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. …
F881 citations in Wisconsin
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
Wisconsin cites F881 more often than its own record predicts
1.52 times the share F881 takes of citations nationally.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F881 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 staff interview and record review, the facility did not implement their antibiotic stewardship program to ensure the accurate use of antibiotics for 2 residents (R) (R28 and R40) of 2 sampled residents.R40 received antibiotic therapy in March 2026 for a urinary tract infection (UTI) that did not meet McGeer criteria.R28 received antibiotic therapy in March 2026 for an eye infection that did not meet McGeer criteria.Findings include:The facility's Antibiotic Stewardship Program, revised 11/18/22 indicates: The program includes antibiotic use protocol and a system to monitor antibiotic use .i. Nursing staff shall assess/gather data on residents who are suspected to have an infection and notify the physician .iii. …
Based on staff interview and record review, the facility did not ensure an antibiotic stewardship policy was developed to determine antibiotic use protocols and/or to monitor appropriate antibiotic usage which has the potential to affect all 110 residents that reside at the facility. The facility did not have a policy and/or procedures documenting an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Findings include: On 7/18/18, the Surveyor reviewed the facility's infection control program. An antibiotic stewardship policy was not provided to the Surveyor for review. On 7/18/18 at 2:23 PM, the Surveyor interviewed RN (Registered Nurse)-Q, who is responsible for the facility's infection control program. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.28% | 0.60× |
| 2024 | 0.59% | 1.33× |
| 2025 | 0.73% | 1.52× |
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