Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westmoreland Manor during CMS and state inspections, most recent first.
An LPN failed to follow professional standards and state scope-of-practice rules by crushing multiple medications ordered to be given PO (including apixaban, gabapentin, magnesium oxide, potassium chloride, and midodrine) for a resident with a midline catheter and administering them via the midline instead of orally. The resident, who had a history including atherosclerotic heart disease and required staff assistance with daily care, had an order for oral tablets to be crushed and mixed in pudding and a midline specifically for IV Zosyn. Witnessing staff and the resident’s daughter raised concerns after the LPN admitted to crushing the scheduled oral medications, dissolving them in water, and pushing them through the midline using a flush syringe. Later that evening, the resident’s O2 saturation remained in the mid-80s on high-flow supplemental O2, the physician was notified, and the resident was transferred to the hospital, where hyponatremia was identified and the midline was removed.
A resident with a midline IV catheter and multiple chronic conditions had several oral medications ordered to be crushed and given by mouth. An LPN instead crushed the evening doses of apixaban, gabapentin, magnesium oxide, midodrine, and potassium chloride, mixed them with water, and administered them through the resident’s midline catheter, contrary to the prescribed route and facility policy requiring adherence to the six rights of medication administration. Other staff became aware after the resident’s family questioned the practice and IV medications could not be infused through the midline. The LPN admitted to administering the oral medications via the midline, and the resident subsequently experienced low oxygen saturations and was sent to the hospital, where evaluation showed hyponatremia but otherwise stable status.
Failure to Follow Wound Treatment Orders: A resident who was cognitively intact, dependent on staff, and had limited ROM and pressure ulcers was found to have a Stage 4 pressure sore and a MASD area. Wound consults ordered calcium alginate with silver to the wound beds every 2 days, but TAR review showed the left ischial treatment was done daily and there was no documented evidence the right gluteus treatment was provided as ordered. The DON confirmed the wound consultant's recommendations were not followed.
Failure to follow feeding tube orders for two residents with feeding tubes. One resident with cognitive impairment and dependence for daily care continued to receive bolus TF at 10:00 p.m. even after the order changed to daytime boluses only if meal intake was under 50%; the CRNP confirmed the order was not being followed. Another resident with severe cognitive impairment had a continuous TF order that was later changed to hold TF for 6 hours and check residual before resuming, but the MAR had no documentation that the TF was held as ordered, which the DON confirmed.
A resident with severe cognitive impairment, anxiety, and dementia was prescribed an increased dose of Klonopin (clonazepam) for anxiety and agitation, along with other psychotropic meds. The clinical record did not show that the resident representative was informed in advance of the risks and benefits or treatment alternatives before the higher dose was started, and the CRNP confirmed the lack of documentation.
Damaged wheelchair armrests were observed for two residents, including torn vinyl exposing foam padding and armrests wrapped with duct tape on one wheelchair and peeling vinyl on another. An LPN and a maintenance employee confirmed the conditions, and the NHA stated that repairs were handled through work orders, but no specific work order was documented for one resident’s armrests and no routine wheelchair checks were known to maintenance.
Care plans were not revised to match the current needs of three residents. One resident with DM had physician orders for BG checks twice daily, but the care plan listed weekly checks. Another resident’s shower preference changed from mornings to evenings, yet the care plan was not updated. A third resident’s care plan still listed wheelchair use, transfer aids, and being out of bed even though current orders required the resident to be non-weight bearing, not use a Hoyer lift, and remain in bed; the DON confirmed the plans were not revised.
The facility failed to follow physician orders for two residents. One resident with impaired cognition received Midodrine even when BP readings indicated it should have been held, and another resident with diabetes had multiple blood sugar results over 300 mg/dL without the ordered 2-hour re-checks being documented. The DON confirmed the missed order compliance.
A resident with BPH and intermittent catheterization orders did not receive straight cath care as ordered on several shifts. The TAR and paper flowsheet lacked documentation that the resident was catheterized after attempted voiding when the residual volume was over 300 ml, and the NHA confirmed the missing evidence.
