Based on staff interview and policy and procedure review, the facility failed to ensure a system to monitor antibiotic usage. The census was 74. The findings were:1. Interview with the infection preventionist on 7/24/25 at 8:45 AM revealed physicians ordered antibiotics while labs were pending and would change the antibiotic when the results were obtained. He revealed antibiotics were reviewed at the end of the month and not when they were ordered. He confirmed the facility had not implemented an antibiotic stewardship program.2. Review of the facility policy titled Antibiotic Stewardship Program (ASP) dated 2016 showed .5. Tracking a. IP [infection preventionist] will be responsible for infection surveillance and MDRO [multi-drug resistant organisms] tracking b. …
F881 citations in Wyoming
Antibiotic stewardship · Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Wyoming cites F881 more often than its own record predicts
2.32 times the share F881 takes of citations nationally.
Of every deficiency written in Wyoming in 2025, this is the portion that was F881.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Wyoming surveyors wrote
F881 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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