Casper Mountain Rehabilitation And Care Center

F 0553

c. Review of the resident's care plan showed it was last revised on 7/24/25.

Level of Harm - Minimal harm or potential for actual harm

1. 4. Interview with the interim DON on 8/26/25 at 5:42 PM revealed care conferences were held on a

quarterly basis. Further interview revealed there was no evidence the residents participated in the planning process.

Residents Affected - Some

2. 5. Review of the Care Planning-Resident Participation policy and procedure showed .The facility will

discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes.

The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan .

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casper Mountain Rehabilitation and Care Center

4305 S Poplar Casper, WY 82601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure the advanced directive was formulated and accurate for 2 of 28 sample residents (#84, #93) reviewed. The findings were: 1. Review of the electronic medical record (EMR) showed resident #84 was listed as do not resuscitate (DNR). Further review of the medical record showed no evidence the resident had signed and dated an advance directive. Interview with the interim DON and MDS coordinator on [DATE REDACTED] at 5:37 PM confirmed there was no evidence the resident had elected a DNR status.

1. 2. Review of the EMR showed resident #93 was listed as a full code status. Review of a cardiopulmonary

resuscitation (CPR) designation form provided by the interim DON on [DATE REDACTED] at 4:48 PM was initialed No, do not administer CPR and signed and dated by the resident on [DATE REDACTED]. Interview with the interim DON on [DATE REDACTED] at 4:48 PM confirmed the EHR did not match the most recent election of no CPR.

2. 3. Review of the Advance Directive policy showed . 7. Prior to or upon admission of a resident, the social

services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 8. If the resident indicates that he or

she has not established advance directives, the facility staff will offer assistance in establishing advance directives .10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive .

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casper Mountain Rehabilitation and Care Center

4305 S Poplar Casper, WY 82601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Level of Harm - Potential for minimal harm

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure the appropriate Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) were issued correctly for 2 of 3 sample residents (#13, #32). The findings were: 1. Review of the NOMNC/ABN for resident #13 indicated the last covered day for Medicare Part A services was 2/7/25. The following concerns were identified:a. Review of the NOMNC form showed a written note of Verbal received by [resident #13's representative] and the form was signed by the social services director on 2/4/25.b. Review of the SNF ABN form provided by the facility for resident #13 showed resident #32's name was at the top of the form. The form showed Medicare may not pay for physical therapy/occupational therapy following discharge from Medicare Part A services; however, the reason Medicare may not pay or the estimated cost was not included on the form. The form showed a written note of Verbal received by [resident #13's representative] and the form was signed by the social services director on 2/4/25.2. Review of the SNF ABN form for resident #32 indicated the last covered day for Medicare Part A services was 4/14/25. The form showed Medicare may not pay for Skilled nursing and skilled therapy; however, the reason Medicare may not pay or the estimated cost was not included on the form. 3. Interview with the interim DON and MDS coordinator on 8/26/25 at 5:37 PM confirmed the NOMNC and ABN forms were inaccurate.4. Review of the Medicare Advanced Beneficiary Notice policy showed Residents are informed in advance when changes will occur to their bills .1. If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled services(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). a. The facility issues the Skilled Nursing Facility Advanced Beneficiary Notice .to the resident prior to providing care that Medicare usually covers, but may not pay for because the care is considered not medically reasonable and necessary, or custodial. b. The resident (or representative) may choose to continue receiving the skilled services that may not be covered, and assume financial responsibility. 2. If the resident's Medicare Part A benefits are terminating for coverage reasons, the director of admissions or benefits coordinator issues the Notice of Medicare Non-Coverage .to the resident at least two calendar days before Medicare covered services end (for coverage reasons). a. The Notice of Medicare Non-Coverage informs the resident of the pending termination of coverage and of his/her right to an expedited review of service determination .