A resident with a history of aggressive behaviors pushed another cognitively impaired resident after being tapped on the shoulder, causing a fall and a hip fracture. The incident occurred despite care plan interventions requiring close monitoring and redirection for the aggressive resident, and the facility's investigation substantiated that abuse occurred.
A resident with a history of CVA and diabetes filed a grievance alleging that an LPN repeatedly engaged in upsetting and inappropriate behaviors, including preparing incorrect insulin and making distressing comments. The facility did not document a thorough investigation into these concerns or obtain a statement from the LPN, as required by policy.
A resident with left-side hemiplegia requested coffee without a lid, which was prepared by a nurse aide using a Keurig and delivered without checking the temperature. The resident spilled the hot coffee onto his thigh, resulting in blisters and redness. Staff interviews confirmed that temperature checks for hot liquids were not routinely performed by nursing staff, and the hot liquid safety policy was not applied to them.
Two residents did not receive care in accordance with physician orders when staff failed to hold prescribed blood pressure medications despite documented low systolic blood pressure readings, as required by the orders. Medication Administration Records showed that Hydralazine and metoprolol tartrate were administered without adherence to hold parameters, and this was confirmed by Clinical Compliance.
The facility did not accurately complete MDS assessments for four residents, including failures to document administration of anticonvulsant and antiplatelet medications, incorrect coding of a resident's fall and fracture history after hospital readmission, and an error in recording a resident's discharge location. These inaccuracies were confirmed by the Director of Case Management.
A resident with renal failure and peripheral vascular disease was prescribed 250 mg calcium citrate twice daily, but was administered 950 mg calcium citrate with 200 mg calcium after the pharmacy substituted the medication due to a backorder. The pharmacy did not notify the facility, and nursing staff did not clarify the change with the provider, resulting in the administration of a non-equivalent medication without proper order clarification.
The facility did not ensure that two residents with PICC lines received IV flushes with saline before and after administration of IV antibiotics, as ordered by physicians and required by facility policy. Medication administration records lacked documentation of these flushes, and staff confirmed the omission.
Two residents received incorrect medication dosages during observed administration, resulting in a medication error rate of 6.67%. An LPN administered a higher dose of calcium citrate than ordered to a resident with renal failure and peripheral vascular disease, and only one drop of artificial tears instead of two to a resident with multiple sclerosis. The DON confirmed the discrepancies between the administered medications and physician orders.
The facility failed to maintain electrical equipment as required by NFPA 70, with two electrical panels obstructed by wheelchairs in a storage room, affecting one smoke compartment. This was confirmed by the Facility Administrator and Maintenance Director.
The facility was found to have improperly used an electrical extension cord as a fixed power source for a pump in the Maintenance/Shop Storage room. This deficiency was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain a safe and homelike environment in the A1 dining room, where residents reported concerns about peeling and rough tables that could cause skin tears. Observations confirmed the poor condition of all eight tables, and both the Maintenance Director and DON acknowledged the issue.
A facility failed to ensure a resident was free from unnecessary psychotropic medications by not attempting non-pharmacological interventions before administering Lorazepam. Despite a policy requiring such interventions and a psychiatric evaluation recommending them, the resident received Lorazepam multiple times without documented attempts at non-pharmacological approaches. The DON confirmed this oversight, indicating non-compliance with the facility's policy.
A facility failed to properly label medications and date multi-dose insulin vials. A resident received a different insulin dosage than labeled, and several insulin vials were not dated upon opening, as confirmed by staff interviews.
A nurse aide in an LTC facility failed to follow sanitary food handling practices by using bare hands to prepare a resident's meal, violating the facility's policy requiring gloves or barriers. This was confirmed by both the aide and the CRNP.
The facility failed to obtain required hospice documentation for two residents receiving hospice services. One resident, with cognitive impairment and malnutrition, lacked updated hospice nurse aide charting since January. Another resident, with a cerebrovascular accident, lacked updated hospice RN and nurse aide charting since admission. These deficiencies were confirmed by the DON.
The QAPI committee at the facility failed to address recurring deficiencies related to assessment accuracy, tube feeding management, drug labeling/storage, and infection control. Despite previous plans of correction, the committee was ineffective in maintaining compliance, leading to repeated citations.
