Windber Woods: Safety Oversight Failures Repeat - PA
Inspectors who visited Windber Woods Senior Living & Rehabilitation Center in late March 2025 found that the facility had failed to correct accident hazard violations that dated back to a survey completed in April 2024. Nearly a year had passed. The problems remained.
What made the finding particularly stark was not just that the violations persisted, but how they persisted. Windber Woods had not ignored its previous citation and moved on. The facility had written a formal plan of correction. Staff had committed to conducting audits. Those audit results were supposed to be carried back to the facility's Quality Assurance and Performance Improvement committee, known as QAPI, where leadership would review them and confirm that the problems were being addressed.
That process existed on paper. In practice, the QAPI committee failed to ensure ongoing compliance. The audit loop that was supposed to catch continuing problems and force corrections did not catch them, or did not force them, or both.
The 2024 deficiency that triggered the plan of correction involved pharmacy procedures, services, and records. The specifics of what went wrong with pharmacy operations in 2024 are part of that earlier record. What the 2025 inspection established is that whatever corrective steps were taken were not enough to bring the facility into lasting compliance with regulations governing accident hazards.
Repeat deficiencies of this kind carry a specific weight in federal nursing home oversight. When a facility identifies a problem, writes a correction plan, and then fails to implement that plan effectively enough to prevent the same violation from recurring, it raises questions that go beyond the original deficiency. The question is no longer only what went wrong with pharmacy procedures. The question becomes what is wrong with the system the facility put in place to make sure things stop going wrong.
QAPI is that system. Federal nursing home regulations require facilities to maintain an ongoing quality assurance program precisely because problems in long-term care tend to be structural. A single audit finding is not supposed to be the end of the process. It is supposed to feed back into a cycle of monitoring, adjustment, and verification. At Windber Woods, inspectors concluded that cycle broke down.
The facility sits in Windber, a small borough in Somerset County in southwestern Pennsylvania, a community where Windber Woods is one of the primary options for residents who need skilled nursing or rehabilitation services.
What the March 2025 inspection does not detail, at least in the narrative available, is exactly where the breakdown occurred. Whether audits were conducted and their results never meaningfully acted upon, whether audits were conducted inconsistently, or whether the QAPI committee reviewed results but failed to identify that the underlying problem had not been resolved, the inspection record does not say. What it says is that the outcome, continued noncompliance with accident hazard standards, was the same as if no corrective plan had existed at all.
That gap, between the documented intention to fix something and the documented failure to fix it, is the core of what inspectors cited.
For residents at a skilled nursing facility, accident hazard regulations exist for a direct reason. Falls, unsafe equipment, environmental dangers, and medication errors are among the leading causes of serious harm and death in long-term care settings. A pharmacy-related deficiency that goes uncorrected for nearly a year is not an abstraction. It describes a period during which residents received care in a facility that had acknowledged a problem and had not solved it.
The plan said audits would happen. The plan said results would go to the committee. The committee was supposed to make sure the facility stayed in compliance.
It did not.
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 made the finding particularly stark was not just that the violations persisted, but how they persisted.
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.