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Inspection visit

Inspection

WINDBER WOODS SENIOR LIVING & REHABILITATION CTRCMS #3950902 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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

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Citations

2 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0583GeneralS&S Dpotential for harm

    F583 - Privacy and Confidentiality

    Keep residents' personal and medical records private and confidential.

  • 0600GeneralS&S Dpotential for harm

    F600 - Freedom from Abuse, Neglect, and Exploitation

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

FAQ · About this visit

Common questions about this visit

What happened during the March 27, 2024 survey of WINDBER WOODS SENIOR LIVING & REHABILITATION CTR?

This was a inspection survey of WINDBER WOODS SENIOR LIVING & REHABILITATION CTR on March 27, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at WINDBER WOODS SENIOR LIVING & REHABILITATION CTR on March 27, 2024?

Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Keep residents' personal and medical records private and confidential."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.