A facility failed to prevent the misappropriation of medication for a resident with chronic pain. Despite documentation of five narcotic cards being received, only four were delivered to the nursing unit. An investigation confirmed that a nurse was the last person in possession of the missing card, leading to the conclusion of misappropriation.
A facility failed to update a resident's care plan to reflect her new preference for receiving medications early due to a change in her dialysis schedule. The resident's care plan was outdated, and the DON confirmed it should have been revised.
A facility failed to provide a resident with weekly showers as per their policy. The resident, who was alert and oriented, had a care plan specifying morning showers. However, during April, the resident did not receive showers on two occasions, instead receiving bed baths due to testing positive for COVID-19. This was confirmed by the DON.
A facility failed to follow its policy for feeding tube management for a resident with cognitive impairment and a feeding tube due to stroke and dementia. The policy requires that feeding tube bags be labeled with the date and time they are started, but an observation revealed that the bag in use was not labeled as required. This was confirmed by a nurse and the DON.
A facility failed to ensure proper hand hygiene during wound care for a resident with multiple ulcers, as two nurses did not wash their hands between glove changes. Additionally, a nurse aide improperly handled soiled linens by throwing them on the floor during a bed bath for another resident. These actions were confirmed by staff interviews and did not comply with the facility's infection control policies.
The facility failed to provide written notification of emergency hospital transfers to responsible parties and the State Ombudsman for three residents. One resident with end-stage renal disease was transferred after a dialysis catheter incident, another with dementia after a fall, and a third with Huntington's disease due to hypoxemia. The Nursing Home Administrator confirmed the lack of notification and was unaware of the requirement.
Improper IV Administration of Oral Medications via Midline by LPN
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality by not ensuring that medications were administered by licensed personnel in accordance with Pennsylvania medical and nursing regulations. Pennsylvania’s Nursing Practice Act specifies that LPNs must exercise sound nursing judgment, seek guidance when patient care needs exceed their scope of practice, obtain instruction and supervision for unfamiliar procedures, and are prohibited from administering medications via IV push or bolus. The facility’s own medication administration policy required that all medications be administered by licensed personnel in accordance with Pennsylvania regulations and that the six rights of medication administration, including the right route, be followed. Resident 2 was cognitively intact, required staff assistance with daily care, and had diagnoses including atherosclerotic heart disease. Physician orders directed that the resident receive multiple medications by mouth, including apixaban, gabapentin, magnesium oxide, potassium chloride extended release, and later midodrine, with an order that oral tablets be crushed and mixed in pudding. The resident also had a right upper arm midline catheter for IV administration of Zosyn. On the evening in question, the 6:00 p.m. oral medications (Eliquis 5 mg, gabapentin 100 mg, magnesium oxide 400 mg, midodrine 5 mg, and potassium 20 mEq) were instead crushed, mixed with warm water, and administered via the resident’s midline catheter. According to witness statements, an RN reported that an LPN admitted to crushing the resident’s oral medications, dissolving them in water, and administering them through the midline using a normal saline flush syringe. Another RN reported that the LPN similarly described using a Silent Knight to crush the medications, dissolving them in water, and giving them through the midline. A different LPN stated that the resident’s daughter questioned whether it was appropriate for the LPN to put medications into the midline catheter, and that when she attempted to assist with IV antibiotic administration, the midline would not infuse or flush despite the LPN stating he had just flushed it. The LPN later admitted to this nurse that he had crushed and administered the 6:00 p.m. medications through the midline. Subsequently, the resident’s oxygen saturation remained between 85% and 87% on 12 liters of supplemental oxygen, the physician was notified, and the resident was sent to the hospital, where evaluation revealed hyponatremia and otherwise stable status after removal of the midline.
