Based on observations, record review and interviews, the facility failed to have a system in place to ensure all residents were offered and received an updated COVID-19 vaccination which matched the current variants.Record review revealed the facility was in outbreak status when nine residents tested positive for COVID-19 on 1/13/26. Within the next 14 days, an additional seven residents tested positive for COVID-19. Record review revealed the residents' electronic medical records (EMR) did not include documentation prior to the outbreak on 1/13/26 that indicated that residents or their representatives were provided education regarding the potential benefits and potential risks associated with the updated COVID-19 vaccine and there was no documentation of the COVID-19 vaccine being… …
F887 · COVID-19 vaccination
Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F887 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F887 finding.
The harm level
How severely F887 is cited
0.5% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J10.1% | K— | L— |
| Actual harm | G60.4% | H— | I— |
| No harm, potential for more than minimal | D79256.9% | E46533.4% | F1208.6% |
| No harm, potential for minimal | A— | B20.1% | C50.4% |
In the surveyor’s words
What an F887 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review, the facility did not ensure that a resident's medical record included documentation that indicates the resident or resident representative was provided education regarding the benefits and potential side effects of the COVID-19 vaccine, and that the resident (or representative) either accepted, received or declined the COVID-19 vaccine for 2 of 6 residents (R10 and R7) reviewed for COVID-19 vaccinations. R10 was not vaccinated for COVID-19 and became infected with COVID-19 that resulted in a hospitalization. The facility did not have documentation stating that the vaccination was offered, declined/consented to, or that the resident and or POA (Power of Attorney) was provided education on the vaccine. R7 was not vaccinated for COVID-19. …
Based on record reviews and staff interviews, the facility failed to ensure residents were offered the COVID-19 vaccination for 5 of 5 residents reviewed for immunizations (Resident #3 Resident #4, Resident #9, Resident #24 and Resident #45).The findings included:A review of the Center for Disease Control (CDC) guidelines, dated 11/19/25, indicated that the CDC recommended a 2025 to 2026 COVID-19 vaccine for individuals that were age [AGE] and older, were at high risk for severe COVID-19, or had never received a COVID-19 vaccine. a. …
Based on interview and record review, the facility failed to maintain documentation of staff education of the risks and benefits associated with the COVID-19 vaccine and documentation of the COVID-19 vaccination status for all staff members. Findings include:During an interview on 6/16/26 at 4:00 p.m., staff member A stated, I do not ask staff about their COVID status because it (the vaccine) is no longer mandatory. We don't provide any education to staff regarding COVID vaccines.During an interview on 6/17/26 at 3:47 p.m., staff member G stated the facility was not tracking COVID-19 status documentation unless it was self-reported by staff.A request was made on 6/16/26 for the COVID-19 vaccination status, consent or declination, education, and administration for staff member K. …
By state — 2025
Where F887 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- Washington2.40× · 25 citations
- Maryland2.26× · 25 citations
- California0.91× · 52 citations
Co-occurrence
Cited alongside F887
Of the 2025 surveys that cited F887, these tags appeared in the same inspection more often than chance would predict.
- F88361.2% of F887 surveys · 23.2× chance
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- F88121.3% of F887 surveys · 10.7× chance
Implement a program that monitors antibiotic use.
- F9479.6% of F887 surveys · 8.4× chance
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- F8657.6% of F887 surveys · 7.7× chance
Have a plan that describes the process for conducting QAPI and QAA activities.
- F73010.9% of F887 surveys · 7.7× chance
Observe each nurse aide's job performance and give regular training.
Cited in the same inspection, not caused by one another.
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