Based on staff interview, and review of compliance history information, the facility failed to develop and implement policies and procedures for how it will develop, monitor and evaluate performance indicators to prevent repeat deficiencies from previous surveys. The census was 23. The findings were: 1. Review of the [NAME] 3 report last updated on 2/8/23 showed F727 was previously cited on 3/2/22, F758 was previously cited on 3/2/22, and F880 was previously cited on 3/2/22 as well as in 2021 and 2018. 2. …
F867 citations in Wyoming
QAPI improvement activities · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2023
Wyoming cites F867 more often than its own record predicts
1.14 times the share F867 takes of citations nationally.
Of every deficiency written in Wyoming in 2023, this is the portion that was F867.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wyoming surveyors wrote
F867 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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