F 0552
Ensure that residents are fully informed and understand their health status, care and treatments.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that
the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of
psychotropic medications (medications that affect the persons mental state, emotions and behavior) and
the treatment alternatives prior to the administration of the medication for two of 33 residents reviewed
(Residents 1 and 14). Findings include: A facility policy related to psychotropic medications, dated
December 18, 2025, indicated that resident and/or representatives have the right to decline treatment with
psychotropic medications. The staff and physician will review with the resident/representative the risks
related to not taking the medication as well as appropriate alternatives. A significant change Minimum Data
Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1,
dated November 22, 2025, revealed that the resident was cognitively intact, received psychotropic
medications, including antidepressant medications, and had a diagnosis of depression. A nursing note for
Resident 1, dated November 20, 2025, at 3:21 p.m. revealed that the resident was seen by the physician
and orders were obtained to increase her Sertraline (an antidepressant medication) dose to 100 milligrams
(mg) daily. Physician's orders for Resident 1, dated November 21, 2025, included an order for the resident
to receive 100 mg of Sertraline daily for depression. There was no documented evidence in Resident 1's
clinical record to indicate that the resident and/or resident representative were informed in advance of the
risks and benefits and treatment alternatives prior to initiating the increased dose of Sertraline. Interview
with the Nursing Home Administrator on February 25, 2026, at 4:15 p.m., confirmed that there was no
documented evidence in Resident 1's clinical record that the resident's representative was informed in
advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of
Sertraline. She indicated that she was not aware that an informed consent needed to be completed when
initiating or increasing psychotropic medications. A Quarterly MDS assessment Resident 14, dated May 27,
2026, revealed that the resident was cognitively impaired, received psychotropic medications, including
antidepressant medications. Physician's orders for Resident 14, dated June 7, 2025, included an order for
the resident to receive 0.5mg of Ativan (an antianxiety medication) every 8 hours as needed for anxiety and
behaviors. There was no documented evidence in Resident 14's clinical record to indicate that the resident
and/or resident representative were informed in advance of the risks and benefits and treatment
alternatives prior to initiating the increased dose of Ativan. Interview with the Nursing Home Administrator
on February 24, 2026, at 2:26 p.m., confirmed that there was no documented evidence in Resident 14's
clinical record that the resident's representative was informed in advance of the risks and benefits and
treatment alternatives prior to initiating the increased dose of Ativan. 28 Pa. Code 201.14(a) Responsibility
of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a): Resident rights.
Residents Affected - Few
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 20
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
02/27/2026
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 0605
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's
ability to function.
Based on a review of facility policies and clinical records as well as staff interviews, it was determined that
the facility failed to ensure that residents medication regimen was free from unnecessary psychotropic
medication (drugs that affect a person's mental state, emotions, and behavior) for four of 33 residents
reviewed (Residents 10, 13, 14, 92).Findings include:The facility's policy regarding psychotropic medication
use, dated December 18, 2025, indicated that non-pharmacological approaches (intervention intended to
improve the health or well-being of individuals that do not involve the use of drugs or medicine) are used
(unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow
for discontinuation of medications when possible.A significant change Minimum Data Set (MDS)
assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 10
dated January 26, 2025, indicated that the resident had cognitive impairment, required assistance from
staff for daily care needs, and had diagnosis that included dementia and depression.Physician's orders for
Resident 10 dated January 21, 2026, included an order for the resident to receive 50 milligrams (mg) of
Trazadone (an antidepressant medication) every eight hours as needed for anxiety and agitation.Review of
the Medication Administration Record (MAR) for Resident 10 dated February 2026 revealed that 50 mg of
Trazodone was administered to the resident on February 1 at 8:29 a.m.; on February 2 at 7:22 a.m.; on
February 4 at 9:53 a.m.; on February 6 at 9:58 a.m.; on February 7 at 8:35 a.m.; on February 7 at 10:09
p.m.; on February 9 at 8:40 a.m.; on February 10 at 8:29 a.m.; on February 11 at 7:28 a.m.; on February 12
at 7:18 a.m.; on February 13 at 7:40 a.m.; on February 14 at 7:33 a.m.; on February 15 at 7:06 a.m.; on
February 16 at 7:53 a.m.; on February 17 at 7:46 a.m.; on February 18 at 7:22 a.m.; on February 19 at 7:55
a.m.; on February 20 at 9:17 a.m.; on February 24 at 9:38 a.m.; on February 25 at 8:01 a.m.; and on
February 26 at 8:38 a.m. There was no documented evidence that non-pharmacological interventions were
attempted prior to administering the as needed doses of Tramadol on these dates and times.Interview with
the Nursing Home Administrator on February 27, 2026, at 12:45 p.m. confirmed that there was no
documented evidence that non-pharmacological interventions were attempted before administering
Tramadol to Resident 10 on the above-mentioned dates and times and there should have been. She also
confirmed that there was no duration included in the physician's order on January 21, 2026, and no
documented evidence from a physician or prescriber to indicate the rationale to extend the as needed
Tramadol for Resident 10 beyond 14 days.An admission MDS assessment for Resident 13 dated December
16, 2025, indicated that the resident had cognitive impairment, required assistance from staff for daily care
needs, and had diagnosis that included dementia and depressionPhysician's orders for Resident 13 dated
January 28, 2026, included an order for the resident to receive 0.25 milligrams (mg) of Xanax (an
antianxiety medication) every twelve hours as needed for anxiety and agitation for fourteen days.Review of
the Medication Administration Record (MAR) for Resident 13 dated January and February 2026 revealed
that 0.25 mg of Xanax was administered to the resident on January 28 at 7:49 a.m.; on January 29 at 6:45
p.m.; on January 30 at 7:15 p.m.; on February 1 at 8:29 a.m.; on February 1 at 9:13 p.m.; on February 3 at
8:35 a.m.; on February 4 at 8:29 a.m.; on February 4 at 8:32 p.m.; on February 5 at 9:05 a.m.; on February
7 at 7:00 p.m.; on February 9 at 8:24 a.m.; and on February 10 at 8:14 a.m. There was no documented
