Based on interview and record review, the facility failed to offer the influenza vaccine at the start of influenza season for two of nine residents (R40, R4) reviewed for Influenza Vaccines in the sample of 18. This failure contributed to the facility experiencing an Influenza Outbreak and the hospitalization of R40 and R4. The findings include: 1. R40's Admission Record shows she was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, anxiety disorder, major depressive disorder, bipolar disorder, and chronic pain. R40's MDS (Minimum Data Set) dated December 23, 2024 shows she is cognitively intact. R40's Progress Notes dated December 18, 2024 shows she was admitted to the local hospital with pneumonia and influenza A. …
F883 citations in Illinois
Flu and pneumonia vaccines · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Illinois cites F883 more often than its own record predicts
1.25 times the share F883 takes of citations nationally.
Of every deficiency written in Illinois in 2025, this is the portion that was F883.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F883 findings written in Illinois, 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 interview and record review the facility failed to administer the influenza vaccine to a resident during flu season. The facility failed to educate, offer, and administer pneumococcal immunizations to residents. These failures apply to 4 of 5 residents (R21, R22, R5, R32) reviewed for immunizations in the sample of 37.The findings include:R21's admission Record showed R21 was admitted to the facility on [DATE]. R21's immunization record dated 7/14/26 showed no documentation the facility educated, offered, or administered the pneumococcal immunization to R21.R22's admission Record showed R22 was admitted to the facility on [DATE]. …
Based on interview and record review the facility failed to offer both the 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23) and the 13-valent pneumococcal conjugate vaccine (PCV13) to all residents. This applies to all 188 residents in the facility. The findings include: On 3/11/20 at 8:14 AM V2(Director of Nursing) and V3 (Assistant Director of Nursing) stated, The consent for the pneumonia vaccine is done with admission. I think the consent says Prevnar 13 but I'm not sure which one we give. I print out the log from the electronic medical record. It shows who has had it and who hasn't. Review of the pneumonia vaccine for 5 residents shows the following: R104 received PCV13 on 2/24/05 prior to admission and was never offered the PPSV23. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 1.30% | 1.48× |
| 2024 | 1.00% | 1.32× |
| 2025 | 0.79% | 1.25× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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