Pennsylvania Department of Health
CASSELMAN HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CASSELMAN HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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CASSELMAN HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an abbreviated complaint survey completed on June 29, 2026, it was determined that Casselman Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Observations: Based on review of facility documents, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident and staff environment was maintained in a safe and sanitary environment in one of two medication rooms (third floor). Findings include: Observations of the third-floor medication room on June 29, 2026, at 9:47 a.m. revealed that upon entering the medication room there was a strong musty odor. The ceiling had an area approximately two feet in diameter that was discolored, water damaged and had loose plaster and tape. There was a basin on the floor that contained water. The medication room contained the Pyxis machine (medication dispensing machine) and over the counter medications stored in cabinets. An e-mail communication, dated May 26, 2026, revealed that there were several roof leaks that were coming in on the third floor. The roof was in bad shape with shingles missing, waterways cracked and open, missing caps, nails popped up, and rotted plywood. A quote was received regarding the cost of the materials required to repair the roof. An e-mail communication, dated June 8, 2026, revealed that approval was received to purchase the materials to repair the roof with a debit card and the worker wanted to start that week. An email communication, dated June 29, 2026, included a quote for the cost of the roof, however there was no documented evidence that any materials had actually been purchased to repair the leaking roof and medication room ceiling. Interview with the Director of Nursing on June 29, 2026, at 9:47 a.m. revealed that the damage to the ceiling was caused by the roof leaking. Interview with Registered Nurse Supervisor 1 on June 29, 2026, at 9:51 a.m. revealed the roof has been leaking for the past few months. Interview with the Nursing Home Administrator on June 29, 2026, at 3:35 p.m. indicated that the condition of the third-floor medication room ceiling and leaking roof was not affecting the residents, and that coming up with the money to repair the roof was not easy. 28 Pa. Code 207.2(a) Administrator's Responsibility

Plan of Correction - To be completed: 07/14/2026

Facility completed a temporary roof repair to the section above the medication room on third floor. The attic area above the medication room was sprayed with a moisture/odor repellant. The section of the ceiling was cut out in the medication room and replaced. The room was cleaned and will be painted.
The Nursing Home Administrator inspected the room on 7/9/2026 after a hard rain and no further leaking was identified.
The facility is projected to have a new roof installed in sections later this summer. The materials were ordered for the first section on 7/8/2026.

51.3 (f) LICENSURE NOTIFICATION:

51.3 Notification

(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.

Observations: Based on review of facility documents, as well as observations and staff interviews, it was determined that the facility failed to notify the Department of Health regarding events that could compromise quality assurance for residents and staff. Findings include: Observations of the third-floor medication room on June 29, 2026, at 9:47 a.m. revealed that upon entering the medication room there was a strong musty odor. The ceiling had an area approximately two feet in diameter that was discolored, water damaged and had loose plaster and tape. There was a basin on the floor that contained water. The medication room contained the Pyxis machine (medication dispensing machine) and over the counter medications stored in cabinets. An e-mail communication, dated May 26, 2026, revealed that there were several roof leaks that were coming in on the third floor. The roof was in bad shape with shingles missing, waterways cracked and open, missing caps, nails popped up, and rotted plywood. A quote was received regarding the cost of the materials required to repair the roof. An e-mail communication, dated June 8, 2026, revealed that approval was received to purchase the materials to repair the roof with a debit card and the worker wanted to start that week. An email communication, dated June 29, 2026, included a quote for the cost of the roof, however there was no documented evidence that any materials had actually been purchased to repair the leaking roof and medication room ceiling. There was no documented evidence that the facility reported to the Department of Health that the roof was leaking and caused the third-floor medication room ceiling to be damaged. Interview with the Director of Nursing on June 29, 2026, at 9:47 a.m. revealed that the damage to the ceiling was caused by the roof leaking. Interview with Registered Nurse Supervisor 1 on June 29, 2026, at 9:51 a.m. revealed the roof has been leaking for the past few months. Interview with the Nursing Home Administrator on June 29, 2026, at 3:35 p.m. confirmed that she did not report the leaking roof to the Department of Health and indicated that the condition of the third-floor medication room ceiling and leaking roof was not affecting the residents.

Plan of Correction - To be completed: 07/14/2026

Event report was submitted to department of health on 6/29/2026. The report was accepted on 7/9/2026 after the completion of the roof and ceiling repair.
The Nursing Home Administrator and Director of Nursing reviewed the notification requirements to the Department of Health for any situation or occurrence of an event which could compromise quality assurance and patient safety. Quality Assurance committee will review at next meeting.

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