Based on record review and staff interviews, the facility failed to offer influenza and pneumococcal immunizations as required. In addition, there was no documentation the resident was provided education regarding the benefits and potential side effects of the influenza (flu) and pneumococcal immunizations. This occurred for 3 of 5 residents reviewed for immunizations (Residents #9, #79, and #3).The findings included:A review of the facility's Vaccines and Immunizations policy revealed the Policy Statement indicated, Minimize the risk of residents acquiring, transmitting, or experiencing complications from communicable diseases through immunizations by following Centers for Disease Control (CDC) Guidance found utilizing the link below. https://www.cdc.gov/vaccines/hcp/current-vis/. …
F883 citations in North Carolina
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
North Carolina cites F883 more often than its own record predicts
1.14 times the share F883 takes of citations nationally.
Of every deficiency written in North Carolina 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 North Carolina surveyors wrote
F883 findings written in North Carolina, 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 record review and staff interviews, the facility failed to include documentation in the medical record of education regarding the benefits and potential side effects of the Influenza and Pneumococcal Immunizations for 3 of 5 residents reviewed for infection control (Resident #138, #53, and #47). The findings included: 1.a. Resident #138 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment (MDS) dated [DATE] indicated Resident #138 had moderate cognitive impairment, and the influenza as well as the pneumococcal immunizations were checked as not up to date or offered (section O300). A review of the immunization section of the medical record profile for Resident #138, revealed no documentation related to influenza or pneumococcal immunization status. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 1.01% | 1.15× |
| 2024 | 0.80% | 1.05× |
| 2025 | 0.72% | 1.14× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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