Based on record review and interview, it was determined that the facility failed to maintain documentation related to staff COVID-19 vaccination that included that staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine; offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and the COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). Specifically, 4 staff members had no documentation that they were offered or provided Covid-19 immunizations. Staff identifiers: 1, 2, 3, and 4. On 6/29/26 at 9:00 AM, the employee records were reviewed for Staff 1, 2, 3, and 4. …
F887 citations in Utah
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
Utah cites F887 less often than its own record predicts
0.61 times the national share — cited less often here than elsewhere.
Of every deficiency written in Utah 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 Utah surveyors wrote
F887 findings written in Utah, 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.
The short window
Recent years
| Year | Share of Utah citations | vs expected |
|---|---|---|
| 2023 | 0.46% | 1.78× |
| 2024 | 0.35% | 1.21× |
| 2025 | 0.22% | 0.61× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Utah surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction