F0883

D

Failure to Maintain and Offer Up-to-Date Pneumococcal Vaccinations

Seattle, Washington Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure pneumococcal vaccinations were current and properly offered in accordance with its own policy and CDC recommendations. The facility’s pneumococcal vaccine policy, revised in March 2022, states that all residents are to be offered pneumococcal vaccines to prevent pneumonia and pneumococcal infections, that residents are to be assessed for eligibility prior to or upon admission, and that indicated vaccines are to be offered within 30 days of admission. The policy also states that administration is to follow current CDC recommendations. CDC guidance cited in the report specifies that an adult who previously received both PCV13 and PPSV23, but did not receive PPSV23 at age 65 or older, should receive one dose of PCV20 or PCV21 at least five years after the last pneumococcal vaccine dose.

For one resident, admitted on an unspecified date, review of the EHR showed no pneumococcal immunization record and no documentation that the pneumococcal vaccine was offered, contrary to the facility’s policy requiring assessment and offering within 30 days of admission. For another resident born in 1950, the immunization record showed receipt of PPSV23 in 2004 and PCV13 in 2019, but no documentation that the recommended follow-up dose of PCV20 or PCV21 was offered or administered at least five years after the 2019 dose, as required by the cited CDC schedule. During a joint phone interview and record review, the DON stated that pneumococcal vaccines were offered annually and that CDC guidelines were followed, but acknowledged that one resident’s pneumococcal immunization was not up to date, and the regional operations staff confirmed that neither the missing pneumococcal record for the first resident nor the PCV20/PCV21 record for the second resident could be found in the EHR.