evidence that non-pharmacological interventions were attempted prior to administering the as needed
doses of Xanax on these dates and times.Interview with the Nursing Home Administrator on February 27,
2026, at 12:45 p.m. confirmed that there was no documented evidence that non-pharmacological
interventions were attempted before administering Xanax to Resident 13 on the above-mentioned dates
and times and there should have been.A quarterly MD
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395090
If continuation sheet
Page 2 of 20
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
02/27/2026
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 0605
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
assessment for Resident 14 dated January 26, 2025, indicated that the resident had cognitive impairment,
required assistance from staff for daily care needs.Physician's orders for Resident 14 dated June 7, 2026,
included an order for the resident to receive 0.5 mg of Ativan (an antianxiety medication) every eight hours
as needed for anxiety and behaviors.Review of the MAR for Resident 14 dated June 2025 revealed that
0.5mg of Ativan was administered to the resident on June 9 at 4:24 p.m., June 10 at 3:30 p.m., June 11 at
6:21 p.m., and June 12 art 7:32 p.m. There was no documented evidence that non-pharmacological
interventions were attempted prior to administering the as needed doses of Ativan on these dates and
times.Interview with the Nursing Home Administrator on February 24, 2026, at 2:45 p.m. confirmed that
there was no documented evidence that non-pharmacological interventions were attempted before
administering Ativan to Resident 14 on the above-mentioned dates and times and there should have
been.A quarterly MDS assessment for Resident 92, dated November 19, 2025, indicated that the resident
was cognitively impaired, had no behavioral symptoms, received psychotropic medications including
antianxiety medications, and had diagnosis that included anxiety and depression. Physician's orders for
Resident 92, dated November 21, 2025, December 8, 2025, January 2, 2026, January 19, 2026, and
February 11, 2026, included orders for the resident to receive 1 mg of Ativan (an antianxiety medication)
every six hours as needed for anxiety and agitation for fourteen days. Review of the MAR for Resident 92,
dated December 2025, through February 2026, revealed that 1 mg of Ativan was administered to the
resident on December 1 at 3:22 p.m.; December 3 at 9:53 a.m. and 5:46 p.m.; December 4 at 9:00 a.m. and
4:50 p.m.; December 5 at 2:03 a.m.; December 8 at 7:03 p.m.; December 11 at 12:34 p.m. and 10:43 p.m.;
December 14 at 5:43 p.m.; December 15 at 5:41 p.m.; December 20 at 5:53 p.m.; January 2 at 7:21 p.m.;
January 3 at 5:48 p.m.; January 5 at 3:33 p.m.; January 9 at 2:10 a.m. and 5:54 p.m.; January 11 at 6:08
p.m.; January 14 at 4:58 p.m.; January 19 at 7:27 p.m.; January 24 at 9:56 a.m.; January 26 at 4:51 p.m.;
January 28 at 3:24 p.m.; January 29 at 3:28 a.m.; and February 12 at 10:07 a.m. There was no documented
evidence that non-pharmacological interventions were attempted prior to administering the as needed
doses of Ativan on these dates and times. Interview with the Nursing Home Administrator on February 26,
2026, at 4:33 p.m. confirmed that there was no documented evidence that non-pharmacological
interventions were attempted before administering as needed Ativan to Resident 92 on the
above-mentioned dates and times. 28 Pa. Code 211.12(d)(5) Nursing Services
Event ID:
Facility ID:
395090
If continuation sheet
Page 3 of 20
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
02/27/2026
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 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of policies and clinical records, as well as staff interviews, it was determined that the
facility failed to conduct a thorough investigation of a bruise to rule out neglect and/or abuse for one of 33
residents reviewed (Resident 61). Findings include: The facility's policy for abuse prohibition, dated
December 18, 2025, indicated that the facility will have procedures in place to identify suspicious bruising of
residents, occurrences, patterns and trends that may constitute abuse. This information may be obtained
through or risk management reporting policy currently in place. The facility's policy for risk management
reporting, dated December 18, 2025, indicated that all injuries/incidents are required to be reported through
risk management in the electronic medical record. This includes abrasions, bruises, skin tears, falls,
elopement, and acts of aggression toward other residents. The risk management report is the actual
investigation into the cause of the injury or incident and to rule out abuse. An admission Minimum Data Set
(MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61,
dated February 17, 2026, revealed that the resident was cognitively intact, required assistance with daily
care needs, had a diagnosis of ends stage renal disease and was receiving dialysis (medical treatment that
filters waste, toxins, and excess fluid from the blood when the kidneys have failed). A nurse's note for
Resident 61 dated February 13, 2026, revealed that the resident was given a shower, and the nurse aide
noticed a bruise on his right knee. There was no documented evidence that an investigation was initiated to
identify the cause of the bruise or to rule out abuse. Interview with the Nursing Home Administrator on
February 26, 2026, at 12:00 p.m. confirmed that she was unable to find an incident report or investigation
for Resident 61's bruise that occurred on February 13, 2026. 28 Pa. Code 201.18(e)(1) Management. 28
Pa. Code 211.10(d) Resident Care Policies. 28 Pa. Code 211.12(d)(5) Nursing Services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395090
If continuation sheet
Page 4 of 20
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
02/27/2026
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 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 facility policies and clinical records, as well as staff interviews, it was determined that
the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific
care needs for five of 33 residents reviewed (Residents 1, 5, 68, 92, 97). Findings include: A facility policy
for Comprehensive Care Planning, dated December 18, 2025, indicated that an interdisciplinary plan of
care be established and updated as indicated for every resident in accordance with state and federal
regulatory requirements. The care plan is reviewed on an ongoing basis and revised as indicated by the
residents' needs, wishes, or a change in condition.A significant change Minimum Data Set (MDS)
assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated
November 22, 2025, revealed that the resident was cognitively intact, received oxygen therapy and had
diagnoses that included respiratory failure, congestive heart failure and pneumonia. A care plan for the
resident, dated November 16, 2025, indicated that the resident had pneumonia. There was no documented
evidence in the resident's clinical record that indicated the resident had an active diagnosis of pneumonia.
