Health inspection·April 18, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment for one of 32 residents reviewed (Resident 7). Residents Affected - Few Findings include: The facility's policy regarding cleaning and disinfecting, dated December 14, 2023, indicated that housekeeping was to remove visible debris from surfaces and that proper cleaning was necessary to provide a healthy environment. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated March 12, 2024, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care needs, had diagnoses that included pulmonary embolism (a blood clot that stops blood flow to the lung) and anemia (not enough red blood cells to carry oxygen to the tissues). A care plan, dated March 14, 2024, indicated that Resident 7 had a potential for altered respiratory status related to her pulmonary embolism and was to receive oxygen as needed at 2 to 4 liters per minute via nasal cannula (tube that delivers oxygen into the nostrils). Observations on April 15, 2024, at 11:54 a.m. revealed that the resident was lying in her bed with a fan sitting on her over-bed table. The fan was blowing directly on her. The fan was noted to have a moderate amount of visible dirt and debris accumulated on the blade cover. Observations on April 16, 2024, at 9:07 a.m. revealed that the resident was sitting in her chair with a fan sitting on her dresser. The fan was blowing directly on the resident. The fan was noted to have a moderate amount of visible dirt and debris accumulated on the blade cover. Interviews with Housekeeper 1 and Licensed Practical Nurse 2 on April 16, 2024, at 11:04 a.m. confirmed that the fan was blowing directly on the resident, it had a moderate amount of dirt and debris accumulated on the blade cover, and that it should have been clean and it was not. Interview with the Nursing Home Administrator on April 16, 2024, at 1:55 p.m. confirmed that Resident 7's fan cover should be clean, and it was not. 28 Pa. Code 207.2(a) Administrator's Responsibility. 28 Pa. Code 211.12(d)(5) Nursing Services. Page 1 of 9 395090 395090 04/18/2024 Windber Woods Senior Living & Rehabilitation Ctr 277 Hoffman Avenue Windber, PA 15963

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of clinical records and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for one of 32 residents reviewed (Resident 51). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated February 2, 2024, revealed that the resident was cognitively intact, required assistance with daily care needs, and had diagnoses that included obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). A care plan for Resident 51, revised on February 16, 2024, indicated that the resident had an indwelling foley catheter (tube that is inserted into the bladder allowing urine to drain in to a collection bag) size 16 French, 10 cc balloon. Physician's orders, dated February 2, 2024, included an order to change the size of the indwelling foley catheter to an 18 French, 10 cc balloon. There was no documented evidence in Resident 51's clinical record to indicate that her care plan was revised when the size of the indwelling foley catheter was changed. Interview with the Nursing Home Administrator on April 17, 2024, at 3:10 p.m. confirmed that Resident 51's care plan should have been revised when the size of the indwelling foley catheter was changed. 28 Pa. Code 211.12(d)(5) Nursing Services. 395090 Page 2 of 9 395090 04/18/2024 Windber Woods Senior Living & Rehabilitation Ctr 277 Hoffman Avenue Windber, PA 15963

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible by transporting a resident without leg rests for one of 32 residents reviewed (Resident 70), and failed to conduct thorough investigations for one of 32 residents reviewed (Resident 84) by using photocopied witness statements for fall investigations. Findings include: An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 70, dated February 21, 2024, revealed that the resident was cognitively intact, required extensive assistance for all of her care, and used a wheelchair. Observations on April 16, 2024, at 12:47 p.m. revealed that Licensed Practical Nurse 3 pushed Resident 70 in a wheelchair without leg rests around other residents who were waiting at the elevator, through the hallway, and into the common area while the resident elevated her feet. The leg rests were in a bag hanging off the back of the wheelchair. An interview with Licensed Practical Nurse 3 on April 16, 2024, at 12:51 p.m. revealed that she was aware that leg rests were to be used when transporting Resident 70 in her wheelchair. An interview with the Director of Nursing on April 16, 2024, at 1:27 p.m. confirmed that staff should be using leg/footrests on wheelchairs when residents are being transported in their wheelchairs. An accident/incident policy, dated December 14, 2023, revealed that every witness to an incident is to complete a paper witness statement form. A quarterly MDS assessment for Resident 84, dated February 15, 2024, revealed that the resident was cognitively impaired, required extensive assistance for daily care needs, and had a history of falls. Nursing notes for Resident 84 revealed that the resident had unwitnessed falls on August 12, 2023; September 9, 2023; and October 11, 2023. Witness statements for the incident with Resident 84 on August 23, 2023, all stated, Bed alarm sounded when staff responded, resident was observed lying on right side of bottom of bed on the floor, resident continent at this time, slipper socks on, call bell within reach, not on. Resident stated she hit her head, no injury noted by registered nurse. The witness statement was photocopied and each witness signed an exact copy. There was no evidence to indicate that a thorough investigation was conducted. Witness statements for the incident with Resident 84 on September 9, 2023, all stated, Resident noted to be in a 'praying position' in her room. Her upper body was on the bed, and she was kneeling on the floor. Alarm did not sound due to her upper body still being on it. She stated she didn't know what happened. The witness statement was photocopied, and all witnesses signed an exact copy. There was no evidence to indicate that a thorough investigation was conducted. 395090 Page 3 of 9 395090 04/18/2024 Windber Woods Senior Living & Rehabilitation Ctr 277 Hoffman Avenue Windber, PA 15963

