Based on record review and interview, the facility did not ensure all staff were fully vaccinated for COVID-19. The facility's current staff vaccination rate is 95.5% and is not at 100%. Findings include: On 3/31/22, the facility's policy titled Employee Inoculation COVID-19 Pandemic dated 11/8/21 was reviewed and read: All employees must be inoculated unless specifically exempted. On 3/31/22, Surveyor reviewed the NHSN (National Health Safety Network)'s most recent data for the facility dated 3/20/22. On 3/20/22, the facility's percentage of fully vaccinated staff for COVID-19 was noted at 90.2%. On 3/31/22, Surveyor was provided with facility's current staff vaccination rates as of 3/31/22. On 3/31/22, the facility's percentage of fully vaccinated staff for COVID-19 was noted at 95.5%. …
F888 citations in Wisconsin
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.
Against expectation — 2023
Wisconsin cites F888 more often than its own record predicts
2.79 times the share F888 takes of citations nationally.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F888 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 document review, facility policy review, and staff interviews, it was determined that the facility failed to ensure 1 (Certified Nursing Assistant [CNA] L) of 24 facility staff members were fully vaccinated for COVID-19. Findings included: Review of a facility policy titled, Employee COVID-19 Vaccinations, dated 10/24/2022, specified, It is the policy of this facility to ensure that all eligible employees are vaccinated against COVID-19 as per applicable Federal, State and local guidelines. The policy indicated, Individuals are considered fully vaccinated for COVID 14 days after receipt of the second dose of a two-dose primary vaccination series. 5. …
Based on observation, interview and record review, the facility did not implement policies and procedures to decrease the spread of COVID 19. The facility did not have a staff vaccination policy to mitigate those employees who were unvaccinated for COVID-19. The 16 staff members who were not vaccinated for COVID 19 were not required to take any extra precautions. At the time of the survey, the community transmission level was substantial. The facility chose to make facemasks optional. …
What else Wisconsin surveyors cite →
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