Based on interview and record review, the facility failed to follow their policy and Centers for Disease Prevention and Control (CDC) guidance to offer and administer pneumococcal vaccinations to residents (R807, R801, R803, R811, R803 R815, R814, administer influenza vaccinations to residents who consented to receive them, screen and assess residents for eligibility of receiving pneumococcal vaccinations, and educate residents on risks versus benefits of the vaccination for any resident who resided in the facility since May 2022, resulting in facility acquired pneumonia for 20 residents between June 2022 and March 2023 and residents who wished to receive the influenza vaccination not being immunized against influenza. …
F883 citations in Michigan
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
Michigan cites F883 more often than its own record predicts
1.38 times the share F883 takes of citations nationally.
Of every deficiency written in Michigan 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 Michigan surveyors wrote
F883 findings written in Michigan, 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.
All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to offer and provide pneumococcal vaccinations to three Residents (#28, #44 & #1) of five residents reviewed for immunizations. This deficient practice resulted in R28 being hospitalized for pneumonia and subsequently expiring from pneumonia-associated complications. Findings include: Resident #28 (R28) R28 was admitted to the facility [DATE]. An annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 00 indicating R28 had severe cognitive impairment. R28's diagnoses included a primary medical condition of non-traumatic brain dysfunction. …
Based on observation, interview, and record review the facility failed to offer Pneumococcal immunizations in one (Resident 18) out of five reviewed for Pneumococcal immunizations. Findings include:Resident 18 (R18) Review of the medical record reflected R18 was admitted to the facility on [DATE], with diagnoses that included aphasia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/29/26, reflected R18 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 0.84% | 0.95× |
| 2024 | 1.13% | 1.50× |
| 2025 | 0.88% | 1.38× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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