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casper Mountain Rehabilitation and Care Center

4305 S Poplar Casper, WY 82601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure residents were free from unnecessary medications for 2 of 5 residents (#9, #20) reviewed for unnecessary medications. The findings were:

1. 1. Review of the 3/10/25 quarterly MDS assessment showed resident #9 was admitted to the facility on

[DATE REDACTED] and had a diagnosis of schizophrenia. The resident was coded as receiving antipsychotic, antianxiety, and antidepressant medications during the 7-day look-back period. The last attempted gradual dose reduction (GDR) was documented as occurring on 12/31/24. The following concerns were identified: a. Review of the 8/24/25 Psychotropic Medication Utilization Report showed the resident was prescribed quetiapine fumarate (antipsychotic) and buspirone hydrochloride (an antianxiety medication), for paranoid schizophrenia with the last risk-benefit statement completed on 9/17/24; however, 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 as noted on the 3/10/25 quarterly MDS assessment. b. Review of the physician orders showed the resident was prescribed 1 milligram (mg) of lorazepam (an antianxiety medication) every 8 hours as needed (PRN) on 8/1/25 for comfort focused care; however, no stop date was indicated. Review of the August 2025 medication administration record showed the resident had not been administered a PRN dose of lorazepam during the month. c. Interview with the interim DON on 8/27/25 at 12:56 PM confirmed the physician order for PRN lorazepam did not have a stop date. In addition, the interim DON revealed she was currently working on organizing the psychotropic medication review process. An additional interview with the interim DON at 3:15 PM confirmed

the GDR documentation for resident #9 could not be located.

2. 2. Review of the 6/26/25 quarterly MDS assessment showed resident #98 was admitted to the facility on

[DATE REDACTED] and had a diagnosis of depression. The resident was coded as receiving antipsychotics and antidepressants during the 7-day look-back period. The MDS showed no GDR was attempted or documented as being clinically contraindicated. The following concerns were identified: a. Review of the physician orders showed that the resident was prescribed 100 mg of Sertraline daily for depression on 1/23/24. b. Review of the 10/28/24 Medication Regimen Review, signed by the physician, showed that no reduction of Sertraline was ordered at that time, and no clinical rationale was documented. c. Interview with the interim DON on 8/27/25 at 11:30 AM confirmed that no GDR was attempted and no rationale was documented for the resident.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casper Mountain Rehabilitation and Care Center

4305 S Poplar Casper, WY 82601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0628

such notices .

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casper Mountain Rehabilitation and Care Center

4305 S Poplar Casper, WY 82601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

Based on medical record review, staff interview, and review of the MDS RAI manual, the facility failed to ensure MDS assessments were accurate for 3 of 28 sample residents (#10, #12, #55). The findings were:

Residents Affected - Few

1. 1. Review of the 2/9/22 Wyoming PASRR (pre-admission screening and resident review) Level II

Determination Summary Report showed resident #12 had psychiatric diagnoses which included bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, and sleep terror. Further review showed the resident met the state definition of mental illness. The following concerns were identified: a. Review of the 7/1/25 annual MDS assessment showed section A1500 was marked no to the question if

the resident was currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability. b. Interview on 8/26/25 at 2:38 PM with the MDS coordinator confirmed section A1500 was marked inaccurately.

2. 2. Review of the 4/18/25 annual MDS assessment for resident #55 showed section GG (used to assess

functional abilities and goals) was marked as not assessed. Interview on 8/26/25 at 2:38 PM with the MDS coordinator revealed the facility did not have staff available at that time to perform the assessment so section GG was dashed out.

3. 3. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User Manual version

1.19.11 last revised October 2024 showed .A1500: Preadmission Screening and Resident Review (PASRR) .code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1520, Level II Preadmission Screening and Resident Review (PASRR) Conditions. Section GG of the RAI manual showed the intent of this section included items focused on prior function, admission and discharge performance, discharge goals, performance throughout

a resident's stay, mobility device use, and range of motion. Functional status was assessed based on the resident's need for assistance when performing self-care and mobility activities.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casper Mountain Rehabilitation and Care Center

4305 S Poplar Casper, WY 82601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Actual harm

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. Review of a physician note, dated 5/15/25, showed the resident had a nickel sized unstageable pressure ulcer located on his/her right buttocks with orders for wound care and monitoring. Review of the medical record showed no treatment orders for wound care or monitoring.b.

