Casselman Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Casselman Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF684Sep 29, 2023

  Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that podiatry appointments were carried out, failed to follow podiatry recommendations, failed to provide weekly surgical wound assessments, and failed to provide treatments for an ingrown toenail resulting in an infection and pain for one of three residents reviewed (Resident 2). Findings include: An interview with the Resident 2 on September 27, 2023, revealed that she had concerns about cancelled podiatry appointments. One appointment was cancelled because she was late, but the other appointment was cancelled for an unknown reason, and she was not informed the reason. Resident 2 explained that she has been on treatments for an ingrown toenail for months now. […]

• No harm, potential for more than minimal, widespreadF804Sep 17, 2025

  Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food that was palatable and at safe and appetizing temperatures.Findings include: The facility's policy regarding food safety requirements, dated April 7, 2025 indicated that foods and beverages shall be distributed and served in a manner that is palatable, and the temperatures will be at the recommended temperatures per the Federal Food Code temperature Requirements which states that hot food must be held at 135 degrees Fahrenheit or higher.Observations in the kitchen for the lunch meal service on September 17, 2025, at 11:31 a.m. revealed that a test tray left the kitchen and arrived on the west wing at 12:01 p.m. […]

• No harm, potential for more than minimal, widespreadF620Aug 9, 2023

  Based on a review of the facility's admissions agreement, as well as resident and staff interviews, it was determined that the facility failed to establish an admissions policy that did not request/require residents to waive potential facility liability for losses of personal property. Findings include: An undated admission agreement given to every new resident included the statement that the facility would not be responsible for the loss of the resident's personal property, such as money, documents, clothing, or other personal effects. The agreement did not describe the types of losses that the facility would be liable for. Interview with a group of residents on August 8, 2023, at 1:30 p.m. […]

• No harm, potential for more than minimal, patternF684Aug 6, 2026

  Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for two of 34 residents reviewed (Residents 4 and 37).Findings include: A facility policy regarding medication orders, dated January 8, 2026, indicated that medications should be administered only upon the signed order of a person lawfully authorized to prescribe. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 21, 2026, revealed that the resident was cognitively intact, required maximum assistance from staff for daily care needs, had diagnoses that included diabetes, and received insulin (a diabetic medication to regulate glucose levels). […]

• No harm, potential for more than minimal, patternF688Aug 6, 2026

  Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of 34 residents reviewed (Resident 39). Findings include: Review of the facility policy for Restorative Nursing Programs dated May 31, 2026, revealed that it is the policy of the facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust as independently and safely as possible. […]