Based on record review and interview, the facility did not offer and/or administer the influenza immunization to each resident, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and benefits of the influenza and immunization for 1 of 6 (R64) residents reviewed for immunizations that resulted in actual harm, and 2 of 6 residents (R34 and R27) reviewed for immunizations that resulted in the potential for harm. R64 consented to have the influenza immunization upon admission to the facility. …
F883 citations in Wisconsin
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
Wisconsin cites F883 more often than its own record predicts
1.49 times the share F883 takes of citations nationally.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F883 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 interview and record review, the facility did not ensure 2 residents (R) (R8 and R19) of 8 sampled residents received pneumococcal vaccines as indicated. The facility did not review R8's vaccination history and offer the PCV20 (Prevnar 20 vaccine) or influenza vaccine. The facility did not review R19's vaccination history and offer the PCV20 vaccine. Findings include: The facility's Pneumococcal Vaccine policy, dated March 2023, indicates: All residents will be offered the pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23) and pneumococcal conjugate vaccine (PCV20, Prevnar 20) to aid in preventing pneumococcal infection. …
[NAME] 5 of 5 reviewed for immunization No documentation of risk benefit in the medical record for 5 of 5 residents reviewed for immunizations. FACILITY Infection Control 02/17/25 10:10 AM interview with NHA and [NAME] Regional Director New in position Surveyor Explained what we are missing. While it shows weekly flushing of hoppers and toilets. It does not indicate tracking of which ones are done. The closed unit is done once a month per interview. Temperatures need to be kept above 140 and there is no documentation this is done. Maintenance says they do temp tanks and valves, but they keep it in their head and call a plumber if temps are outside the proper temp range. Interviews state they keep that in their head. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 1.84% | 2.08× |
| 2024 | 1.15% | 1.52× |
| 2025 | 0.95% | 1.49× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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