Review of the skilled nursing evaluation, dated 5/21/25 and timed 1:30 PM, showed the resident had an abraded area noted to the buttocks and cream was applied by RN #1. c. Review of the skilled nursing evaluation, dated 5/22/25 and timed 11:25 PM showed new pressure ulcers were present to the right and left heels, left medial calf, and an abrasion to the coccyx. Further review showed RN #1 notified the DON of

the new ulcers, the DON observed pressure areas, and the DON planned to discuss the new ulcers with

the certified wound nurse regarding treatment options. d. Review of a physician note dated 5/25/25 showed

the resident had prevalon boots and orders to continue with wound care until completely healed. Review of

the resident's medical record showed no evidence the prevalon boots, or wound care was added to the orders until 5/27/25. e. Interview with the resident's representative on 8/27/25 at 5:12 PM revealed the resident had been sent to the emergency room for another matter on 5/26/25 and the physician found concerning pressure ulcers on the resident's heels and buttocks. The resident did not return to the facility following the emergency room visit.f. Interview with the interim DON on 8/27/25 at 5:30 PM confirmed there were no wound care orders or documentation the facility was treating the resident's pressure ulcers prior to 5/27/25, after the resident had discharged .

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casper Mountain Rehabilitation and Care Center

4305 S Poplar Casper, WY 82601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the interim DON's pharmacist monthly medication

review binder, the facility failed to have a system in place to ensure the pharmacist's monthly medication reviews and recommendations were acted upon and documented in the resident's record for 1 of 5 sample residents (#9) reviewed for unnecessary medications. The findings were: Review of the 3/10/25 quarterly MDS assessment showed resident #9 was admitted to the facility on [DATE REDACTED] and had a diagnosis of schizophrenia. The resident was coded as receiving antipsychotic, antianxiety, and antidepressant medications during the 7-day look-back period. Review of the resident's medical record and the interim DON's pharmacist monthly medication review binder showed no evidence the pharmacist had performed a monthly medication review which included any irregularities or recommendations for March, April, May, or June of 2025. Interview with the interim DON on 8/27/25 at 12:56 PM revealed she was in the process obtaining the missing documentation and updating the binder.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casper Mountain Rehabilitation and Care Center

4305 S Poplar Casper, WY 82601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation and staff interview, the facility failed to ensure a sanitary environment in 1 of 1 food preparation area. The census was 82. The findings were: 1. Observation on 8/24/25 at 1:10 PM showed an upright fan was blowing on a food preparation area located in front of the 3-compartment sink. On the food preparation counter was a cutting board and knife. The fan was darkened and soiled with debris. Further

observation showed a rack used to store clean utensils and cookware was located directly behind the hooded gas cooking area. Between the grill/oven area and the storage rack were pipes that were visibly dirty and soiled.2. Observation on 8/26/25 at 9:04 AM showed the upright fan was blowing on the same food preparation area where dietary aide #1 was preparing individual syrup cups for residents. Interview with the dietary manager and cook #1 at that time confirmed the fan was not clean. [NAME] #1 immediately disconnected the fan and took it apart to clean it. The area behind the grill/oven remained the same.3.

Interview with the dietary manager on 8/26/25 at 12:15 PM confirmed the area behind the grill/oven area was not clean and was not included on the cleaning schedule.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casper Mountain Rehabilitation and Care Center

4305 S Poplar Casper, WY 82601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

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. Observation on 8/25/25 at 9:25 AM showed resident #84 was in bed and his/her catheter bag was placed in a dignity bag and lying flat on the floor. Interview with the interim DON and the ADON on 8/26/25 at 3:14 PM confirmed catheter bags should not be placed directly on the floor. 2. Review of the Legionella Water Safety Program policy, dated 7/29/25 showed control measures had been identified and the facility was to Maintain logs for each control measure, including corrective actions taken for out-of-range values. Review data monthly to detect trends or deficiencies. Interview with the NHA on 8/27/25 at 2:15 PM revealed the water management plan for Legionella had not been implemented. 3.

