Windber Woods Senior Living & Rehabilitation CTR

In the surveyor’s words

From the most serious findings on record at Windber Woods Senior Living & Rehabilitation CTR, in the surveyor’s own words.

• Actual harm, isolatedF760Mar 27, 2025

  Based on review of manufacturer's directions for use, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to follow the manufacture's direction for use, resulting in a significant medication error for one of 44 residents reviewed (Resident 85), which resulted in Resident 85 requiring medical intervention to correct a critically low blood sugar. Findings include: The manufacturer's direction for use for Insulin Lispro (a rapid acting insulin), dated July 2023, indicated to administer the dose of Insulin Lispro within 15 minutes before a meal or immediately after a meal. The facility's policy regarding medication administration, dated December 20, 2024, indicated that medications are to be administered in a safe and legal manner. […]

• Actual harm, isolatedF600Oct 23, 2024

  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. […]

• Actual harm, isolatedF689Oct 23, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF812Apr 18, 2024

  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. 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. […]

• No harm, potential for more than minimal, patternF605Feb 27, 2026

  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… […]