Failure to Offer Recommended Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The deficiency involves the facility’s failure to ensure that eligible residents were offered pneumococcal vaccination in accordance with CDC recommendations and the facility’s own immunization policy. For one resident (R23), the face sheet showed admission to the facility and age over 65, and the Immunizations Report showed no pneumococcal vaccine on record. A progress note documented that this resident reported having received a Pneumococcal 23 (PPSV23) vaccination after age 65, but no additional documentation of any pneumococcal vaccine was available in the record. For another resident (R36), the face sheet showed admission and age over 65, and the Immunizations Report documented a PPSV23 vaccine administered on 12/8/21, with no other pneumococcal vaccines recorded and no further documentation provided. During an interview, the Administrator in training stated that the unit clerk is responsible for tracking residents’ immunization status and determining when they are due for specific immunizations, and that the facility follows CDC recommendations for pneumococcal and other vaccines. The CDC Adult Immunization Schedule cited in the report specifies that adults aged 65 years or older who have previously received only PPSV23 should receive one dose of PCV15, PCV20, or PCV21 at least one year after the last PPSV23 dose. The facility’s written Immunization Policy and Procedure, revised in 9/2025, states that the facility shall offer and administer recommended vaccines to all eligible residents, document all immunizations, refusals, and contraindications, comply with CDC requirements, and provide PCV20 or sequential PCV15 plus PPSV23 per CDC guidelines upon admission and as needed based on immunization history. Despite these policies and guidelines, the records for R23 and R36 did not show that the appropriate pneumococcal vaccines were offered or administered in line with CDC recommendations.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.