Casper Mountain Rehabilitation and Care Center

In the surveyor’s words

From the most serious findings on record at Casper Mountain Rehabilitation and Care Center, in the surveyor’s own words.

• Actual harm, isolatedF686Aug 27, 2025

  Based on resident representative and staff interview, and medical record review, the facility failed to provide services to prevent, treat, and heal pressure ulcers for 1 of 4 sampled residents (#98) reviewed for pressure ulcers. This failure resulted in actual harm to resident #98 who developed pressure ulcers. The findings were: 1. Review of the admission MDS assessment, dated 5/18/25, showed resident (#98) had a BIMS score of 3 out of 15, which indicated s/he had severe cognitive impairment, and diagnoses which include type 2 diabetes mellitus, chronic kidney disease, coronary artery disease, and heart failure. Further review showed no wounds were present upon admission and the resident was at risk for pressure ulcers / injuries. The following concerns were identified: a. […]

• Actual harm, isolatedF684May 16, 2025

  Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to implement treatment to maintain or improve conditions for 1 of 4 sample residents (#1) reviewed with non-pressure wound care. This failure resulted in actually harm to resident #1 who was transferred to the hospital and treated for an infection related to the wound. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #1 admitted to the facility on [DATE] and had a BIMS score of 15 out 15, which indicated the resident was cognitively intact. The resident had diagnoses which included congestive heart failure, hypertension, renal insufficiency, benign prostatic hyperplasia, and encephalopathy. […]

• Actual harm, isolatedF600May 18, 2022

  Based on medical record review, and resident interview and staff interview, the facility failed to ensure residents were free from physical abuse for 1 of 5 residents (#2) reviewed for behavioral symptoms. This failure resulted in harm to resident #2, who was punched in the face by another resident, and sustained bruises to the face and wrist. The findings were: 1. Review of the 5/4/22 quarterly MDS assessment for resident #1 showed the resident was admitted on [DATE] with diagnoses which included unspecified dementia with behavioral disturbance. The resident had severe cognitive impairment with a BIMS score of 4 out of 15. The resident also had physical and verbal behavioral symptoms on 1 to 3 days during the look back period. […]

• Actual harm, isolatedF600Oct 15, 2021

  Based on medical record review, resident and staff interview, and review of the facility's investigation, the facility failed to ensure residents were free from abuse for 1 of 6 sample residents (#1) with allegations of abuse. This failure resulted in actual harm to resident #1 who suffered pain, bruising, and emotional trauma resulting from assault by a staff member. Corrective measures were implemented by the facility and compliance was determined to be met on 10/4/21. The findings were: 1. Review of the 8/7/21 quarterly MDS assessment showed resident #1 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880Aug 27, 2025

  Based on observation, staff interview, review of the facility Outbreak Investigation Tool, State Licensing incident database review, and policy and procedure review, the facility failed to implement a water management program to prevent, detect, and control the risk of water-borne pathogens, failed to report an outbreak of infectious disease involving 14 residents, and failed to ensure effective infection control practices were followed during 2 random observations. The census was 82. The findings were: 1. Observation on 8/24/25 at 5:08 PM showed resident #84 was in bed and his/her catheter bag was lying flat on the floor. Interview with CNA #1 at that time revealed the bed did not have a place to hang the bag so it was put on the floor. […]