Interview with the Assistant Director of Nursing on February 26, 2026, at 10:48 a.m. confirmed that
Resident 1 did not have an active diagnosis of pneumonia and was not currently being treated for it, and
that the care plan should have been resolved.An admission MDS assessment for Resident 5, dated
January 30, 2026, indicated that the resident had cognitive impairment, required assistance with daily care
needs, and had diagnoses that included cognitive communication deficit. A care plan dated January 24,
2026, revealed that Resident 5 had an indwelling catheter.A nurse's note for Resident 5, dated February 7,
2026, at 11:59 a.m. indicated that the resident was incontinent of a large amount of urine this morning
since her indwelling urinary catheter (a tube inserted in the bladder) was discontinued.An interview with
Licensed Practical Nurse 1 on February 25, 2026, at 9:52 a.m. confirmed that Resident 5 did not have an
indwelling catheter.Interview with the Administrator on February 25, 2026, at 10:25 a.m. confirmed that
Resident 5 did not have an indwelling catheter and her care plan should have been revised to reflect that. A
quarterly MDS assessment for Resident 68, dated February 13, 2026, indicated that the resident was
cognitively intact, required assistance with daily care needs, and had a diagnosis of cancer. A nursing note
for Resident 68, dated September 10, 2025, at 12:35 a.m. revealed that the resident returned from the
hospital on September 9, 2025, and had a dry dressing to her port site from her mediport (a small medical
device surgically implanted under the skin, usually in the chest, providing long-term, easy access to a vein
for chemotherapy, medication, fluids, or blood draws) being de-accessed (removing the specialized needle
from the port device under your skin). A care plan for the resident, dated April 21, 2025, indicated that she
had a mediport to her right chest and was receiving Heparin flushes and saline flushes intravenously to her
accessed mediport every evening shift, and that staff may access her mediport for blood draws one time a
day every seven days and as needed. There was no documented evidence that the resident had orders to
flush her mediport. Interview with the Assistant Director of Nursing on February 26, 2026, at 11:28 a.m.,
revealed that Resident 68 does not currently have orders to flush her mediport due to it being de-accessed
and that they do not do anything with her port at this time. She also revealed that currently, they do not draw
labs from the mediport and confirmed that the care plan should have been revised to reflect that they were
not flushing the mediport. Interview with the Nursing Home Administrator on February 27, 2026, at 10:15
a.m. revealed that Resident 68 has her blood draws at the cancer center and if they use her mediport, they
do the flushes there. She indicated that if she did not get the flushes at the cancer center, they would flush
them every 30 days to keep the port
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395090
If continuation sheet
Page 5 of 20
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
02/27/2026
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
open, but since the cancer center flushes it so frequently, they no longer do the flushes at the facility. She
confirmed that the care plan should have been revised to reflect that they no longer do the flushes to her
mediport. A quarterly MDS assessment for Resident 92, dated November 19, 2025, indicated that the
resident was cognitively impaired, had no behavioral symptoms, received psychotropic medications
including antianxiety medications, and had diagnoses that included anxiety and depression. A care plan for
the resident, dated February 1, 2026, indicated that the resident was receiving Ativan (an antianxiety
medication); however, there was no documented evidence in the resident's clinical record that she was
ordered Ativan. Interview with the Director of Nursing on February 26, 2026, at 3:46 p.m. confirmed that
Resident 92's care plan should have been revised to reflect that the Ativan was discontinued. A quarterly
MDS assessment for Resident 97, dated January 9, 2026, revealed that the resident was cognitively intact
and was moderately dependent on staff for daily care needs. The current care plan for Resident 97
indicated that she had actual skin impairment from necrotizing fasciitis (a bacteria that destroys skin and
soft tissue) and surgical wounds on her back. There was no documented evidence in the resident's clinical
record that indicated the resident had an active diagnosis of necrotizing fasciitis or surgical back wounds.