F 0689 Level of Harm - Minimal harm or potential for actual harm Witness statements for incident with Resident 84 on October 11, 2023, all stated, Bed alarm sounding, noted resident sitting upright on floor beside her bed. Resident denies pain and denies hitting head, she stated she was 'getting outta here.' Registered nurse in to assess, resident's roommate stated, 'She slid right onto her butt.' The witness statement was photocopied, and all witnesses signed an exact copy. There was no evidence to indicate that a thorough investigation was conducted. Residents Affected - Few There was no documented evidence that witnesses completed individual witness statements for the above incidents with Resident 84, and no evidence to indicate that a thorough investigation was conducted for each. Interview with the Nursing Home Administrator on April 16, 2024, at 3:14 p.m. confirmed that there was no individualized witness statements for the above incidents, and that the witnesses needed to write statements in their own words, not just sign a photocopy of someone else's statement. 28 Pa. Code 211.12(d)(5) Nursing Services. 395090 Page 4 of 9 395090 04/18/2024 Windber Woods Senior Living & Rehabilitation Ctr 277 Hoffman Avenue Windber, PA 15963

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a no smoking/oxygen-in-use sign was in place for one of 32 residents reviewed (Resident 7). Residents Affected - Few Findings include: The facility's policy regarding oxygen therapy, dated December 14, 2023, indicated that a sign would be in place indicating that oxygen was in use. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated March 12, 2024, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care needs, had diagnoses that included pulmonary embolism (a blood clot that stops blood flow to the lung ) and anemia (not enough red blood cells to carry oxygen to the tissues). Physician's orders, dated September 27, 2023, included orders for the resident to receive oxygen as needed at a flow rate of 2 to 4 liters per minute by nasal cannula (tubes that deliver oxygen into the nostrils). The resident's care plan, revised March 14, 2024, revealed that she has a potential for altered respiratory status related to a pulmonary embolism. Observations of Resident 7 on April 15, 2024, at 11:54 a.m. and April 16, 2024, at 9:07 a.m. revealed that the resident was in her room with oxygen in place via nasal cannula at 2 liters per minute. There was no signage on Resident 7's door frame indicating that oxygen was in use. An interview with Licensed Practical Nurse 4 on April 16, 2024, at 10:28 a.m. confirmed that Resident 7 was receiving oxygen at 2 liters per minute, and there was no signage in place on her door indicating that oxygen was in use, and there should have been. An interview with the Nursing Home Administrator on April 16, 2024, at 1:55 a.m. confirmed that Resident 7 was receiving oxygen at 2 to 4 liters per minute, and there was no signage in place on her door frame indicating that oxygen was in use, and there should have been. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. 395090 Page 5 of 9 395090 04/18/2024 Windber Woods Senior Living & Rehabilitation Ctr 277 Hoffman Avenue Windber, PA 15963

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 accountability for controlled medications (drugs with the potential to be abused) for one of 33 residents reviewed (Resident 64). Findings include: The facility's policy regarding narcotic patches, dated December 14, 2023, indicated that all narcotic patches should be placed immediately in a sharps container when discarding and require a double signature. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 64, dated January 2, 2024, revealed that the resident was cognitively intact, received routine pain medication, received an opioid (a controlled pain medication), and had diagnoses that included a fracture. Physician's orders for Resident 64, dated January 4, 2024, included an order for the resident to receive a 12 micrograms (mcg) Fentanyl (a narcotic pain patch) patch to be applied every three days for pain. The Medication Administration Record (MAR) and a controlled drug count record (tracks each dose of a controlled medication) for Resident 64 dated January, February and March 2024 revealed that a new Fentanyl patch was applied to the resident on the following dates: January 9, 2024; January 12, 2024; January 15, 2024; January 18, 2024; January 21, 2024; January 24, 2024; February 20, 2024; February 29, 2024; March 3, 2024; March 6, 2024; March 9, 2024; March 11, 2024; March 14, 2024; March 17, 2024; and March 20, 2024. There was no documented evidence of two signatures when the old Fentanyl patch was removed and discarded on the above dates. Interview with the Nursing Home Administrator on April 17, 2024, at 10:13 a.m. confirmed that there were not two witness signatures for the destruction of Fentanyl patches for the above dates in January 2024, February 2024, and March 2024, and there should have been. 28 Pa. Code 211.9(a)(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395090 Page 6 of 9 395090 04/18/2024 Windber Woods Senior Living & Rehabilitation Ctr 277 Hoffman Avenue Windber, PA 15963

