Health inspection·July 2, 2025

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical records and facility investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation of medications for one of five residents reviewed (Resident 3).Findings include:The facility's policy regarding controlled narcotics dated April 7, 2025, indicated that the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the comprehensive drug abuse prevention and control act of 1976). Misappropriation was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent example drug diversion (taking the residents medication).A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 29, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had medical diagnoses that included peripheral vascular disease (affects blood circulation to lower legs).Physician's orders for Resident 3, dated March 27, 2025, included orders for the resident to receive 30 milligrams of Morphine (a controlled narcotic used for pain) every twelve hours for pain.The controlled drug record for Resident 3 for April 2025 indicated that three doses of Morphine were signed out on April 28, 2025 at 7:00 a.m.An investigation report, dated May 6, 2025, revealed that Resident 3's medication packet containing Morphine was missing three 30 mg doses and that Licensed Practical Nurse 1 misappropriated the Morphine tablets and had replaced them with other pills.Interview with the Director of Nursing on July 2, 2025, at 4:14 p.m. confirmed that Resident 3's Morphine was taken by Licensed Practical Nurse 1. She indicated that the police were notified and Licensed Practical Nurse 1 was referred to the Pennsylvania Department of State.28 Pa. Code 201.14(a) Responsibility of License.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 211.12(d)(3)(5) Nursing Services. Residents Affected - Few Page 1 of 2 395661 395661 07/02/2025 Casselman Healthcare and Rehabilitation Center 201 Hospital Drive Meyersdale, PA 15552

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of three residents reviewed (Resident 1).Findings include:The facility's policy regarding medication administration, dated April 7, 2025, indicated that the individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones.The facility's policy regarding controlled substance administration, dated April 7, 2025, states that an individual controlled substance record is made for each resident who will be receiving a controlled substance.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 14, 2025, revealed that the resident is cognitively intact, required assistance for daily care needs, and had medical diagnosis that include lumbosacral disc displacement.Physician's orders for Resident 1, dated May 3, 2025, included an order for the resident to receive two milligrams (mg) tablet of Dilaudid (a controlled narcotic pain medication) every six hours as needed for severe pain.A review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 1, for April and May 2025 indicated that a 2 mg tablet of Dilaudid was signed out for the resident on April 14, 2025 at 9:50 p.m., May 12, 2025 at 4:47 p. m., and June 7, 2025 at 10:40 a.m. However, there was no documented evidence in the resident's Medication Administration (MAR) that the signed-out tablets of Dilaudid were administered to the resident on these dates.Interview with the Director of Nursing on July 2, 2025, at 1:46 p.m. confirmed that there was no documented evidence to indicate that Resident 1 actually received the doses of Dilaudid on the dates listed above dates.28 Pa. Code 211.9(h) Pharmacy services.28 Pa. Code 211.12(d)(1) Nursing service28 Pa. Code 211.12(d)(5) Nursing services. 395661 Page 2 of 2