Inspection·August 15, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative in writing of the transfer and reason for hospitalization for one of 31 residents reviewed (Resident 54). Findings include: A nursing note for Resident 54, dated May 20, 2024, revealed that the resident was admitted to the facility that afternoon. A nursing note for Resident 54, dated May 25, 2024, revealed that the writer received a call from the resident's son at 7:28 p.m. that the resident was not answering her cell phone. The resident's son stated that he felt that the resident has had a decline over the last few days. The writer relayed information to the resident's son that she received in report about the resident's increased weakness and orthostatic blood pressures (a condition where blood pressure drops suddenly when someone stands up from a sitting or lying position). The writer assured the resident's son that she would go back and assess the resident, update him, and make sure the resident's phone was charged and within reach. The writer went into the resident's room to assess her. The resident was alert and oriented, and appeared very fatigued and weak. The resident appeared to have had a significant decline since admission. The resident stated that she has episodes of dizziness, especially with standing. Orthostatic blood pressures were monitored, and a significant change was noted when going from a sitting to a standing position. The resident was tearful during the conversation, stating that she feels like she is going backward instead of forward. The resident reported, I just don't feel well. I am weak and have no energy. The resident stated that she felt that she should be evaluated at the hospital. The resident's son was notified of the transfer to the hospital, and the resident was transported to the hospital via ambulance at 8:14 p.m. The resident took her cell phone, charger, and glasses with her to the hospital. There was no documented evidence that a written notice of Resident 54's transfer to the hospital was provided to the resident and/or resident's representative regarding the reason for transfer. Interview with the Nursing Home Administrator on August 15, 2024, at 3:35 p.m. confirmed that the facility did not provide a written notice to the resident and/or the resident's representative when the resident was transferred to the hospital, because the resident was her own responsible party. 28 Pa. Code 201.25 Discharge Policy. 28 Pa. Code 201.29(f)(g) Resident Rights. 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 Page 1 of 4 Event ID: 395661 Printed: 05/15/2026 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 395661 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casselman Healthcare and Rehabilitation Center 201 Hospital Drive Meyersdale, PA 15552 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)