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of policies, observations, and staff interviews, it was determined that the facility failed to ensure that food stored in the kitchen was labeled, dated and secured. Residents Affected - Many Findings include: The facility policy regarding food storage, dated December 14, 2023, revealed that any food that has been opened must be labeled, dated and secured in such a way that the food item is air tight. Observations in the walk-in freezer on April 15, 2024, at 8:35 a.m. revealed that there was one bag containing six chicken tenders that was not labeled, dated or secured and one bag containing five chicken patties that was dated but unsecured. Observations in the cook's cooler on April 15, 2024, at 8:40 a.m. revealed that there was approximately eighteen sausage patties in a box that was dated but the bag holding the sausage patties was open and unsecured. Interview with the Dietary Manager on April 15, 2024, at 8:45 a.m. confirmed that all food items in the kitchen should be labeled, dated and secured. Interview with the Nursing Home Administrator on April 15, 2024, at 10:26 a.m. confirmed that all food items in the kitchen should be labeled, dated and secured. 28 Pa. Code 211.6(f) Dietary Services. 395090 Page 7 of 9 395090 04/18/2024 Windber Woods Senior Living & Rehabilitation Ctr 277 Hoffman Avenue Windber, PA 15963

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending March 16, 2023, and March 12, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending April 18, 2024, identified repeated deficiencies related to free of accident hazards/supervision/devices, respiratory care, pharmacy services/procedures/records, and food procurement storage/prepare/serve-sanitary. The facility's plan of correction for a deficiency regarding free of accident hazards/supervision/devices, cited during the survey ending March 12, 2024, revealed that free of accident hazards/supervision/devices would be monitored by QAPI. The results of the current survey, cited under F689, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding free of accident hazards supervision devices. The facility's plan of correction for a deficiency regarding respiratory care, cited during the survey ending March 16, 2023, revealed that respiratory care would be monitored by QAPI. The results of the current survey, cited under F695, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding respiratory care. The facility's plan of correction for a deficiency regarding pharmacy services/procedures/records, cited during the survey ending March 16, 2023, revealed that pharmacy services/procedures/records would be monitored by QAPI. The results of the current survey, cited under F755, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding pharmacy services/procedures/records. The facility's plan of correction for a deficiency regarding food procurement, storage/prepare/serve-sanitary, cited during the survey ending March 16, 2023, revealed that food procurement, storage/prepare/serve-sanitary would be monitored by QAPI. The results of the current survey, cited under

F812, revealed that the QAPI committee was ineffective in maintaining compliance with food procurement, storage/prepare/serve-sanitary. Refer to F689, F695, F755, F812 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 395090 Page 8 of 9 395090 04/18/2024 Windber Woods Senior Living & Rehabilitation Ctr 277 Hoffman Avenue Windber, PA 15963

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, a review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain an effective pest control program. Residents Affected - Few Findings include: The facility's policy on pest control, dated December 14, 2023, indicated that the facility will maintain a pest control program and that treatment will be rendered as required to control insects. Observations of the handwashing sink in the kitchen on April 15, 2024, at 8:36 a.m. revealed a large number of ants on the sink around the faucet area, as well as on the wall directly behind the sink. There were also several gnats in the area as well as a gnat trap on the sink by the faucet. Interview with Dietary Manager on April 15, 2024, at 8:38 a.m. revealed that he did not realize that the ants were there. However, he was aware of some gnats in the sink area, as there was a small red container on the sink to catch gnats. He stated that the ants and gnats should not be around the handwashing sink in the kitchen. Interview with Maintenance Director on April 17, 2024, at 9:39 a.m. revealed that the pest control company was last there on February 27, 2024, and that they were due to come again on April 24, 2024. They are scheduled to come four times a year and anytime the facility calls them. He stated they have a good working relationship with them. He went on to say that because of all the recent rain that the ants and spiders are getting pushed out of their burrows and coming more to the surface. He stated it can be a constant battle, especially in the spring. He indicated that he has placed ant traps and frequently sprays the perimeter of the facility. He stated that the ants and gnats should not be around the handwashing sink in the kitchen. Interview with the Nursing Home Administrator on April 18, 2024, at 9:26 a.m. confirmed that ants and gnats should not be in the kitchen. 28 Pa. Code 207.2(a) Administrator's Responsibility. 28 Pa. Code 201.18(e)(2)(3) Management. 395090 Page 9 of 9