Inadequate Staff Education on Pneumococcal Vaccine
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by the lack of education provided to staff on the risks and benefits of the pneumococcal vaccine. During the recertification survey, it was found that two Certified Nursing Aides (CNAs) did not receive documented education on the pneumococcal vaccine within the past year. This deficiency was confirmed during an interview with the Infection Control Coordinator, who acknowledged the absence of records indicating that the required education was provided to the CNAs.
Plan Of Correction
Plan of Correction: Approved April 28, 2025 No residents were affected by this deficient practice. No residents have the potential to be affected by the deficient practice. The pneumococcal vaccination consent form has been updated to include a signature and date line under the options to accept or decline the vaccination beginning 4/2/25. This is attached to the Center for Disease Control's Vaccination Information Sheet for the pneumococcal vaccination. This form will be given to all staff upon hire and with each vaccination eligibility. The existing pneumococcal spreadsheet tracks all employees, vaccination education, signatures, and dates for record compliance effective 4/2/25. This worksheet will be audited monthly, and results of these audits will be shared with the Quality Assurance Performance Improvement committee who will determine the need for monitoring and reporting until compliance is achieved. Any identified deficient practice will be addressed through staff re-education and/or formal disciplinary action. The Infection Control Nurse is responsible for this plan of correction.
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.