Interview with the Nursing Home Administrator on February 26, 2026, at 12:47 p.m. confirmed that
Resident 97 was not currently receiving treatment for necrotizing fasciitis and surgical wounds and the care
plan should have been resolved.28 Pa. Code 211.12(d)(5) Nursing services.
Event ID:
Facility ID:
395090
If continuation sheet
Page 6 of 20
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
02/27/2026
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 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it
was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident
after a change in condition for two of 33 residents reviewed (Resident 61 and 95). Findings include:The
Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11
(a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine
nursing care needs, analyze the health status of individuals and compare the data with the norm when
determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the
well-being of individuals.An admission Minimum Data Set (MDS) assessment (a mandated assessment of
a resident's abilities and care needs) for Resident 61, dated February 17, 2026, revealed that the resident
was cognitively intact, required assistance with daily care needs, had a diagnosis of ends stage renal
disease and was receiving dialysis (medical treatment that filters waste, toxins, and excess fluid from the
blood when the kidneys have failed). A nurse's note for Resident 61 dated February 13, 2026, revealed that
the resident was given a shower, and the nurse aide noticed a bruise on his right knee. There was no
documented evidence that registered nurse assessment of the bruise was completed. Interview with the
Nursing Home Administrator on February 26, 2026, at 12:00 p.m. confirmed that there was no documented
evidence that a registered nurse assessment was completed for the bruise that was identified on Resident
61's right knee on February 13, 2026. A quarterly MDS assessment for Resident 95 dated January 17,
2026, indicated that the resident had severe cognitive impairment, was dependent on staff for most daily
care needs, and had diagnosis that included dementia.Physician's orders for Resident 95 dated January
25, 2026, included for the resident to have he left shin wound cleansed with wound cleanser, dry with
gauze, apply a small amount of bacitracin, cover with nonadherent dressing, and secure with kerlix and
tape every day. A nurse's note for Resident 95 dated January 25, 2026, indicated that the resident had an
old bruise/blood collection that opened on her left shin area. As of February 26, 2026, there was no
documented evidence of any further assessments of the resident's change in skin condition to her left shin
that was identified on January 25, 2026. An interview with the Director of Nursing on February 27, 2026, at
3:13 p.m. revealed Resident 95 had a previous blood blister that opened on her left shin, and that there was
no documented evidence of any assessments of the change in skin condition since it was identified on
January 25, 2026, and there should have been. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395090
If continuation sheet
Page 7 of 20
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
02/27/2026
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow
physician's orders and clarify physician's orders for four of 33 residents reviewed (Resident 2, 5, 8, 68).
Findings include: An annual Minimum Data Set (MDS) assessment (a mandatory assessment of a
resident's abilities and care needs) for Resident 2, dated December 10, 2025, revealed that the resident
was cognitively impaired, requires assistance from staff for daily care needs, and had medical diagnosis
that included dementia.A Pharmacist recommendation review dated January 16, 2026, revealed that the
pharmacist recommendation was to change Resident 2's multivitamin to a multivitamin-M and discontinue
vitamin B12, vitamin D, magnesium oxide and folic acid. On January 30, 2026, the physician agreed to the
pharmacist recommendation.A review of Resident 2's January 2026 and February 2026 Medication
Administration record revealed that the multivitamin was not changed to multivitamin M and that Vitamin
B12, Vitamin D, Magnesium oxide, and folic acid were administered to the resident.Interview with the
Director of Nursing on February 26, 2025, at 12:55 p.m. confirmed that there was no documented evidence
that Resident 2's multivitamin was changed to multivitamin M and that Vitamin B12, Vitamin D, Magnesium
oxide, and folic acid were discontinued per pharmacy recommendations.An admission MDS assessment for
Resident 5, dated January 30, 2026, indicated that the resident had cognitive impairment, required
assistance with daily care needs, and had diagnosis that included cognitive communication deficit.A nurse's
note dated February 7, 2026, at 11:59 a.m. revealed Resident 5 had a large amount incontinent urine this
morning since her indwelling catheter (a tube inserted in the bladder) was discontinued.An interview with
Licensed Practical Nurse 1 on February 25, 2026, at 9:52 a.m. confirmed that Resident 5 did not have an
indwelling catheter.Physician's orders for Resident 5 dated January 23, 2026, included an order to change
foley catheter as needed for leakage or blockage. An interview with the Nursing Home Administrator on
February 25, 2026, at 10:25 a.m. confirmed that Resident 5 does not have an indwelling catheter and that
the physician's order to change foley catheter for blockage and leakage as needed should have been
discontinued. A quarterly MDS assessment for Resident 8, dated December 23, 2025, indicated that the
resident was cognitively intact, required assistance with daily care needs, and had a diagnosis of
hypertension (high blood pressure).Physician's orders for Resident 8, dated May 4, 2025, indicated that the
resident was to receive 25mg carvedilol (a medication to treat high blood pressure) and to hold the
medication if her pulse was less than 60 beats per minute (bpm) or her systolic blood pressure (the top
number of the blood pressure) was less than 100.Review of resident 8's Medical Administration Records
(MAR) for January and February 2026 revealed that she received 25mg Carvedilol on January 10 with a
pulse of 58 bpm, January 19 with a pulse of 58bpm, January 23 with a pulse of 56, January 30 with a pulse
of 50, and February 8 with a pulse of 58. Interview with the Director of Nursing on February 25, 2026, at
3:10 p.m. confirmed that Resident 8's carvedilol should have been administered on the above times and
dates and should have been held according to the parameters on the physician's orders.A quarterly MDS
assessment for Resident 68, dated February 13, 2026, indicated that the resident was cognitively intact,
required assistance with daily care needs, received an anticoagulant medication (medication that thins the
blood) and had a diagnosis of cancer. A nursing note for Resident 68, dated February 2, 2026, at 7:48 a.m.
revealed that the resident was seen by the physician and orders were obtained to hold her Eliquis (an
anticoagulant medication) three days prior to her upcoming breast biopsy. A physician's order for Resident
68, dated February 3, 2026, indicated that staff was to hold her Eliquis three days prior to her breast biopsy.
