Based on record review and staff interviews, the facility failed to implement a facility-wide system to monitor the use of antibiotics. This was evident for 8 of 9 months (July 2025, August 2025, September 2025, October 2025, November 2025, December 2025, February 2026, March 2026) that surveillance data was reviewed. This practice had the potential to affect all residents in the facility. Findings included: The facility's Antibiotic Stewardship Program policy last revised on December 2016, indicated that all clinical infections treated with antibiotics will undergo review by the Infection Preventionist or designee. …
F881 citations in North Carolina
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.
Against expectation — 2025
North Carolina cites F881 less often than its own record predicts
0.20 times the national share — cited less often here than elsewhere.
Of every deficiency written in North Carolina in 2025, this is the portion that was F881.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F881 findings written in North Carolina, 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 record review, staff interviews, and physician interviews, the facility failed to implement an Antibiotic Stewardship Program. Findings included: Record review of the Antibiotics Stewardship Policy dated 9/2014 and revised 1/22/2018 revealed the facility was responsible to utilize the pharmacy consultant and/or others regarding the appropriate use of antibiotics, provide prescribing practitioners with verbal or written feedback on their antibiotic prescribing practices quarterly, and education offerings on antibiotic stewardship and any developed antibiotic use protocols will occur bi-annually to prescribing practitioners and facility ' s staff. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.05% | 0.10× |
| 2024 | 0.08% | 0.18× |
| 2025 | 0.10% | 0.20× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina 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