Based on review of facility documentation, clinical records and staff interview it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccine and providing education for 17 of 17 unvaccinated residents (Resident R5, R11, R13, R14, R17, R21, R22, R30, R23, R29, R24, R25, R31, R20, R26, R27, and R28). This failure resulted eight of 17 unvaccinated residents becoming positive with COVID-19 (Resident R5, R11, R13, R14, R17, R21, R22, and R30) and in the actual harm of six of the eight positive residents having symptoms of COVID-19 (Resident R5, R11, R13, R14, R21, and R22). Review of facility provided infection control documentation from 7/30/22-8/2/22, revealed the following: Resident vaccination matrix requested on 7/30/22. …
F887 citations in Pennsylvania
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
Pennsylvania cites F887 less often than its own record predicts
0.71 times the national share — cited less often here than elsewhere.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F887 findings written in Pennsylvania, 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 facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the COVID-19 (a respiratory disease) vaccine for three of six residents (Resident R3, R14, and R54). Findings include: Review of admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/29/26, indicated the diagnoses of heart failure, anxiety, and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). MDS Section O- Special treatment, Procedures, and Programs O0350 indicated COVID vaccine was coded a 0- resident not up to date. …
Based on review of facility policy, facility documentation, clinical records and staff interview, it was determined that the facility failed to ensure that each resident's medical record included documentation that indicated, at a minimum that the resident or resident's representative was provided education regarding the benefits and potential side effects of COVID-19 immunization; and that the resident either received the COVID-19 immunization or did not receive the COVID-19 immunization due to medical contraindications or refusal for eight of eight residents reviewed (Residents R9, R24, R25, R26, R28, R31, R35, and R37). …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.13% | 0.49× |
| 2024 | 0.25% | 0.87× |
| 2025 | 0.26% | 0.71× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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