Observation on 8/24/25 at 1 PM showed several residents had been confined to their room due to a gastrointestinal outbreak with symptoms of nausea, diarrhea, and vomiting. Review of the Outbreak Investigation Tool showed the outbreak began on 8/22/25 and involved 14 residents. Review of the state licensing agency incident data base showed no evidence the facility had reported an infectious disease outbreak. Interview with the interim DON on 8/27/2025 at 3:41 PM revealed she was unaware of the requirement.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casper Mountain Rehabilitation and Care Center

4305 S Poplar Casper, WY 82601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policies, the facility failed to have a system in place to maintain documentation residents were provided education regarding the benefits and potential side effects of the pneumococcal and influenza vaccines and documentation of the consent or refusal of the immunization for 1 of 4 sample residents (#59) reviewed for immunizations. The findings were: 1. Review of

the 8/8/25 annual MDS assessment showed resident #59 was admitted to the facility on [DATE REDACTED]. Further

review of the MDS assessment showed the resident was offered and had declined the influenza and pneumococcal vaccines. Further review of the medical record failed to show evidence the resident was educated on the benefits and risks of the vaccines and a copy of the consent/declination form was maintained. 2. Interview with the interim DON and ADON on 8/26/25 at 3:14 PM confirmed no further documentation was available. 3. Review of the Influenza Vaccine policy showed 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized .4. Prior to

the vaccination, the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine .Provision of such education shall be documented in the resident's/employee's medical record. 5. For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's/employee's medical record. 6. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record. 4. Review of the Pneumococcal Vaccine policy showed 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series .3. Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding

the benefits and potential side effects of the pneumococcal vaccine .Provision of such education is documented in the resident's medical record .5. Residents/representatives have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medical record indicating

the date of refusal of the pneumococcal vaccination. 6. For each resident who receives the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination are documented in the resident's medical record .

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casper Mountain Rehabilitation and Care Center

4305 S Poplar Casper, WY 82601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of policy and procedures, the facility failed to have a system in place to maintain documentation residents were provided education regarding the benefits and potential side effects of the COVID-19 vaccination and documentation of the consent or refusal of the immunization for 4 of 4 sample residents (#9, #10, #59, #84) reviewed for immunizations. The findings were: 1. Review of the 7/28/25 quarterly MDS assessment for resident #9 showed s/he was admitted to the facility on [DATE REDACTED] and was coded as not being up-to-date on the COVID-19 vaccination. Further review of

the medical record failed to show evidence the resident was educated on the benefits and risks of the vaccines and a copy of the consent/declination form was maintained. 2. Review of the 8/8/25 quarterly MDS assessment for resident #10 showed s/he was admitted to the facility on [DATE REDACTED] and was coded as not being up-to-date on the COVID-19 vaccination. Further review of the medical record failed to show evidence the resident was educated on the benefits and risks of the vaccines and a copy of the consent/declination form was maintained. 3. Review of the 8/8/25 annual MDS assessment for resident #59 showed s/he was admitted to the facility on [DATE REDACTED] and was coded as not being up-to-date on the COVID-19 vaccination. Further review of the medical record failed to show evidence the resident was educated on the benefits and risks of the vaccines and a copy of the consent/declination form was maintained. 4. Review of the 6/22/25 quarterly MDS assessment fore resident #84 showed s/he was admitted to the facility on [DATE REDACTED] and was coded as not being up-to-date on the COVID-19 vaccination.

Further review of the medical record failed to show evidence the resident was educated on the benefits and risks of the vaccines and a copy of the consent/declination form was maintained. 5. Interview with the interim DON and ADON on 8/26/25 at 3:14 PM confirmed no further documentation was available. 6.

Review of the Coronavirus Disease (COVID-19) - Vaccination of Residents policy showed Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident is fully vaccinated. 1. Residents who are eligible to receive the COVID-19 vaccine are strongly encouraged to do so. 2. The resident (or resident representative) can accept or refuse a COVID-19 vaccine and can change his/her decision. 3. COVID-19 vaccine education, documentation and reporting are overseen by the infection preventionist and coordinated by his or her designee .6. Before the COVID-19 vaccine is offered,

the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine .10. Residents must sign a consent to vaccinate form prior to receiving the vaccine. The form is provided to the resident in a language and format understood by the resident or representative

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