Windber Woods Rehab: Care Plan Failures Persist - PA
What they found at Windber Woods Senior Living & Rehabilitation Center during a March 2025 inspection was that none of it had worked.
The violations go back at least a year. Inspectors first cited Windber Woods for deficiencies related to accident hazards following a survey that ended April 18, 2024. The facility responded the way facilities typically respond: it wrote a plan of correction. That plan committed to completing audits and bringing the results to the Quality Assurance and Performance Improvement committee, known as QAPI, for review.
By October 23, 2024, inspectors were back. The same deficiency, accident hazards, was cited again.
The facility wrote another plan of correction.
When inspectors returned in March 2025, they found the QAPI committee had failed to successfully implement the plan meant to ensure residents' care plans were being kept current. The committee exists specifically to catch these kinds of failures before they compound. It is the mechanism a facility uses to police itself. At Windber Woods, that mechanism wasn't working.
Care plans are not administrative paperwork. They are the documents that tell nurses, aides, and therapists what a resident needs, what risks they carry, and how staff should respond when something goes wrong. An outdated care plan can mean a resident with a new diagnosis goes without a documented response. It can mean a fall risk isn't flagged. It can mean the people responsible for someone's daily care are working from information that no longer reflects who that person is or what they need.
The inspection report does not describe which residents were affected or what specific harms, if any, resulted. What it documents is a system failure: the committee charged with catching compliance problems failed to catch its own.
The pattern here is what makes the March 2025 finding notable. A single citation can reflect a momentary lapse. Two citations for the same violation within six months raise a harder question. A third inspection finding, this one focused on whether the facility's own internal oversight was functioning, suggests the problem isn't a lapse at all. It suggests the audits either weren't happening, weren't surfacing accurate information, or weren't prompting the committee to act when they did.
The QAPI process is supposed to be self-correcting. A facility identifies a problem, designs a response, measures whether the response worked, and adjusts. At Windber Woods, inspectors found the process had broken down at the measurement step, or somewhere before it. The committee was not successfully implementing the plan. The report does not say why.
What it does say is that the facility had been given the opportunity, twice, to correct course on its own. It had named the problem. It had written down what it intended to do. It had committed to a structure, audits reviewed by a committee, that should have produced accountability. That structure did not produce the compliance it promised.
For residents and families at Windber Woods, the practical question is straightforward: if the committee responsible for quality oversight isn't successfully doing its job, who is catching the problems that committee is supposed to catch? The inspection report doesn't answer that. It only documents, for the third time in less than a year, that something in the facility's internal quality system isn't working the way it should.
The residents living at Windber Woods in March 2025 had care plans. Whether those care plans reflected their current conditions, their current risks, and their current needs, that question is what the QAPI committee was supposed to be able to answer. According to federal inspectors, it couldn't.
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.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
WINDBER WOODS SENIOR LIVING & REHABILITATION CTR in WINDBER, PA was cited for violations during a health inspection on March 27, 2025.
What they found at Windber Woods Senior Living & Rehabilitation Center during a March 2025 inspection was that none of it had worked.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.