Deficiency Records for Casper Mountain Rehabilitation and Care Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Casper Mountain Rehabilitation and Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-08-03 | 2023-08-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-03 | 2023-08-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-21 | 2023-06-26 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-03-21 | 2023-05-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-14 | 2023-04-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-14 | 2023-04-18 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2023-03-21 | 2023-04-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-23 | 2023-03-23 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-03-23 | 2023-03-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-23 | 2023-03-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-23 | 2023-03-23 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-23 | 2023-03-23 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-03-23 | 2023-03-23 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-23 | 2023-03-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-21 | 2022-11-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-19 | 2022-11-10 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-19 | 2022-11-10 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-05-18 | 2022-06-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-18 | 2022-05-20 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-12-16 | 2022-03-10 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-12-16 | 2022-02-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-12-16 | 2022-02-15 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-12-16 | 2022-02-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-12-16 | 2022-02-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-12-16 | 2022-02-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-12-16 | 2022-02-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-16 | 2022-02-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-16 | 2022-02-15 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-12-16 | 2022-02-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-17 | 2022-01-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-12-17 | 2022-01-19 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-12-17 | 2022-01-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-17 | 2022-01-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-17 | 2022-01-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-17 | 2022-01-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-17 | 2022-01-19 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-17 | 2022-01-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-17 | 2022-01-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-09 | 2021-12-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-15 | 2021-10-04 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-10-15 | 2021-10-04 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-01-09 | 2020-02-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-09 | 2020-02-18 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-01-09 | 2020-02-13 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2020-01-09 | 2020-02-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-09 | 2020-02-13 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-01-09 | 2020-02-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-09 | 2020-02-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-07 | 2020-02-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-01-07 | 2020-02-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-07 | 2020-02-13 | N |
