Based on the review of the 10/28/21 recertification 2567, QAPI meeting minutes review and staff interview, the facility failed to ensure the QAPI program adequately addressed identified infection control concerns in 3 of 3 cottages (Founders, [NAME], [NAME]) where elders resided. The findings were: Review of the 10/28/21 recertification 2567 showed the facility was cited at F-880 for staff not wearing protective PPE as required in 2 of 4 cottages. Review of the 5/18/22, 6/9/22, 7/25/22, 8/15/22, and 9/21/22 QAPI meeting minutes showed the facility had a QAPI program with the required staff members, and issues were identified and addressed; however, the facility failed to address infection control concerns, which included staff wearing PPE as required in 3 of 3 cottages (Founders, [NAME],… …
F865 citations in Wyoming
QAPI program · Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
No F865 citations were recorded in Wyoming for 2025. That means none appear in the CMS file for that year — not that the requirement does not apply.
In the surveyor’s words
What Wyoming surveyors wrote
F865 findings written in Wyoming, 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.
What else Wyoming surveyors cite →
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