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F0883
D

Failure to Offer and Document Pneumococcal Vaccinations and Absence of Related Policy

Goshen, Indiana Survey Completed on 03-23-2026

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

The facility failed to provide pneumococcal immunizations and lacked related documentation and policy for two residents whose immunization records were reviewed. Resident 39, who had diagnoses including dementia, major depressive disorder, and chronic pulmonary disease, had no documentation in her record indicating she had been offered or administered the pneumococcal vaccination within the last year. Resident 40, with diagnoses including vascular dementia, hypertension, dysphagia, and major depression, also had no documentation in her record showing she had been offered or administered the pneumococcal vaccination within the last year. During an interview, the Infection Prevention Nurse stated that vaccinations should be offered yearly and indicated she would need to check whether these two residents had been offered or received the pneumococcal vaccine. In a separate interview, the Region Nurse Consultant confirmed that the two residents had not been offered or administered the pneumococcal vaccination, despite the expectation that they should have been, and further acknowledged that the facility did not have a policy related to pneumococcal vaccination.

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