Deficiency Index

F888 citations in Pennsylvania

Infection Control Deficiencies

Ensure staff are vaccinated for COVID-19

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

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F888 in Pennsylvania. Pick another state for the same tag.

Against expectation — 2023

Pennsylvania cites F888 less often than its own record predicts

Versus expected share0.32×

0.32 times the national share — cited less often here than elsewhere.

Share of Pennsylvania citations0.03%

Of every deficiency written in Pennsylvania in 2023, this is the portion that was F888.

Each state is measured against its own expected share, not against other states.

In the surveyor’s words

What Pennsylvania surveyors wrote

F888 findings written in Pennsylvania, 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.

K · Immediate jeopardy, patternAugust 9, 2022

Based on a review of observations, clinical records, facility employee vaccination data, and staff interviews, it was determined that the facility failed to implement policies and procedures to ensure that all staff were vaccinated for COVID-19 and mitigation actions for non-vaccinated staff were implemented. This failure created an Immediate Jeopardy situation for 32 of 103 residents not up-to-date with the COVID-19 vaccination, or for whom vaccination status is unknown (Residents R1, R5, R9, R11, R12, R13, R14, R15, R17, R18, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R31, R32, R33, R34, R , R37, R38, R39, R40, R41, R42, R43). …

Kadima Rehabilitation & Nursing at Irwin

G · Actual harm, isolatedFebruary 5, 2022

Based on a review of select facility policy, standards established by the Centers for Medicare and Medicaid Services and the facility's employee vaccination data and staff interviews, it was determined that the facility failed to fully develop and implement policies and procedures to ensure that all staff were vaccinated for COVID-19. Review of facility employee vaccination status information revealed, that as of February 5, 2022, the facility's staff vaccination rate was 98.3 % and there were four COVID resident infections since January 27, 2022 (Residents 29, 57, 73, and Resident 12) Findings include: According to the CMS Memorandum QSO-22-07 On November 5, 2021, CMS published an IFC with comment period (86 FR ), entitled Medicare and Medicaid Programs; Omnibus COVID-19 Health Care… …

Oak Ridge Rehabilitation & Healthcare Center

D · No harm, potential for more than minimal, isolatedMay 10, 2023

Based on review of policy, staff vaccination logs, personnel scheduling records, and staff interview, it was determined that the facility failed to ensure all working personnel completed their COVID-19 vaccination or completed a COVID-19 vaccination waiver for one of three unvaccinated employees reviewed (Licensed Nurse Employee E4). Findings include: Review of facility policy, COVID-19 Vaccine Policies and Procedures, last updated January 2022, revealed the purpose of the policy was to ensure all staff are vaccinated against COVID-19 unless they have a medical or religious exemption to help reduce the risk residents and staff have of contracting and spreading COVID-19. …

Susquehanna Health and Wellness Center

What else Pennsylvania surveyors cite →

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