On 01/25/21 at 5:05 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to develop and implement an antibiotic use protocol which included reporting results of laboratory data to the ordering practitioner for resident #10. Resident #10 was hospitalized and subsequently passed away. On 01/25/21 the IJ situation was verified with the Oklahoma State Department of Health. On 01/25/21 at 5:05 p.m., the administrator and the assistant director of nurses were notified of the IJ situation related to failures in communicating pertinent lab results to the ordering physician. On 01/26/21 at 11:30 a.m., the plan of removal for the Immediate Jeopardy pertaining to notification of the physician was accepted. …
F881 · Antibiotic stewardship
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F881 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F881 finding.
The harm level
How severely F881 is cited
0.4% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G80.4% | H— | I— |
| No harm, potential for more than minimal | D95447.2% | E60830.1% | F42921.2% |
| No harm, potential for minimal | A— | B40.2% | C190.9% |
In the surveyor’s words
What an F881 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 failed to ensure the implementation of an effective antibiotic stewardship program, including adherence to evidence-based criteria and accurate tracking of antibiotic use, for 3 of 10 residents (R3, R13, R97) reviewed for antibiotic therapy. R97 was prescribed an antibiotic the identified organism was resistant to in April 2026. R97 then developed 3 more UTIs over the following weeks and developed resistance to two additional antibiotics. R97 eventually required treatment with IV (intravenous) antibiotics to treat their urinary tract infection. …
Licensure Reference Number 175 NAC 1-005.06(C)Licensure Reference Number 175 NAC 12-006.18Based on record review and interview the facility failed to as part of their infection control program to maintain policies and procedures for antibiotic stewardship. This had the potential to affect all of the residents residing in the facility. The facility census was 54.Findings are:Record review of a facility policy titled Antibiotic Stewardship Program and dated 06/01/2026 revealed it was the policy of the facility to implement an Antibiotic Stewardship Program as part of the facilities overall infection prevention and control program. …
Based on observations, review of facility policy and interviews the facility failed to ensure antibiotic stewardship tracking and monitoring for review of antibiotic usage rates was completed. Based on observation(s), review of facility documentation, facility policy and interviews the facility failed to ensure antibiotic stewardship tracking and monitoring for review of antibiotic usage rates was completed.Interview and review of facility documentation with Licensed Practical Nurse (LPN) #4 on 7/22/26 at 10:42 AM identified there was no consistent mechanism for antibiotic stewardship tracking and monitoring of the rate of antibiotic use with review of those rates with the practitioners. …
By state — 2025
Where F881 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- Missouri1.99× · 36 citations
- Ohio1.91× · 59 citations
- California1.30× · 99 citations
- Illinois1.06× · 34 citations
Co-occurrence
Cited alongside F881
Of the 2025 surveys that cited F881, these tags appeared in the same inspection more often than chance would predict.
- F88210.6% of F881 surveys · 14.0× chance
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
- F88716.1% of F881 surveys · 10.7× chance
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.
- F88320.7% of F881 surveys · 7.9× chance
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- F8657.3% of F881 surveys · 7.4× chance
Have a plan that describes the process for conducting QAPI and QAA activities.
- F75620.9% of F881 surveys · 6.4× chance
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Cited in the same inspection, not caused by one another.
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