Based on record reviews, and interviews, the facility failed to offer and provide or obtain a signed declination for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) for Resident (R)11, R4 and R25.Findings included:- Review of R11's clinical record revealed R11 received the PCV-13 on 03/07/2019, and the PPV23 on 01/20/2021. R11's medical record lacked a declination for the PCV20, or evidence that the PCV20 was offered and administered.R4's clinical record lacked a declination for the PCV20, or evidence the PCV20 vaccine was offered and administered.R25's clinical record lacked a declination for PCV20, or evidence the PCV20 vaccine was offered and administered.On 07/21/2026 at 02:10 PM, Administrative Nurse D stated immunizations were tracked by the… …
F883 citations in Kansas
Flu and pneumonia vaccines · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Kansas cites F883 more often than its own record predicts
2.47 times the share F883 takes of citations nationally.
Of every deficiency written in Kansas in 2025, this is the portion that was F883.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Kansas surveyors wrote
F883 findings written in Kansas, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
The short window
Recent years
| Year | Share of Kansas citations | vs expected |
|---|---|---|
| 2023 | 1.14% | 1.30× |
| 2024 | 2.13% | 2.81× |
| 2025 | 1.57% | 2.47× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Kansas surveyors cite →
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