A nursing note for Resident 68, dated February 3, 2026, at 3:33 p.m. revealed that
Residents Affected - Few
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395090
If continuation sheet
Page 8 of 20
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
02/27/2026
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
the resident's biopsy was scheduled for February 18, 2026, at 10:00 a.m. Review of resident 68's clinical
records revealed that she was hospitalized on [DATE], and returned to the facility on February 11, 2026.
There was no documented evidence that the facility clarified the order to hold the Eliquis three days prior to
her biopsy when she returned from the hospital. A nursing note for Resident 68, dated February 17, 2026,
at 10:21 a.m. revealed that the facility received a phone call from the Breast Care Center regarding holding
the resident's Eliquis three days prior to her appointment and the Eliquis was given. Her biopsy was
rescheduled for March 4, 2026. Interview with the Nursing Home Administrator on February 25, 2026, at
1:37 p.m. confirmed that Resident 68's Eliquis should have been clarified when she returned from the
hospital to hold it prior to her biopsy and it was not, resulting in her biopsy having to be rescheduled. 28 Pa.
Code 211.12(d)(1)(3)(5) Nursing Services.
Event ID:
Facility ID:
395090
If continuation sheet
Page 9 of 20
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
02/27/2026
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to
ensure that pressure ulcer care/prevention treatments were provided as ordered for one of 33 residents
reviewed (Resident 3). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated
assessment of a resident's abilities and care needs) for Resident 3, dated January 17, 2026, revealed that
the resident had moderate cognitive impairment, required assistance from staff for daily care needs, and
had medical diagnosis that included stroke, hemiplegia and dementia. Care plan for Resident 3 dated
August 5, 2025, indicated that the resident has the potential for pressure ulcer development and required
extensive-total assist with bed mobility. An intervention dated January 23, 2026, indicated that the resident
was to have B Prevalon boots ( medical devices designed to prevent heel pressure injuries in
non-ambulatory, bedridden patients) on all times when in bed, and her skin integrity checked with
application and removal.Physician's orders for Resident 3, dated January 22, 2026, included an order for
the resident to have B Prevalon boots on all times when in bed. Check skin integrity with application and
removal.Observations of Resident 3 on February 24, 2026, at 11:00 a.m. and on February 26, 2026, at
10:15 a.m. revealed the resident lying in bed without the presence of B Prevalon boots. Interview with
Nurse Aide 2 on February 26, 2026, at 10:15 a.m. revealed that Resident 3 did not have B Prevalon boots
in place, and that she did not have any B prevalon boots available in her room to put in place as ordered.
Interview with the Nursing Home Administrator on February 26, 2026, at 12:49 p.m. revealed that B
prevalon boots were not added to Resident 3's task list to alert nurse aides to apply them, they should have
been available in her room, and there was no documented evidence that they were being applied as
ordered. 28 Pa. Code 211.12(d)(5) Nursing services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395090
If continuation sheet
Page 10 of 20
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
02/27/2026
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that
the facility failed to ensure that assistance devices to prevent accidents or injury were in place for one of 33
residents reviewed (Resident 14)Findings include: The facility's policy regarding falls, dated December 18,
2025, indicated that residents identified as fall risks will have interventions in place to prevent further falls. A
quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care
needs) for Resident 14 dated February 27, 2026, indicated that the resident was cognitively impaired, and
required assistance for daily care. Resident 8's current care plan, indicated that the resident was at risk for
falls. Fall interventions included keeping her personal belongings within reach, and that she would have a
reacher tool (used to grab objects that are beyond your reach). Observations of Resident 14 on February
24, 2026, at 10:45 a.m. revealed that the resident was in her wheelchair and did not have her reacher
available in her room. Observations on February 26, 2025, at 1:15p.m. revealed that the resident was in her
wheelchair in her bedroom reaching for items on her stand and did not have her reacher available to her.
Interview with Nurse Aide 3 on February 26, 2026, at 1:16 p.m. confirmed that Resident 14's reacher was
not in her room and was missing. Interview with the Nursing Home Administrator and Director of Therapy
on February 26, 2026 at 2:52 p.m. confirmed that Resident 14's reacher tool should have been available to
her. 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
Event ID:
Facility ID:
395090
If continuation sheet
Page 11 of 20
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
02/27/2026
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed
to ensure that a resident who needed respiratory care was provided such care consistent with professional
standards of practice for one of 33 residents reviewed (Resident 1). Findings include: A significant change
Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs)
for Resident 1, dated November 22, 2025, revealed that the resident was cognitively intact, received oxygen
therapy and had diagnoses that included respiratory failure, congestive heart failure and pneumonia.
