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 citations in Colorado
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.
Against expectation — 2025
Colorado cites F887 less often than its own record predicts
0.93 times the national share — cited less often here than elsewhere.
Of every deficiency written in Colorado in 2025, this is the portion that was F887.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F887 findings written in Colorado, 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.
Based on observations, record review and interviews, the facility failed to implement policies and procedures to ensure that annual Covid-19 vaccination for two (#1 and #55) residents of six residents reviewed out of 39 sample residents.Specifically, the facility failed to:-Ensure Resident #55 and Resident #1's representatives were provided education regarding the benefits and potential side effects of COVID-19 immunization annually; and,-Ensure Resident #55 and Resident #1 was offered the COVID-19 vaccine.Findings include:I. Facility policy and procedure The Immunizations policy, revised September 2025, was provided by regional clinical resource #2 on 7/9/26 at 4:40 p.m. …
What else Colorado surveyors cite →
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