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F0883
E

Failure to Offer and Document Pneumococcal Vaccination

Winchester, Kansas Survey Completed on 08-12-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to offer, obtain informed declination, or secure physician-documented contraindications for the pneumococcal PCV20 vaccination for several residents, as required by the latest CDC guidance. Record reviews for five sampled residents revealed that none had been offered or received the pneumococcal PCV20 vaccine since admission, nor was there evidence of signed consent or informed declination forms in their medical records. Interviews with nursing staff confirmed that the process for identifying eligible residents and documenting vaccination status or refusals was not consistently followed, resulting in missed opportunities for immunization. Further review of the facility's policy indicated that all residents should be given the opportunity to receive flu and pneumonia vaccines, with documentation of consent or denial required. However, both the clinical records and staff interviews verified that there was no system in place to identify eligible residents for pneumococcal vaccination, and denial forms were absent from the records. This deficiency was observed in a sample of residents and acknowledged by both nursing and administrative staff during the survey.

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