Inspection·January 31, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and staff interviews, it was determined that the facility failed to maintain a clean, homelike environment in the second floor ice room and in resident rooms for one of eight residents reviewed (Resident 1). Findings include: Observations in the second floor ice room on January 29, 2025, at 9:09 a.m. revealed that there was an ice machine sitting on a wooden type bench/platform. The platform was greenish/blue in color with a moderate amount of chipped paint. The front and top of the platform was noted to have a blackish-brown, removable substance on it that measured approximately 10.0 x 15.0 inches. Interview with the Maintenance Director on January 29, 2025, at 12:17 p.m. confirmed that in the past the ice machine leaked and dripped water onto the top of the platform, which over time resulted in the blackish, removable substance. Observations in Residents 1's room on January 29, 2025, at 9:13 a.m. revealed that there were four holes in the dry wall to the left of the resident's television measuring approximately 5.0 x 4.0 inches each. Interview with Resident 1 at that time, confirmed that she did not like the holes in her wall and that the facility was aware that the dry wall needed to be repaired and painted. Interview with the Maintenance Director on January 29, 2025, at 1:10 p.m. confirmed that Resident 1's dry wall was not homelike and needed repaired. Interview with the Nursing Home Administrator on January 29, 2025, at 4:10 p.m. confirmed that Resident 1's dry wall needed repaired and that the removable, black substance underneath the second floor ice machine should not be there. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 207.2(a) Administrator's Responsibility. 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 2 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 01/31/2025 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)