GARDNERVILLE, NV - A recent health inspection at Gardnerville Health & Rehabilitation Center identified critical failures in the facility's vaccination program, with residents not receiving timely pneumococcal and COVID-19 vaccines despite documented eligibility and pending immunization status.
Pneumococcal Vaccine Administration Delays Put Diabetic Resident at Risk
The inspection revealed that Resident #12, who has type two diabetes mellitus with circulatory complications and chronic diastolic heart failure, did not receive appropriate pneumococcal vaccination despite being overdue for the recommended vaccine schedule. The resident's medical records showed they had received the PPSV23 pneumococcal vaccine three times previously - in October 2013, December 2018, and June 2021 - but had not received any of the newer conjugate vaccines required to complete the current vaccination protocol.
According to the facility's Immunization Audit Report, four different pneumococcal vaccines were marked as "pending immunization" for this resident: PCV13, PPSV23, PCV15, and PCV20. The Infection Preventionist confirmed that "pending immunization indicated the resident gave consent and was due/eligible for the vaccine." Despite this documented eligibility and apparent consent, none of these vaccines had been administered to the resident.
The timing failure is particularly concerning given current Centers for Disease Control and Prevention guidelines. For adults over 65 who have previously received PPSV23 vaccines, the CDC recommends administering either PCV20 or PCV21 at least one year after the last PPSV23 dose, or alternatively, PCV15 followed by additional doses. Since Resident #12's last PPSV23 vaccine was administered in June 2021, they had been eligible for the conjugate vaccine for nearly four years at the time of the inspection in May 2025.
COVID-19 Vaccine Never Administered Despite Documented Eligibility
The inspection also uncovered that Resident #4, who suffers from type two diabetes mellitus and hypertension, had never received any doses of the COVID-19 vaccine despite being identified as eligible. The resident's Immunization Audit Report contained no documentation of any COVID-19 vaccination history, with the vaccine status listed as "pending immunization" since April 13, 2025.
A Multi-Vaccine Consent Form from the same date indicated Resident #4 was eligible for the COVID-19 vaccine, yet the form lacked any signature showing whether the resident had consented to or declined vaccination. When questioned during the inspection, the Infection Preventionist confirmed that the resident "should have received or declined the vaccine" and acknowledged that no COVID-19 vaccine had been administered.
This oversight is particularly troubling given that individuals with diabetes face significantly higher risks of severe COVID-19 complications. The CDC explicitly recommends that all nursing home residents receive the 2024-2025 COVID-19 vaccine, with adults 65 and older requiring two doses administered ideally six months apart, or at minimum two months apart.
Medical Implications of Vaccination Failures
The failure to provide timely pneumococcal vaccination poses serious health risks, particularly for residents with underlying conditions. Pneumococcal disease can cause life-threatening infections including pneumonia, meningitis, and bloodstream infections. Adults with diabetes face a three to six times higher risk of invasive pneumococcal disease compared to healthy adults of the same age. The circulatory complications and heart failure affecting Resident #12 further compound this vulnerability, as cardiovascular conditions significantly increase the risk of pneumococcal pneumonia and its complications.
The newer conjugate vaccines (PCV13, PCV15, PCV20, and PCV21) provide broader protection against pneumococcal strains than the older PPSV23 vaccine alone. These conjugate vaccines create stronger, longer-lasting immunity and are particularly important for immunocompromised individuals. The multi-year delay in administering these vaccines left Resident #12 without optimal protection against potentially fatal infections.
For COVID-19, the risks are equally severe. Diabetes increases the likelihood of severe COVID-19 outcomes by two to three times, including higher rates of hospitalization, intensive care admission, and death. Hypertension, which Resident #4 also has, independently increases COVID-19 severity. The combination of these conditions creates a particularly high-risk profile that makes vaccination essential rather than optional.
Nursing home residents face additional environmental risks due to congregate living settings where respiratory infections spread rapidly. Without vaccination, these residents remain vulnerable not only to infection but also to becoming vectors for facility-wide outbreaks that can affect multiple vulnerable individuals.
Systemic Breakdown in Vaccine Administration Protocols
The inspection findings reveal fundamental breakdowns in the facility's vaccination management system. Despite having a formal policy requiring pneumococcal vaccination "upon admission and with repeated vaccination occurring per CDC guidelines," the facility failed to follow through on documented vaccination needs. The policy specifically mandated that licensed nursing staff review potential contraindications and maintain electronic health records documenting vaccination status.
Similarly, the facility's COVID-19 policy, updated in January 2025, clearly stated that residents should be "offered recommended COVID-19 vaccinations upon admission and as eligible per CDC recommendations." The policy required providing fact sheets about vaccine risks and benefits and maintaining logs of acceptance or declination. Yet for Resident #4, none of these requirements were met - no vaccine was offered, no declination was documented, and no follow-up occurred despite the pending status in their records.
The Infection Preventionist's admission during the inspection that they had been "working to screen all residents in the facility for vaccination history and eligibility" suggests this was not an isolated incident but potentially a facility-wide issue. The fact that consent forms were partially completed but lacked resident or representative signatures indicates a breakdown in the administrative process for obtaining and documenting informed consent.
Industry Standards and Expected Practices
Standard nursing home practice requires a systematic approach to vaccination management. This includes conducting admission assessments to determine vaccination history, reviewing medical records from previous facilities or providers, consulting state immunization registries, and establishing clear timelines for vaccine administration based on CDC guidelines. Facilities should have designated staff responsible for tracking vaccination schedules and ensuring timely administration.
Best practices include implementing electronic reminder systems for due vaccines, conducting regular audits of vaccination rates, establishing standing orders for routine vaccinations, and maintaining clear documentation of consent or refusal. When vaccines are marked as pending, there should be specific follow-up protocols with defined timeframes for administration or obtaining formal declination.
The facility's failure to complete the vaccination process despite identifying eligibility and marking vaccines as pending represents a critical gap between assessment and intervention. This suggests inadequate quality assurance mechanisms to ensure that identified healthcare needs are actually addressed.
Additional Issues Identified
Beyond the vaccination failures, the inspection identified several related documentation and process issues. The facility lacked proper signatures on Multi-Vaccine Consent Forms, indicating incomplete informed consent procedures. The Immunization Audit Reports showed multiple vaccines in pending status without clear action plans or timelines for administration.
The absence of documentation showing whether vaccines were offered and declined versus simply not administered makes it impossible to determine if residents made informed choices about their healthcare. The facility's electronic health records, which policy required to be maintained with complete vaccination documentation, contained significant gaps and omissions.
Regulatory Implications and Required Corrections
These violations fall under federal regulations F883 and F887, which mandate that skilled nursing facilities develop and implement comprehensive policies for influenza and pneumonia vaccinations, as well as educate residents and staff about COVID-19 vaccination. The facility must offer vaccines to all eligible residents after appropriate education and maintain proper documentation of vaccination status.
The inspection findings indicate these deficiencies affected few residents but had the potential for minimal to actual harm. However, given the vulnerability of the nursing home population and the serious consequences of vaccine-preventable diseases, these violations require immediate corrective action. The facility must now develop and implement a plan of correction addressing these systemic failures in their vaccination program.
The documented failures at Gardnerville Health & Rehabilitation Center highlight the critical importance of robust vaccination protocols in protecting vulnerable nursing home residents from preventable diseases. With residents facing elevated risks due to age, underlying conditions, and congregate living situations, timely and complete vaccination represents a fundamental standard of care that cannot be compromised.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gardnerville Health & Rehab Center from 2025-05-01 including all violations, facility responses, and corrective action plans.
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