Physician's orders for Resident 1, dated November 13, 2025, included orders for the resident to receive
oxygen at a flow rate of 1-5 liters per minute (LPM) via nasal cannula (a small tube that delivers oxygen
through the nasal passages) to keep her pulse oximetry (measures blood oxygen levels) greater than 90
percent. May titrate as needed for pulse oximetry less than 90 percent and/or shortness of breath.
Observations of Resident 1on February 24, 2026, at 10:42 a.m., February 25, 2026, at 12:44 p.m. and
February 26, 2026, at 8:45 a.m. revealed that the resident was lying in bed with oxygen being supplied via
nasal cannula at a flow rate of 3 LPM. There was no documented evidence in the resident's clinical record
that the facility was documenting her use of oxygen and that they were checking her pulse oximeter to
ensure she was getting the appropriate liter flow. Interview with the Assistant Director of Nursing on
February 26, 2026, at 10:48 a.m. confirmed that there was no documented evidence in Resident 1's clinical
record that the facility was documenting her use of oxygen and that they were checking her pulse oximeter
to ensure she was getting the appropriate liter flow. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395090
If continuation sheet
Page 12 of 20
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
02/27/2026
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 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of policies and clinical records, as well as observations and resident and staff interviews, it
was determined that the facility failed to follow facility policy for the care and monitoring of residents
receiving dialysis for one of 33 residents reviewed (Resident 61). Findings include:Review of the facility's
dialysis policy, dated December 18, 2025, revealed that when a resident is requiring dialysis an order will
be written for the dialysis, place of treatment, port check every shift and as needed, medications to be held
prior to dialysis, and any specific orders from dialysis including dietary restrictions, fluid restrictions and
intake and output and laboratory studies. The Licensed Practical Nurse/Registered Nurse will monitor the
dialysis port or catheter every shift and as needed. The nurse will report any bleeding, redness,
inflammation, drainage or catheter dysfunction. An admission Minimum Data Set (MDS) assessment (a
mandated assessment of a resident's abilities and care needs) for Resident 61, dated February 17, 2026,
revealed that the resident was cognitively intact, required assistance with daily care needs, had a diagnosis
of ends stage renal disease and was receiving dialysis (medical treatment that filters waste, toxins, and
excess fluid from the blood when the kidneys have failed). Care plan for Resident 61 dated February 11,
2026, indicated that the resident had end stage renal failure and required hemodialysis, and staff were to
monitor his fistula (a surgically created connection between an artery and a vein designed to provide
long-term access for hemodialysis) and watch for signs or symptoms of infection and monitor the bruit and
thrill (the audible whooshing and palpable buzzing sensations felt over a functioning hemodialysis fistula or
graft, confirming adequate blood flow) as per orders. Review of Resident 61's clinical records that included
medication and treatment administration records dated February 2026, revealed no documented evidence
that the resident had orders for dialysis that included when and where it was scheduled, and there was no
documented evidence that staff were monitoring the resident's dialysis fistula site.Interview with the Nursing
Home Administrator on February 26, 2026, at 12:00 p.m. confirmed that there was no documented
evidence that the resident's clinical record included orders for dialysis treatments, or that the resident's
fistula was being monitored per the resident's care plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395090
If continuation sheet
Page 13 of 20
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
02/27/2026
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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 12). Findings include: The facility's policy regarding medication
administration, dated December 18, 2025, indicated that documentation of narcotic administration will be
done in accordance with applicable law including documenting necessary medication administration
treatment information on appropriate forms, and removal of fentanyl patches (a narcotic medication) will
require two signatures to ensure proper disposal of the patch. A quarterly Minimum Data Set (MDS)
assessment (a mandated assessment of a residents abilities and care needs) for Resident 12, dated
January 8, 2026, revealed that the resident was cognitively intact, required extensive assistance with daily
care needs, and had diagnoses that included Parkinson's (a progressive neurological disease that affects
movement). Physician's orders for Resident 12 dated October 27, 2025, included an order for the resident
to receive one 25 microgram (mcg) per hour fentanyl transdermal (through the skin) patch, applied every 72
hours for pain management and to remove per schedule. Review of the controlled drug record (tracks each
dose of a controlled medication) and Medication Administration Record (MAR) for Resident 12 for
December, 2025 and January, 2026, revealed that there were not two signatures for the removal and
disposal of the 25 mcg/hour fentanyl patch for December 26, 2025 and January 5, 8, 11, and 14, 2026.
