Deficiency Records for Windber Woods Senior Living and Rehabilitation Ctr
Updated as of March 01, 2024
A list of the most recent deficiencies for Windber Woods Senior Living and Rehabilitation Ctr. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-10-25 | 2023-12-06 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-10-25 | 2023-12-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-27 | 2023-05-08 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-03-27 | 2023-05-08 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-16 | 2023-05-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-16 | 2023-05-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-16 | 2023-05-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-16 | 2023-05-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-16 | 2023-05-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-16 | 2023-05-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-16 | 2023-05-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-16 | 2023-05-08 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-03-16 | 2023-05-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-16 | 2023-05-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-16 | 2023-05-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-16 | 2023-05-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-16 | 2023-05-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-16 | 2023-05-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-22 | 2023-04-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-03 | 2023-01-31 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-03 | 2023-01-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-14 | 2022-12-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-01 | 2022-12-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-01 | 2022-12-20 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-04-25 | 2022-06-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-25 | 2022-06-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-25 | 2022-06-24 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-04-25 | 2022-06-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-04-25 | 2022-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-25 | 2022-06-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-25 | 2022-06-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-21 | 2022-06-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-21 | 2022-06-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-21 | 2022-06-01 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-04-21 | 2022-06-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-21 | 2022-06-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-21 | 2022-06-01 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-21 | 2022-06-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-04-21 | 2022-06-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-04 | 2022-04-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-04 | 2022-04-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-18 | 2022-02-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-18 | 2022-02-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-10 | 2021-06-08 | Y |
| Meet other general requirements. | Fire Safety | 2021-03-11 | 2021-05-03 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-03-11 | 2021-05-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-11 | 2021-05-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-11 | 2021-05-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-11 | 2021-05-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-03-11 | 2021-05-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-03-11 | 2021-05-03 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-03-04 | 2021-04-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-04 | 2021-04-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-04 | 2021-04-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-04 | 2021-04-23 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-03-04 | 2021-04-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-04 | 2021-04-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-04 | 2021-04-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-04 | 2021-04-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-04 | 2021-04-23 | N |
