Based on review of the facility policy and staff interviews, it was determined that the facility failed to implement an antibiotic stewardship program for 12 of 12 months (June 2025 to May 2026). Findings include: Review of facility Antibiotic Stewardship Program policy last reviewed 7/15/26, indicated the facility implements an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose if the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Review of the facility's Infection Control Program from June 2025 to May 2026, failed to include documented evidence that antibiotic (medications used to treat infections) monitoring was completed timely. …
F881 citations in Pennsylvania
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
Pennsylvania cites F881 less often than its own record predicts
0.50 times the national share — cited less often here than elsewhere.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F881 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 review of facility policy and infection control documentation, and staff interview, it was determined that the facility failed to develop and implement an antibiotic stewardship program. Findings include: Review of the facility policy Antibiotic Stewardship Program, dated 11/01/25, revealed it is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.16% | 0.34× |
| 2024 | 0.48% | 1.08× |
| 2025 | 0.24% | 0.50× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania 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