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F0883
E

Failure to Offer and Document Pneumococcal Vaccinations per Current CDC Guidelines

Smyrna, Delaware Survey Completed on 01-09-2026

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

Surveyors identified that the facility failed to offer influenza and pneumococcal vaccinations in accordance with current CDC guidelines and its own policies for multiple residents. Record review showed that several residents over age 50 or 65 did not have documentation of being offered or receiving the recommended pneumococcal conjugate vaccines PCV20 or PCV21. One resident admitted in January 2025, over age 55, had no record of receiving any pneumococcal vaccine or being offered PCV20 or PCV21. Another resident admitted in February 2024, over age 65, similarly had no documentation of pneumococcal vaccination or an offer of PCV20 or PCV21. A third resident, admitted in 2016, had received PPSV23 in December 2016, but there was no evidence that she or her representative had been offered PCV20 or PCV21. Two additional long-stay residents who turned the qualifying age during their stays had received PPSV23 in 2015, but their records lacked any indication that they or their representatives were offered PCV20 or PCV21. A pharmacy report showed only a small number of residents received PCV20 between 2023 and 2025. In interviews, the pharmacist stated PCV20 was ordered in 2025 and would require a report to determine ordering frequency, and the DON/Infection Preventionist confirmed that the identified residents had not been offered PCV20. The Medical Director reported there had been no communication regarding pneumococcal vaccines for at least six months and acknowledged that the facility’s policy had not been updated to reflect current CDC recommendations. Review of the facility’s written protocol showed it still referenced PCV13 and PPSV23 for adults 65 and older, which did not align with the CDC’s updated guidance recommending PCV15, PCV20, or PCV21 for adults 50 and older and shared decision-making use of PCV20 or PCV21 in certain adults 65 and older.

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