Interview with the Director of Nursing on February 26, 2026, at 12:53 p.m. confirmed that there was not two
signatures for the removal and disposal of the fentanyl patches for Resident 12 on the above dates. Current
physician's orders for Resident 12 included an order for the resident to receive one 37.5mcg/hour fentanyl
transdermal patch applied every 72 hours and to remove the patch per schedule. Review of the controlled
drug record for Resident 12 revealed that a 37.5mcg/hr fentanyl transdermal patch was signed out on
February 23, 2026, however a review of Resident 12's MAR for February, 2026 revealed no documented
evidence the patch was administered on the above date. Interview with the Nursing Home Administrator on
February 27, 2026 at 8:35 a.m. confirmed that there was no documented evidence that the fentanyl patch
that was signed out on February 23, 2026, was administered to Resident 12. 28 Pa. Code 211.9(a)(h)
Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Event ID:
Facility ID:
395090
If continuation sheet
Page 14 of 20
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
02/27/2026
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 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of manufacturer's instructions and clinical records, as well as observations and staff
interviews, it was determined that the facility failed to maintain a medication error rate of less than five
percent.Findings include: Observations during medication administration on February 26, 2026, and
February 27, 2026, revealed that three medication administration errors were made during 38 opportunities
for error, resulting in a medication administration error rate of 7.89 percent. Manufacturer's directions for
Trelegy Ellipta (medication that reduces inflammation in the airways)100-62.5-25 micrograms/activation
(mcg/act), dated January 2019, indicated to advise patients to rinse his/her mouth with water without
swallowing after inhalation to reduce the risk of candida albicans, an infection of the mouth and pharynx
(throat). Physician's orders for Resident 68, dated February 11, 2026, included an order for the resident to
receive one puff (inhalation) of 100-62.5-25 mcg/act of Trelegy Ellipta daily in the morning for chronic
obstructive pulmonary disease (COPD) (chronic lung disease making breathing difficult). Observations
during medication administration on February 26, 2026, at 8:18 a.m. revealed that Licensed Practical Nurse
4 administered one puff of Resident 68's Trelegy Ellipta then proceeded to give her a drink of iced tea.
Interview with Licensed Practical Nurse 4 at 8:40 a.m. revealed that she was not sure if she needed to have
Resident 68 rinse her mouth out with water without swallowing after administering Trelegy Ellipta. Interview
with the Nursing Home Administrator on February 26, 2026, at 4:33 p.m. confirmed that Licensed Practical
Nurse 4 should have had Resident 68 rinse her mouth out with water and spit after administering her
Trelegy Ellipta. Manufacturer's directions for use of Xtandi (used to treat prostate cancer), dated January
2025, revealed that tablets should be taken whole and should not be cut, crushed or chewed. Instructions
on the bottle indicated that the medication should be swallowed whole and should not be cut, crushed, or
chewed. Manufacturer's directions for use of Ferrous Sulfate (an iron supplement), dated March 2020,
revealed that tablets should be taken whole and should not be chewed or crushed. Physician's orders for
Resident 31, dated January 5, 2026, included an order for the resident to receive 160 milligram (mg) of
Xtandi daily for prostate cancer. Physician's orders for Resident 31, dated January 5, 2026, included an
order for the resident to receive 325 mg of Ferrous Sulfate daily. Observations during the medication
administration on February 27, 2026, at 8:14 a.m. revealed that Licensed Practical Nurse 5 crushed
Resident 31's Ferrous sulfate tablet and crushed one 40 mg tablet of Xtandi, and then administered the
crushed medications to the resident. Observations during the medication administration on February 27,
2026, at 8:14 a.m. revealed that Licensed Practical Nurse 5 prepared and administered one 40 mg table of
Xtandi to Resident 31. The physician's order indicated that the resident was to receive 160 mg of Xtandi
daily. The medication was supplied in a bottle containing 40 mg tablets. Interview with Licensed Practical
Nurse 5 on February 27, 2026, at 8:45 a.m. confirmed that Resident 31's Ferrous Sulfate and Xtandi should
not have been crushed, and confirmed that she should have administered Resident 31 a total of four 40 mg
tablets of Xtandi to equal the ordered dose of 160 mg and she did not. Interview with the Nursing Home
Administrator and Director of Nursing on February 27, 2026, at 10:35 a.m. confirmed that Resident 31's
Ferrous Sulfate and Xtandi should not have been crushed, and that Resident 31 received the incorrect
dose of Xtandi. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395090
If continuation sheet
Page 15 of 20
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
02/27/2026
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 0773
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the
results.
Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain a
physician's order for an invasive procedure to collect a specimen for a laboratory test for one of 33
residents reviewed (Resident 4).Findings include: A quarterly Minimum Data Set (MDS) assessment (a
mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 12, 2026,
revealed that the resident was cognitively intact and had diagnoses that included a urinary tract infection.
Physician's orders for Resident 4, dated June 24, 2025 included an order for staff to obtain a urine
specimen to rule out a urinary tract infection. A progress note for Resident 4, dated June 24, 2025, revealed
that the writer performed a straight catheterization (the manual insertion of a plastic tube into the bladder to
drain urine) on the resident at this time to obtain a urinalysis and culture and sensitivity (UA C&S - urine
tests to check for the presence of bacteria and determine which antibiotics the bacteria is sensitive
to).There was no documented evidence that staff obtained a physician's order to obtain Resident 4's urine
specimen via catheterization. Interview with the Nursing Home Administrator on February 25, 2026, at 2:05
p.m. confirmed that there was no evidence that a physician's order was obtained for Resident 4 to be
catheterized to obtain the urine specimen on June 24, 2025 and there should have been. 28 Pa. Code
211.12(d)(1)(3)(5) Nursing Services.
Event ID:
Facility ID:
395090
If continuation sheet
Page 16 of 20
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
02/27/2026
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
facility policies, observations, and staff interviews, it was determined that the facility failed to store, prepare,
distribute and serve food in accordance with professional standards for food service safety. Findings
include:A facility policy for food storage dated December 18, 2025, revealed that food would be stored
closed to open air and that no employee food or drinks would be stored in pantry refrigerators.
