $3,537.39 10/31/18 $3,859.65 11/30/18 $4,181.96 12/31/18 $4,504.27 04/01/19 $5, 083.81 Interview on 04/01/19 at 4:30 P.M. with Administrative Accounts Payable staff (AAP) #53 revealed Resident #32 with an account balance of $5,083.81. AAP #53 confirmed a quarterly statement was sent to the resident's representative for the time-period of 10/09/18 through 12/31/19. AAP #53 identified a line on the bottom of the quarterly statement which identified Resident #32's account was over the amount necessary to remain Medicaid eligible. The statement requested the resident's representative to contact the Licensed Social Worker. Interview on 04/02/19 at 10:10 A.M. with Social Worker (SW) #85 revealed she was not aware of the statement on the bottom of the quarterly statement. SW #85 additionally stated she has never followed up on any personal funds accounts for any reason. Telephone interview on 04/04/19 at 10:57 A.M. with Resident #32's Power of Attorney (POA) did confirm knowledge Resident #32 being over the maximum amount. Resident #32 confirmed receiving quarterly statements which had a notice informing that Resident #32 exceeded the amount necessary to remain Medicaid eligible. Interview on 04/04/19 at 11:17 A.M. with Administrator confirmed no additional notifications were sent to Resident #32's other than the quarterly statements. Administrator confirmed resident was within the $200 dollars of exceeding the maximum amount on 04/23/19. Resident #32's representative did not receive a notice of spend down until 06/30/19 when the quarterly statements were mailed. Review of the facility policy titled, Management of Resident's Personal Funds dated March of 2017 reveals if the facility manages the resident's funds, the facility will act as a fiduciary of the resident fund and hold, safeguard, manage and account for the personal funds of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident had a valid Ohio Comfort Care Do Not Resuscitate order. This affected one (Resident #24) of twenty-four residents reviewed during first stage of the survey. The facility census was 61. Findings include: Review of Resident #24's medical record revealed being admitted on [DATE] with diagnoses including Alzheimer's Disease, depression, anxiety and dementia. Review of the Minimum Data Set (MDS) assessment, dated 01/17/19, revealed the resident had a severe cognitive deficit. Review of Resident #24's undated Ohio Do Not Resuscitate (DNR) Comfort Care form revealed resident was a Do Not Resuscitate Comfort Care -Arrest (DNRCC-A). The form had resident's name, address and signature of resident's Power of Attorney. However, it did not have the physician's signature. The form did have a notation at the bottom of having been faxed to the physician on 12/16/18. Interview on 04/01/19 at 3:50 P.M. with Licensed Practical Nurse (LPN) #58 confirmed Resident #24's Ohio DNR Comfort Care order did not have a physician's signature. LPN #58 was not able to provide a signed form for Resident #24. Interview on 04/02/19 at 3:50 P.M. with Director of Nursing confirmed Resident #24 did not have a signed Ohio DNR Comfort Care Arrest order. Review of the facility policy titled, Advanced Directives, dated 10/29/15, revealed the nurse will notify the attending physician of the advance directives so that the appropriate orders can be documented in the resident's medical record.