WINDBER, PA - Federal health inspectors documented significant infection control failures at Windber Woods Senior Living & Rehabilitation Center during a March 27, 2025 inspection, finding staff failed to implement required safety protocols for residents with open wounds.
Critical Infection Control Lapses
The facility violated federal infection prevention and control requirements by failing to follow Centers for Disease Control (CDC) guidelines designed to prevent the spread of multidrug-resistant organisms among vulnerable residents. Inspectors found two residents with pressure ulcers were not receiving the enhanced barrier precautions required by federal regulations updated in April 2024.
According to the inspection report, Resident 47 had a Stage 3 pressure ulcer on her sacrum - a deep wound extending into subcutaneous tissue. Despite physician orders for daily wound cleaning and treatment, no Enhanced Barrier Precaution signs were posted outside her room, and no personal protective equipment was available for staff caring for her.
Similarly, Resident 106 had multiple wounds including an unstageable pressure ulcer on her left heel and a diabetic foot ulcer on her right plantar heel. When inspectors observed wound care being performed on March 24, the licensed practical nurse wore gloves but failed to don the required protective gown during the procedure.
Medical Significance of Protocol Failures
Enhanced Barrier Precautions represent a critical infection control intervention specifically designed to reduce transmission of resistant organisms in skilled nursing facilities. These protocols require staff to wear gowns and gloves during high-contact care activities for residents with chronic wounds or indwelling medical devices.
The CDC guidance underlying these requirements emphasizes that multidrug-resistant organism transmission is common in skilled nursing facilities, contributing to substantial resident illness, death, and increased healthcare costs. Bacteria that have become resistant to certain antibiotics pose particular risks to elderly residents whose immune systems may already be compromised.
Stage 3 pressure ulcers like the one documented in Resident 47's case represent full-thickness skin loss extending deep into tissue layers. These wounds create direct pathways for bacteria to enter the body and establish serious infections. Without proper barrier precautions, staff can inadvertently transfer dangerous organisms between residents during routine care activities.
Facility Policy Contradicted by Practice
The facility's own Enhanced Barrier Precaution policy, updated December 20, 2024, clearly outlined requirements for gown and glove use during high-contact care for residents with wounds or medical devices. The policy specified that clear signage should be posted outside resident rooms indicating required protective equipment, and orange-colored stickers should alert staff to enhanced precaution requirements.
Despite having comprehensive written policies, facility administration acknowledged the implementation failures. The Nursing Home Administrator confirmed during interviews that both residents should have had Enhanced Barrier Precautions in place due to their pressure ulcers, and that staff should have worn protective gowns during wound care procedures.
Regulatory Standards and Best Practices
Federal infection control requirements were strengthened in April 2024 when the Centers for Medicare & Medicaid Services updated guidance to include Enhanced Barrier Precautions for all residents with chronic wounds, regardless of their infection status. This expansion recognized the high risk of organism transmission in nursing home environments.
Standard infection control protocols in healthcare settings mandate multiple layers of protection during wound care. Proper hand hygiene, appropriate personal protective equipment use, and environmental controls all work together to create barriers preventing cross-contamination between patients.
The facility's violations occurred despite clear federal guidance stating that Enhanced Barrier Precautions should be implemented for residents known to be colonized or infected with multidrug-resistant organisms, as well as those at increased risk of acquisition due to wounds or indwelling medical devices.
Vulnerable Population at Risk
Both residents involved in the violations were documented as cognitively impaired and requiring assistance with daily care activities. Resident 47's quarterly assessment revealed she needed staff help with care and had existing pressure sores requiring ongoing treatment. Resident 106 was admitted with multiple wounds and diabetes-related complications affecting her feet.
These clinical profiles represent the type of vulnerable residents most susceptible to serious complications from healthcare-associated infections. Cognitive impairment can limit patients' ability to communicate symptoms of developing infections, while existing wounds and medical conditions compromise natural immune defenses.
Immediate Health Risks
The documented failures create multiple pathways for dangerous infection transmission within the facility. Staff performing wound care without proper protective equipment can carry organisms on their clothing and hands to other residents during subsequent care activities.
Pressure ulcers themselves pose significant infection risks even under optimal conditions. When combined with inadequate barrier precautions, these wounds become potential sources for spreading resistant bacteria throughout the facility population.
Healthcare-associated infections in nursing homes can lead to sepsis, prolonged hospitalizations, and increased mortality rates among elderly residents. The economic burden includes additional medical treatments, extended facility stays, and potential legal liabilities.
Inspection Findings and Administrative Response
The March 2025 inspection classified these violations as causing "minimal harm or potential for actual harm" affecting "few" residents. However, infection control breaches have the potential to escalate rapidly in congregate care settings where vulnerable populations live in close proximity.
Federal surveyors documented their findings through direct observation of care practices and interviews with facility leadership. The administrator's acknowledgment of the violations during the inspection process confirmed that staff were aware of requirements but failed to implement them consistently.
The facility must now submit a plan of correction addressing how they will ensure consistent implementation of Enhanced Barrier Precautions for all applicable residents and provide additional staff training on infection control protocols.
This inspection report highlights the ongoing challenges nursing homes face in maintaining consistent adherence to complex infection control requirements while providing daily care to medically fragile residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windber Woods Senior Living & Rehabilitation Ctr from 2025-03-27 including all violations, facility responses, and corrective action plans.
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