Observations of the walk in cooler on February 24 ,2026 at 9:09 a.m. revealed a half of a box of dinner rolls
and a full box of dough balls open to air. Observations in the prep refrigerator in the kitchen revealed an
employee fountain drink that was half full. Observations of the refrigerator in the medication room on
Spruce on February 27, 2026, at 8:45 a.m. revealed a cup of [NAME] coffee, a sandwich, two containers of
yogurt and an Oikos yogurt drink belonging to an employee. Interview with the Dietary Director on February
24, 2026, at 9:12 a.m. indicated that food should be stored closed to air and employee food should never be
stored in the prep refrigerator. Interview with the Assistant Director of Nursing on February 27, 2026, at
9:08 a.m. confirmed that no food should be stored in the medication refrigerator in the medication room and
that there is a separate refrigerator. 28 Pa. Code 211.6(f) Dietary Services. 28 Pa. Code 207.4 Ice
Containers and Storage.
Event ID:
Facility ID:
395090
If continuation sheet
Page 17 of 20
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
02/27/2026
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 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 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 27, 2025, 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 February 27,
2026, identified repeated deficiencies related to failure to correct deficient practices related to care plan
revision, quality of care, services to prevent/heal pressure ulcers, safe environment that is free of accident
hazards, laboratory services, complete and accurate accounting of controlled medications and infection
control. The facility's plan of correction for a deficiency regarding a failure to revise residents' care plans,
cited during the survey ending March 27, 2025, revealed that the facility developed a plan of correction that
included completing audits and reporting the results of the audits to the QAPI committee for review. The
results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to
successfully implement their plan to ensure ongoing compliance with regulations regarding care plan
revisions. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey
ending March 27, 2025, revealed that the facility would complete audits and report the results of the audits
to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the
facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding quality of
care. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey
ending March 27, 2025, revealed that the facility would complete audits and report the results of the audits
to the QAPI committee for review. The results of the current survey, cited under F686, revealed that the
facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding services
to prevent/heal pressure ulcers. The facility's plans of correction for deficiencies regarding a safe
environment that is free of accident hazards, cited during the survey ending March 27, 2025, revealed that
the facility developed plans of correction that included completing audits and reporting the results of the
audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that
the facility's QAPI committee failed to maintain compliance with the regulation regarding a safe environment
that is free of accident hazards. The facility's plans of correction for deficiencies regarding laboratory
services, cited during the survey ending March 27, 2025, revealed that the facility developed plans of
correction that included completing audits and reporting the results of the audits to the QAPI committee for
review. The results of the current survey, cited under F773, revealed that the facility's QAPI committee failed
to maintain compliance with the regulation regarding laboratory services. The facility's plan of correction for
a deficiency regarding complete and accurate accounting of controlled medications, cited during the survey
ending March 27, 2025, revealed that the facility developed a plan of correction that included completing
audits and reporting the results of the audits to the QAPI committee for review. The results of the current
survey, cited under F755, revealed that the facility's QAPI committee failed to maintain compliance with the
regulation regarding complete and accurate accounting of controlled medications. The facility's plans of
correction for deficiencies regarding infection control, cited during the surveys ending March 27, 2025,
revealed that the facility developed plans of correction that included completing
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395090
If continuation sheet
Page 18 of 20
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
02/27/2026
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 0867
Level of Harm - Minimal harm
or potential for actual harm
audits and reporting the results of the audits to the QAPI committee for review. The results of the current
survey, cited under F880, revealed that the facility's QAPI committee failed to maintain compliance with the
regulation regarding infection control. Refer to F657, F684, F686, F689, F773, F755, F880 28 Pa. Code
201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395090
If continuation sheet
Page 19 of 20
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
02/27/2026
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of guidance from the Centers for Disease Control (CDC - the national health protection
agency) and clinical records, as well as observations and staff interviews, it was determined that the facility
failed to follow CDC guidelines to reduce the spread of infections and prevent cross-contamination related
to Clostridioides difficile (C-diff-a bacteria that can cause severe diarrhea and inflammation of the colon)
infection for one of 33 residents reviewed (Resident 11). Findings include: The Facility's policy regarding
isolation and transmission-based precautions dated December 18, 2025, indicated that contact precautions
are implemented for residents known or suspected to be infected with microorganisms that can be
transmitted by direct contact with the resident or indirect contact with environmental surfaces or
resident-care items in the resident's environment. Residents with diarrhea and suspected clostridium
difficile will be placed on contact precautions while awaiting laboratory results.A quarterly Minimum Data
Set (MDS) assessment (required assessment of a resident's abilities and care needs) for Resident 11,
dated February 10, 2026, revealed that the resident was cognitively impaired, was always incontinent of
bowel, required assistance for staff with daily care needs, and had diagnosis that included high blood
pressure and a stroke. A nurses note dated February 23, 2026, at 2:43 p.m. stated that Resident 11 had
tested positive for clostridium difficile.A laboratory test dated February 23, 2026, revealed that Resident 11
was positive for clostridium difficile.Observations on February 25, 2026, at 9:54 a.m. revealed that Resident
11 was lying in his bed and did not have contact isolation signs on his door.Interview with Licensed
Practical Nurse 1 on February 25, 2026, at 9:54 a.m. confirmed that Resident 11 did not have contact
isolation on door and he should have.Interview with the Nursing Home Administrator on February 25, 2026,
at 10:48 a.m. confirmed that Resident 11 did not have contact isolation signs on door and that he should
have had them. 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395090
If continuation sheet
Page 20 of 20