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F0883
D

Failure to Administer Pneumococcal Vaccinations per Updated CDC Guidelines

Grand Marais, Minnesota Survey Completed on 07-31-2025

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 ensure that five out of six residents reviewed for immunizations were offered or received timely administration of pneumococcal vaccinations in accordance with the most current CDC recommendations. Document review showed that several residents had received previous pneumococcal vaccines, such as PCV13 or PPSV23, but had not been assessed or administered additional recommended doses like PCV20 or PCV21, as per updated CDC guidelines. The facility's policy on pneumococcal vaccination, dated 1/16/25, did not reflect the latest CDC recommendations, particularly regarding the lowered screening age from 65 to 50 and the updated vaccine administration schedule. Interviews with facility staff, including the assistant director of nursing and the infection preventionist, confirmed that the policy was outdated and did not address the new CDC guidelines. The infection preventionist acknowledged that the facility offered pneumococcal immunizations yearly and was in the process of updating the policy and preparing to offer the vaccines to identified residents. However, the facility was unable to provide current guidelines for determining when to administer pneumococcal vaccinations, and several residents who qualified for additional doses had not yet received them.

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