Windber Woods Senior Living & Rehabilitation Ctr

F-F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding updating residents' care plans.

The facility's plan of correction for a deficiency regarding accident hazards, cited during the surveys ending

on April 18, 2024, and October 23, 2024, 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

F-F689, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accident hazards.

The facility's plan of correction for a deficiency regarding pharmacy procedures, services, and records, cited

during the survey ending April 18, 2024, 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

F-F755.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(e)(1) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 22 395090 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395090 B. Wing 03/27/2025

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 42079 potential for actual harm Based on review of established infection control guidelines, facility policy, and residents' clinical records, as Residents Affected - Few well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for three of 36 residents reviewed (Residents 47, 106).

Findings include:

CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP

during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.

The facility's policy regarding EBP, dated December 20, 2024, referred to the use of gown and gloves for use

during high contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). Clear signage would be posted on the door or wall outside of the resident room indicating the type of precautions, required PPE, and the high contact resident care activities that require the use of gowns and gloves. An orange-colored sticker would be placed on the resident name on the door to alert staff of EBP.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 47, dated February 24, 2025, revealed that the resident was cognitively impaired, required assistance from staff with care, and had pressure sores.

Physician's orders for Resident 47, dated February 18, 2025, included orders for the resident to have the wound on her sacrum cleaned with wound cleanser and hydrogel applied daily. A wound note, dated March 25, 2025, revealed that the resident had a Stage 3 pressure ulcer (involves full-thickness skin loss, extending into the subcutaneous tissue layer, but not exposing bone, tendon, or muscle) of the sacrum.

Observation of Resident 47 on March 24, 2025, at 8:50 a.m. revealed that the resident was in bed, and there was no sign to indicate the resident was on EBP or PPE supplies outside of her door.

Interview with the Nursing Home Administrator on March 25, 2025, at 3:03 p.m. revealed that the resident did not have EBP in place and should have due to having a pressure sore.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 22 395090 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395090 B. Wing 03/27/2025

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 An admission MDS for Resident 106, dated March 13, 2025, revealed that the resident was cognitively impaired, required assistance from staff with care, and had one unstageable pressure ulcer (unable to Level of Harm - Minimal harm or determine the depth of the wound due to slough or eschar) present on admission. A care plan for Resident potential for actual harm 106, dated March 6, 2025, revealed that she had a left heel unstageable ulcer and right plantar heel diabetic foot ulcer that was at risk for further skin breakdown. Staff were to provide treatments a ordered. Residents Affected - Few Physician's orders for Resident 106, dated March 7, 2025, included an order to cleanse the left heel with wound cleanser, then apply medical grade honey (a wound treatment), and cover with a border foam dressing, changed once a day and as needed.

Physician's orders for Resident 106, dated March 11, 2025, included an order to cleanse the right plantar heel with wound cleanser and apply with a border foam dressing, changed once a day and as needed

Observation of Resident 106's on March 24, 2025, at 9:30 a.m. revealed that the resident was in bed, and there was no signage to indicate the resident was on EBP or PPE supplies outside of her door.

Observations of Resident 106 on March 24, 2025, at 9:39 a.m. revealed that Licensed Practical Nurse 4 entered the room with two dressings in her hand. Licensed Practical Nurse 4 put on gloves but did not put on

a gown to complete the wound care.

Interview with the Nursing Home Administrator on March 24, 2025, at 2:29 p.m. revealed that the resident did not have EBP in place and should have due to having a pressure sore, and staff should have worn a gown while performing wound care.

28 Pa. Code 211.12(d)(1)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 22 395090