F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of facility policies, information provided to staff upon hire, investigation documents, and
clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each
resident's personal privacy was maintained for one of three residents reviewed (Resident 2).
Residents Affected - Few
Findings include:
The facility's abuse policy, dated December 14, 2023, included policies and procedures related to training,
preventative measures, identifying, investigating, reporting, and protecting residents from exposure to
abuse, neglect, mistreatment, and misappropriation.
The facility's cell phone usage policy, dated December 14, 2023, indicated that cell phones were not to be
used in resident care units or carried on one's body while the employee was working. No staff member was
allowed to photograph a resident or their surroundings and post it on social media of any kind. Even if a
resident consented, and regardless of the resident's cognitive status, abuse will be presumed and
investigated whenever there was a photograph or recording of a resident, or the manner that it was used (if
it demeaned or humiliated a resident).
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 2, dated March 14, 2024, indicated that the resident was cognitively impaired, had
verbal behaviors, was frequently incontinent of bowel and bladder, and had diagnoses that included
dementia.
Review of information submitted by the facility, dated March 17, 2024, indicated that Nurse Aide 1 took a
picture of Resident 2 on her cell phone while Resident 2 was sitting on the toilet with his pants pulled up
almost the entire way, exposing a small portion of his upper leg. The picture of the resident was from the
waist down and the resident's face was not in the picture. The picture showed the resident sitting on the
commode with his pants pulled almost all the way up, exposing a small portion of his upper leg. The picture
of the resident was then posted on social media.
Investigative interview statements from Nurse Aide 1, dated March 17, 2024, confirmed that she took a
picture of Resident 2 while he was on the toilet.
Investigative interview statements from Nurse Aide 2, dated March 17, 2024, confirmed that she saw the
picture on social media that Nurse Aide 1 took of Resident 2 sitting on the toilet.
Interview with the Nursing Home Administrator on March 27, 2024, at 11:04 a.m. confirmed that Nurse Aide
1 took a picture of Resident 2 on the toilet and posted it on social media, and revealed that
(continued on next page)
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 3
Event ID:
395090
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
395090
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windber Woods Senior Living & Rehabilitation Ctr
277 Hoffman Avenue
Windber, PA 15963
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)
F 0583
employees were not to take any pictures of residents on their cell phones.
Level of Harm - Minimal harm
or potential for actual harm
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
Residents Affected - Few
28 Pa. Code 201.29(j) Resident Rights.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395090
If continuation sheet
Page 2 of 3
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
395090
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windber Woods Senior Living & Rehabilitation Ctr
277 Hoffman Avenue
Windber, PA 15963
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)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Based on review of facility policies, clinical records and investigation documents, as well as staff interviews,
it was determined that the facility failed to ensure that residents were free from mental abuse for one of
three residents reviewed (Resident 2).
Findings include:
The facility's abuse policy, dated December 14, 2023, included policies and procedures related to training,
preventative measures, identifying, investigating, reporting, and protecting residents from exposure to
abuse, neglect, mistreatment, and misappropriation.
The facility's cell phone usage policy, dated December 14, 2023, indicated that cell phones were not to be
used in resident care units or carried on one's body while the employee was working. No staff member was
allowed to photograph a resident or their surroundings and post it on social media of any kind. Even if a
resident consented, and regardless of the resident's cognitive status, abuse will be presumed and
investigated whenever there was a photograph or recording of a resident, or the manner that it was used (if
it demeaned or humiliated a resident).
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and
care needs) for Resident 2, dated March 14, 2024, indicated that the resident was cognitively impaired, had
verbal behaviors, was frequently incontinent of bowel and bladder, and had diagnoses that included
dementia.
Review of information submitted by the facility, dated March 17, 2024, indicated that Nurse Aide 1 took a
picture of Resident 2 on her cell phone while Resident 2 was sitting on the toilet with his pants pulled
almost all the way up. The picture of the resident was from the waist down and the resident's face was not
in the picture. The picture showed the resident sitting on the commode with his pants pulled up almost the
entire way, exposing a small portion of his upper leg. The picture of the resident was then posted on social
media.
Investigative interview statement from Nurse Aide 1, dated March 17, 2024, confirmed that she took a
picture of Resident 2 while he was on the toilet.
Investigative interview statement from Nurse Aide 2, dated March 17, 2024, confirmed that she saw the
picture on social media that Nurse Aide 1 took of Resident 2 sitting on the toilet.
Interview with the Nursing Home Administrator on March 27, 2024, at 11:04 a.m. confirmed that Nurse Aide
1 took a picture of Resident 2 on the toilet and posted it on social media, and revealed that employees were
not to take any pictures of residents on their cell phones.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 201.29(j) Resident Rights.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395090
If continuation sheet
Page 3 of 3