Casper Mountain Rehab: Psychotropic Drug Violations - WY
The August inspection revealed systematic failures in the facility's management of psychotropic drugs, which can severely impair elderly residents' ability to function when used improperly.
Resident #9, diagnosed with schizophrenia, was prescribed three categories of psychiatric medications including the antipsychotic quetiapine fumarate and the anxiety drug buspirone hydrochloride. Federal records showed the facility's last risk-benefit statement for these medications was completed nearly a year ago on September 17, 2024.
The facility claimed it attempted a gradual dose reduction on December 31, 2024, as required by federal regulations. But when inspectors asked to see the documentation, staff couldn't find it.
"The facility was unable to locate the risk-benefit statement signed by the resident's physician or documentation to support the 12/31/24 GDR," inspectors wrote.
More troubling was a separate anxiety medication prescribed for the same resident. On August 1, physicians ordered 1 milligram of lorazepam every eight hours as needed for "comfort focused care." The order contained no stop date, meaning it could theoretically continue indefinitely.
Records showed the resident never actually received a dose of lorazepam during the entire month of August, raising questions about why the medication remained active.
The interim director of nursing confirmed during interviews that the lorazepam order lacked a stop date. She told inspectors at 12:56 PM that she was "currently working on organizing the psychotropic medication review process" — suggesting the system had broken down entirely.
Three hours later, at 3:15 PM, the same director confirmed that staff still couldn't locate the required dose reduction documentation for resident #9.
The second case involved resident #98, who had been prescribed 100 milligrams of Sertraline daily for depression since January 23, 2024. Federal law requires facilities to attempt gradual dose reductions of psychiatric medications unless clinically contraindicated.
The facility never tried to reduce this resident's antidepressant dose. They also never documented why a reduction would be harmful.
A medication review completed on October 28, 2024, and signed by the resident's physician, showed no reduction was ordered. The document contained no clinical rationale explaining why the full dose remained necessary.
The interim director of nursing admitted during her 11:30 AM interview that no dose reduction was attempted and no rationale was documented for resident #98.
Federal regulations require nursing homes to minimize the use of psychotropic medications, which can cause falls, confusion, and other serious side effects in elderly residents. Facilities must regularly attempt to reduce doses unless there's a documented medical reason to continue the current level.
The violations affected residents receiving some of the most powerful psychiatric medications available. Quetiapine, originally developed for schizophrenia, is an antipsychotic that can cause sedation, weight gain, and movement disorders. Lorazepam belongs to a class of drugs that significantly increases fall risk in elderly patients.
Both residents' cases revealed the same pattern: missing documentation, absent safety reviews, and a director of nursing who acknowledged the facility's medication oversight had collapsed.
The inspection occurred following a complaint, though the specific nature of that complaint wasn't disclosed in federal records. Inspectors found the violations caused minimal harm but created potential for actual harm to residents.
Casper Mountain Rehabilitation operates as a 120-bed facility in Wyoming's largest city. The medication violations represent the facility's failure to protect some of its most vulnerable residents — those whose psychiatric conditions make them dependent on staff to monitor their treatment safely.
The facility has not yet submitted its plan of correction to federal regulators.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Casper Mountain Rehabilitation and Care Center from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Casper Mountain Rehabilitation and Care Center in Casper, WY was cited for violations during a health inspection on August 27, 2025.
Federal records showed the facility's last risk-benefit statement for these medications was completed nearly a year ago on September 17, 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.