Based on staff interviews, record review, and facility document review, the facility staff failed to establish an effective infection prevention and control program (IPCP) that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use for facility residents.Findings include: The facility staff failed to consistently monitor the assessment of antibiotic use.On 11/24/25 at approximately 1:45 PM, an interview was conducted with RN-2 on the facility's antibiotic stewardship program, and she replied, I am not sure as I don't know what that is, (name of the Infection Control Nurse) handles all of that.On 11/24/25 at approximately 2:10 PM, an interview was conducted with LPN-1 on did the facility have an antibiotic stewardship program and she… …
F881 citations in Virginia
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
Virginia cites F881 less often than its own record predicts
0.32 times the national share — cited less often here than elsewhere.
Of every deficiency written in Virginia 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 Virginia surveyors wrote
F881 findings written in Virginia, 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 staff interview and facility document review, it was determined the facility staff failed to conduct an ongoing antibiotic stewardship program. The findings include: There was no documentation of any antibiotic stewardship program. Upon entrance on 11/14/2022 a request was made for evidence of an antibiotic stewardship program. On 11/16/2022 at 5:25 p.m. ASM (administrative staff member) #2, the director of nursing, stated the facility had no documentation of an antibiotic stewardship program. ASM #2 stated there was no QA (quality assurance) documentation prior to September 2022. ASM #2 stated she had called the pharmacist who stated they (pharmacist) was not allowed to be involved in the antibiotic stewardship program before. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.20% | 0.43× |
| 2024 | 0.11% | 0.24× |
| 2025 | 0.15% | 0.32× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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