Health inspection·October 23, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on review of facility policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse or neglect caused by staff failing to properly transport a resident in a wheelchair with leg rests, which led to a resident fall that required sutures for a laceration for one of two residents reviewed (Resident 2). This deficiency was cited as past noncompliance. Findings include: The facility's abuse policy, dated December 14, 2023, indicated that staff will be educated on identifying and preventing resident abuse, neglect, mistreatment, and misappropriation of resident property; staff members will be required at orientation and forward on a yearly basis to attend in-servicing related to abuse, neglect, mistreatment, and misappropriation of resident property. Nurse Aide 1 was educated on the facility's abuse policy on May 9, 2024. The facility's policy on wheelchair safety, dated December 14, 2023, indicated that the residents will be encouraged to self-propel if physically able. If the resident needs to be transported long distances, leg rests will be applied for safety. A quarterly Minimum Data Set (MDS) assessment (required assessments of a resident's abilities and care needs) for Resident 2, dated September 20, 2024, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included anxiety and lumbar disc degeneration (breakdown of discs in spine). A nursing note for Resident 2, dated August 28, 2024, at 12:00 p.m., indicated that the resident had a fall out of her wheelchair and fell forward, hitting her head off the floor in the solarium. The resident had a 2-centimeter (cm) laceration on the left side of her head and her right eye was beginning to bruise. The physician was notified and ordered the resident to be transported to the local emergency room. A nursing note for Resident 2, dated August 28, 2024, at 3:35 p.m., revealed that the resident had no fractures but had received four sutures to the laceration on the left side of her head. An incident report for Resident 2, dated August 29, , at 1:43 pm., revealed that the resident had fallen asleep in her wheelchair and was being assisted to her room in her wheelchair without leg rests by Nurse Aide 1. The resident fell forward and hit her head on the floor in the solarium. A witness statement by Nurse Aide 2, dated August 28, 2024, revealed that she witnessed Nurse Aide Page 1 of 4 395090 395090 10/23/2024 Windber Woods Senior Living & Rehabilitation Ctr 277 Hoffman Avenue Windber, PA 15963

F 0600 1 pushing Resident 2 in her wheelchair, while the resident was sleeping, with no leg rests on the wheelchair, and the resident fell forward hitting her head on the solarium floor. Level of Harm - Actual harm Residents Affected - Few Interview with the Nursing Home Administrator on October 23, 2024, at 12:12 p.m. confirmed that Nurse Aide 1 should have had leg rests on Resident 2's wheelchair while she was transporting her. A review of the facility's plan of correction included the following: Reeducation on transporting residents in wheelchairs with leg rests completed for all nursing staff, including agency and hospice staff, activities, therapy and dietary staff. Audits of residents that require leg rests when being transported. Audits completed weekly on all staff transporting residents in wheelchairs. Interviews with nursing staff on October 23, 2024, revealed that they had been educated on transporting residents safely with legs rests. A review of the facility's corrective actions revealed that they were in compliance with F600 on October 16, 2024. Interview with the Nursing Home Administrator on October 23, 2024, at 12:22 p.m. revealed that staff education was completed and ongoing audits will be discussed monthly during the Quality Assurance (QA) meeting. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395090 Page 2 of 4 395090 10/23/2024 Windber Woods Senior Living & Rehabilitation Ctr 277 Hoffman Avenue Windber, PA 15963

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on review of investigation documents and residents' clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe environment for one of two residents reviewed (Resident 2), resulting in a fall that required four sutures. This deficiency was cited as past non-compliance. Findings include: The facility's policy on wheelchair safety, dated December 14, 2023, indicated that the residents will be encouraged to self-propel if physically able. If the resident needs to be transported long distances, leg rests will be applied for safety. A quarterly Minimum Data Set (MDS) assessment (required assessments of a resident's abilities and care needs) for Resident 2, dated September 20, 2024, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included anxiety and lumbar disc degeneration (breakdown of discs in spine). A nursing note for Resident 2, dated August 28, 2024, at 12:00 p.m., indicated that the resident had a fall out of her wheelchair and fell forward, hitting her head off the floor in the solarium. The resident had a 2-centimeter (cm) laceration on the left side of her head and her right eye was beginning to bruise. The physician was notified and ordered the resident to be transported to the local emergency room. A nursing note for Resident 2, dated August 28, 2024 at 3:35 p.m., revealed that the resident had no fractures but had received four sutures to the laceration on the left side of her head. An incident report for Resident 2, dated August 29, 2024 at 1:43 pm., revealed that the resident had fallen asleep in her wheelchair and that Nurse Aide 1 was transporting her to her room without leg rests on the wheelchair. The resident fell forward and hit her head on the floor in the solarium. A witness statement by Nurse Aide 2, dated August 28, 2024, revealed that she witnessed Nurse Aide 1 pushing Resident 2 (who was asleep) in her wheelchair without egress, and the resident fell forward out of the wheelchair, hitting her head on the solarium floor. Interview with the Nursing Home Administrator on October 23, 2024, at 12:12 p.m. confirmed that Nurse Aide 1 should have had put the leg rests on Resident 2's wheelchair while she was transporting her. A review of the facility's plan of correction included the following: Reeducation on transporting residents in wheelchairs with leg rests completed for all nursing staff, including agency and hospice staff, activities, therapy, and dietary staff. Audits of residents that require leg rests when being transported. Audits completed weekly on all staff transporting residents in wheelchairs. 395090 Page 3 of 4 395090 10/23/2024 Windber Woods Senior Living & Rehabilitation Ctr 277 Hoffman Avenue Windber, PA 15963

F 0689 Interviews with nursing staff on October 23, 2024, revealed that they had been educated on transporting residents safely with legs rests. Level of Harm - Actual harm Residents Affected - Few A review of the facility's corrective actions revealed that they were in compliance with F689 on October 16, 2024. Interview with the Nursing Home Administrator on October 23, 2024, at 12:22 p.m. revealed that staff education was completed, and ongoing audits will be discussed monthly during the Quality Assurance (QA) meeting. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395090 Page 4 of 4