Casper Mountain Rehabilitation And Care Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
This requirement was not met as evidenced by: Based on medical record review, and staff, and resident interview, the facility failed to evaluate hazards and risks or identify and implement measures to reduce the hazards/risks as much as possible for 1 (#15) of 6 sample residents. The findings were: Review of the 9/22/25 quarterly MDS assessment showed resident #15 had a BIMS score of 15 out of 15, which indicated
the resident was cognitively intact, and had diagnoses which included diabetes mellitus, morbid obesity, muscle weakness, and gout. Further review showed the resident had functional limitations of the lower extremities, and required the use of an electric wheelchair (w/c). The following concerns were identified:1.Interview with the resident on 12/29/25 at 3:33 PM revealed that s/he had caught his/her leg in
the courtyard doorway at the facility while in his/her wheelchair in June 2025 and sustained a fractured leg. a. Review of the orthopedic physician's note dated 6/26/25 showed the resident had reported right ankle and leg pain after getting his/her foot caught on the facility door. b. Review of the resident's X-ray results of his/her right tibia and fibula dated 7/1/25 showed.1. An acute, nondisplaced oblique fracture through the distal tibial diaphysis.2. Review of a skin injury note dated 10/28/25 and timed 12:30 PM showed the resident had sustained a large bruise to his/her left calf after bumping his/her leg into a bed. Interview with
the resident on 12/29/25 at 3:33 PM confirmed that s/he had hit his/her leg on his/her bed in October while
in an electric wheelchair.3. Interview with the Physical and Occupational Therapy Director on 12/30/25 at 1:35 PM revealed there was not a wheelchair skill, or safety assessment completed on the resident, following the right leg fracture in June 2025, or after bumping his/her left leg on 10/28/25.4. Review of the care plan dated 11/6/25 showed the resident mobilized independently in a motorized w/c. An intervention to educate the resident on the proper use of mobility devices was initiated on 5/29/25. There were no additional interventions to address w/c safety.5. Interview with RN # 8 on 12/29/25 at 3 PM confirmed that safety assessments should have been completed on all residents who required power wheelchairs.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Casper Mountain Rehabilitation and Care Center in Casper, WY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Casper, WY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Casper Mountain Rehabilitation and Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.