Federal inspectors found that Casper Mountain Rehabilitation and Care Center failed to evaluate hazards and implement measures to reduce risks for the wheelchair-bound resident, who has diabetes, morbid obesity, muscle weakness and gout.
The resident, who scored 15 out of 15 on cognitive testing, told inspectors on December 29 that they caught their leg in the facility's courtyard doorway while in their wheelchair in June and sustained a fractured leg.
Medical records confirmed the account. An orthopedic physician's note from June 26 showed the resident reported right ankle and leg pain after getting their foot caught on the facility door. X-ray results from July 1 revealed an acute, nondisplaced oblique fracture through the distal tibial diaphysis.
The accidents didn't stop there.
A skin injury note from October 28 documented that the resident sustained a large bruise to their left calf after bumping their leg into a bed. The resident confirmed to inspectors that they hit their leg on their bed in October while in the electric wheelchair.
Despite two separate wheelchair-related injuries within four months, facility staff never assessed the resident's wheelchair skills or safety needs.
The Physical and Occupational Therapy Director told inspectors on December 30 that no wheelchair skill or safety assessment was completed following either the June leg fracture or the October bed collision.
A registered nurse confirmed to inspectors that safety assessments should have been completed on all residents who required power wheelchairs.
The resident's care plan from November 6 noted they "mobilized independently in a motorized w/c" and included an intervention to educate the resident on proper use of mobility devices that began May 29. But no additional interventions addressed wheelchair safety, even after the documented accidents.
The inspection found the facility failed to identify and implement measures to reduce hazards for the resident, who has functional limitations of the lower extremities and requires the electric wheelchair for mobility.
The resident's medical history showed multiple conditions that could affect mobility and safety, including muscle weakness and morbid obesity, yet staff provided no specialized safety evaluation after the doorway incident resulted in a fractured bone.
Federal regulations require nursing homes to ensure areas are free from accident hazards and provide adequate supervision to prevent accidents. The facility's failure to conduct safety assessments after repeated wheelchair-related injuries violated this requirement.
The first accident occurred when the resident's foot became trapped in the courtyard doorway, causing enough force to fracture the tibia. Four months later, the resident struck their bed while maneuvering the electric wheelchair, causing significant bruising to the opposite leg.
Both incidents involved the same piece of mobility equipment and the same resident, yet triggered no systematic review of wheelchair safety or environmental hazards.
The inspection narrative shows the facility had documented the resident's need for wheelchair safety education as early as May, months before the doorway fracture. However, this education intervention apparently failed to prevent either subsequent accident.
The Physical and Occupational Therapy Director's admission that no assessments were completed following either injury suggests a pattern of reactive rather than preventive care for mobility device users.
The resident remains cognitively intact, with a perfect score on mental status testing, indicating they were fully aware of both accidents and their circumstances when speaking with inspectors.
The facility received a citation for minimal harm with potential for actual harm affecting few residents. The violation indicates systemic problems with hazard identification and risk reduction that could affect other wheelchair users at the facility.
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 2025-12-30 including all violations, facility responses, and corrective action plans.