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F0883
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Failure to Offer Pneumococcal 20-Valent Conjugate Vaccine to Eligible Residents

Greensboro, North Carolina Survey Completed on 07-08-2025

Penalty

Fine: $189,42535 days payment denial
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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 the pneumococcal 20-valent conjugate vaccine (PCV20) to three out of five residents reviewed for pneumococcal immunizations. According to the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP), adults aged 65 years or older, and those aged 19-64 with certain underlying medical conditions, should be routinely offered PCV20 or PCV15 if they have not previously received a pneumococcal conjugate vaccine or if their vaccination history is unknown. Record reviews showed that residents had either declined older pneumococcal vaccines (PCV13 or PPSV23) or there was no documentation of being offered PCV20, and there was no evidence that PCV20 was offered or administered since the last recertification or prior to admission. The facility's immunization policy, last reviewed in March 2024, only referenced offering PCV13 or PPSV23, not PCV20. Documentation for the affected residents did not indicate that PCV20 was offered or declined, and there was no record of prior receipt of PCV20. During an interview, the DON/Infection Preventionist stated she was unaware of the need to offer PCV20 and confirmed that the facility had only been offering PCV13 and PPSV23 to residents.

See complete original report
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