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. …
F887 citations in Wisconsin
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
Wisconsin cites F887 more often than its own record predicts
1.10 times the share F887 takes of citations nationally.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F887 findings written in Wisconsin, 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 interview and record review, the facility did not ensure COVID-19 vaccines were offered or administered for 4 residents (R) (R5, R8, R14, and R19) of 8 sampled residents. R5, R8, R14, and R19's medical records did not indicate they were offered or administered COVID-19 vaccines. Findings include: The facility's COVID-19 Vaccine Residents policy, dated March 2023, indicates: All residents will be offered the COVID-19 vaccine to aid in preventing COVID infections. 1. R5 was admitted to the facility on [DATE] and had diagnoses including falls and diabetes. A Minimum Data Set (MDS) assessment, dated 7/29/26, stated R5 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating intact cognition. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.61% | 2.35× |
| 2024 | 0.24% | 0.86× |
| 2025 | 0.40% | 1.10× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin 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