**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine to 2 of 5 sampled residents for immunizations in accordance with nationally recognized standards, Residents #12 and #13. The findings included: 1. For Resident #12, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 20 (PCV20) or a pneumococcal polysaccharide vaccine 23 (PPSV23) following admission to the facility. A review of the Centers for Disease Control and Prevention (CDC) guideline titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate last reviewed 2/13/23, read in part, .For adults 65 years or older who have only received PCV13, CDC recommends you either: Give 1 dose of PCV20 at least 1 year after PCV13 or Give 1 dose of PPSV23 at least 1 year after PCV13 . Resident #12's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Atherosclerotic Heart Disease, and Essential Hypertension. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 8/08/23 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. Resident #12 was admitted to the facility on [DATE] and was [AGE] years old at the time of admission. A review of Resident #12's clinical record revealed they had received a pneumococcal conjugate vaccine 13 (PCV13) on 3/03/17 prior to admission. Surveyor was unable to locate evidence to indicate Resident #12 was offered a PCV20 or PPSV23 vaccine following admission to the facility. On 9/13/23 at 4:26 PM, surveyor spoke with the director of nursing (DON) and requested any evidence of Resident #12 receiving or being offered any additional pneumococcal vaccinations. The DON stated they would check in the Virginia Immunization System (VIS) and Care Connect for additional information. No additional pneumococcal vaccine information was provided for Resident #12. Surveyor requested and received the facility policy titled Pneumococcal Vaccines issued/revised 11/2021 which read in part, .Communicate the resident's vaccine history to his/her provider. The provider will indicate if the resident needs PCV13 or PPSV23 or both . On 9/14/23 at 1:25 PM, surveyor spoke with the DON who stated the facility focus had been on providing COVID vaccinations and they will work on providing pneumonia vaccines and will also review the facility policy. On 9/14/23 at 5:24 PM, the survey team met with the facility administrative team including the administrator and DON and discussed the concern of Resident #12 not being offered a PCV20 or PPSV23 following admission. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/14/23. 2. For Resident #13, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 20 (PCV20) or a pneumococcal conjugate vaccine 15 (PCV15) following admission to the facility. A review of the Centers for Disease Control and Prevention (CDC) guideline titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate last reviewed 2/13/23, read in part, .For adults 65 years or older who have only received PPSV23, CDC recommends you: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination . Resident #13's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Dementia, Type 2 Diabetes Mellitus, and Malignant Neoplasm of Skin. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 8/31/23 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. Resident #13 was admitted to the facility on [DATE] and was [AGE] years old at the time of admission. A review of Resident #13's clinical record revealed they received a pneumococcal polysaccharide 23 (PPSV23) vaccine on 5/17/18 prior to admission to the facility. Surveyor was unable to locate evidence to indicate Resident #13 was offered a PCV20 or PCV15 vaccine following admission to the facility. On 9/13/23 at 4:26 PM, surveyor spoke with the director of nursing (DON) and requested any evidence of Resident #13 receiving or being offered any additional pneumococcal vaccinations. The DON stated they would check in the Virginia Immunization System (VIS) and Care Connect for additional information. No additional pneumococcal vaccine information was provided for Resident #13. Surveyor requested and received the facility policy titled Pneumococcal Vaccines issued/revised 11/2021 which read in part, .Communicate the resident's vaccine history to his/her provider. The provider will indicate if the resident needs PCV13 or PPSV23 or both . On 9/14/23 at 1:25 PM, surveyor spoke with the DON who stated the facility focus had been on providing COVID vaccinations and they will work on providing pneumonia vaccines and will also review the facility policy. On 9/14/23 at 5:24 PM, the survey team met with the facility administrative team including the administrator and DON and discussed the concern of Resident #13 not being offered a PCV20 or PCV15 following admission. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/14/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and facility document review, it was determined the facility staff failed to accurately implement policies and procedures relating to DNR (do not resuscitate) status for two (2) of 30 facility residents (Resident #12 and Resident #26). The findings include: The facility staff failed to ensure Resident #12's and Resident #26's code status was correctly marked, outside the residents' room, according to the facility's process. The facility's process is that residents with an active DNR will have a blue dot sticker placed beside the resident's name that is posted on the nameplate sign outside of the resident's room. Resident #26's clinical record included a minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE]. Resident #26 was assessed as being able to make self understood and as being able to understand others. Resident #26's Brief Interview for Mental Status (BIMS) summary score was documented as a 12 out of 15. Resident #26 was documented as requiring limited assistance with bed mobility, transfers, toilet use, and personal hygiene. Resident #26's diagnoses included, but were not limited to: high blood pressure, wound infection, arthritis, hip fracture, and depression. Resident #12's clinical record included a minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE]. Resident #12 was assessed as being able to sometimes make self understood and sometimes being able to understand others. Resident #12 was assessed as having problems with short-term memory. Resident #12 was assessed as being dependent on others for transfers, dressing, toilet use, personal hygiene, and bathing. Resident #12's diagnoses included, but were not limited to: high blood pressure, diabetes, aphasia, and depression. On [DATE] at 10:24 a.m., the nameplate sign outside of Resident #26's room was noted to have a blue dot sticker placed beside Resident #26's name. LPN (licensed practical nurse) #21 and LPN #22 were present during this observation. LPN #21 confirmed Resident #26 had a blue dot sticker beside the resident's name. LPN #21 reported the blue dot indicated the resident had a DNR order. LPN #21 and LPN #22 reviewed Resident #26's electronic clinical record and reported a DNR order for Resident #26 was not found. LPN #22 reported the decision to start or not to start CPR is not made based on the blue dot sticker alone. LPN #22 reported the facility's process requires the blue dot sticker/code status be confirmed by two individuals and confirmed by the DNR order in a resident's clinical record. On [DATE] at 10:29 a.m., the facility's Director of Nursing (DON) was shown the blue dot sticker which was placed beside Resident #26 name; the DON was also informed a DNR order for Resident #26 was not found. Resident #26 was care planned as having a code status of Full Code. On the morning of [DATE], the blue dot stickers on the residents' nameplates outside of the resident rooms was reviewed with RN (registered nurse) #23. At 11:05 a.m., it was discovered that Resident #12's clinical documentation did not include orders for DNR although there was a blue dot sticker beside the resident's name on the nameplate outside of the resident's room. RN #23 confirmed Resident #12 had a blue dot sticker beside their name posted on the nameplate outside of the resident room. Resident #12 was care planned as having a code status of Full Code. The following information was found in a facility document titled CODE STATUS (with a revision date of 1/19): - STATEMENT OF POLICY: It is the policy of King's Grant to support the rights of residents in making decisions regarding their care and treatment. King's Grant will honor the resident's wishes regarding the extent of measures that will be taken in the event that life saving measures are deemed necessary. - PURPOSE: To identify the process followed by King's Grant to ensure appropriate code status wishes are followed. - Residents who have an active DNR will also be identified by a blue dot on their door frame. - In the event of a code situation, a resident's code status will be verified in a three-step process: a. Nurse to check in (the electronic medical record) system and/or binder at nurses' station to verify code status b. Nurse to verify code status with another nurse c. Nurse to verify presence of blue dot on resident's door. A survey team meeting occurred on [DATE] at 4:20 p.m. with the facility's DON, Administrator, Infection Preventionist, and RN #23. During this meeting, the incorrect placement of blue dot stickers on Resident #12's nameplate and Resident #26's nameplate was discussed. The blue dot stickers indicated Resident #12 and Resident #26 had DNR orders when in actuality neither resident had DNR orders.