Significant Medication Error from Oral Drugs Given via Midline Catheter
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was free from significant medication errors when ordered oral medications were administered via an intravenous (IV) midline catheter instead of by mouth. Facility policy on medication administration required adherence to the six rights of medication administration, including the right route, and specified that medications be administered by licensed personnel in accordance with Pennsylvania regulations. Resident 2’s MDS indicated that the resident was cognitively intact, required staff assistance with daily care, and had diagnoses including atherosclerotic heart disease. The resident had a right upper arm midline catheter in place for IV medication administration, specifically for Zosyn. Physician orders for the resident included multiple oral medications: apixaban 5 mg by mouth twice daily for atrial fibrillation, gabapentin 100 mg two tablets by mouth three times daily for rheumatoid arthritis, magnesium oxide 400 mg by mouth twice daily for magnesium deficiency, potassium chloride ER 20 mEq by mouth three times daily for potassium deficiency, and midodrine 5 mg two tablets by mouth three times daily for hypotension. The resident also had an order for oral tablets to be crushed and mixed in pudding. On the evening medication pass, the 6:00 p.m. oral medications (Eliquis 5 mg, gabapentin 100 mg, magnesium oxide 400 mg, midodrine 5 mg, and potassium 20 mEq) were instead crushed, mixed with warm water, and administered through the resident’s right arm midline catheter. Multiple staff statements and interviews confirmed that an LPN crushed the resident’s ordered oral medications, dissolved them in water, and administered them via the midline using a normal saline flush syringe, rather than giving them orally as ordered. Another nurse became suspicious when the resident’s daughter questioned whether it was appropriate to put medications into the midline, and when attempts to infuse IV antibiotics and flush the midline were unsuccessful despite the LPN stating he had just flushed it. The LPN later admitted to several staff, including RNs, that he had crushed and administered the 6:00 p.m. oral medications through the midline catheter, stating he had made a mistake and was confused with administering medications through a gastric tube. Subsequently, the resident’s oxygen saturation remained between 85% and 87% on 12 liters of supplemental oxygen, the physician was notified, and the resident was transferred to the hospital, where emergency room evaluation revealed hyponatremia and otherwise stable condition. The physician documented that the resident had been given oral medications dissolved in water through the midline the previous evening and that the midline had since been removed.
Failure to Follow Wound Treatment Orders
Penalty
Summary
The facility failed to follow wound treatment recommendations from wound consultations for one resident with pressure ulcers and moisture associated dermatitis. Resident 15 was cognitively intact, dependent on staff for care, had limited range of motion to the upper and lower extremities, and had pressure ulcers. A wound consultation identified a Stage 4 pressure sore on the left ischial tuberosity and an open area on the right gluteus caused by MASD. The wound plan ordered calcium alginate with silver to the wound beds every two days. A later wound consultation showed the Stage 4 pressure sore on the left ischial tuberosity had decreased in size, and the right buttocks MASD area remained open, with the plan to continue calcium alginate with silver every two days. Review of the TARs for February and March 2026 showed the treatment to the left ischial tuberosity was completed daily rather than as ordered, and there was no documented evidence that calcium alginate with silver was applied to the right gluteus every two days. The DON confirmed that the treatments for the resident's pressure ulcer and MASD were not completed as recommended by the wound consultant.
Failure to Follow Feeding Tube Orders
Penalty
Summary
The facility failed to follow physician’s orders for feeding tube care for two residents who had feeding tubes. One resident was cognitively impaired, dependent on staff for daily care tasks, and had a feeding tube. Although the resident’s orders were changed to a house diet with pureed texture and bolus Jevity 1.2 RTH at 9:00 a.m., 2:00 p.m., and 7:00 p.m. only if meal intake was less than 50%, the MAR showed staff continued to administer tube feeding at 10:00 p.m. on multiple dates in March and April 2026. The Clinical Compliance CRNP confirmed that staff were not following the current physician’s order and that the resident should not have been receiving the feeding at 10:00 p.m. A second resident was severely cognitively impaired, dependent on staff for daily care needs, and had a feeding tube ordered to receive Peptamen continuously at 35 cc per hour for 20 hours per day. The physician later ordered the tube feeding to be held for six hours and residual checked before resuming. Review of the MAR showed no documented evidence that the tube feeding was held as ordered, and the DON confirmed there was no documented evidence that the feeding was held. The facility’s tube feeding policy stated that tube feedings were to have a physician’s order and that the order was to be documented on order recaps, the eMAR, and the tube feeding container.
Failure to Inform Resident Representative Before Increasing Psychotropic Medication
Penalty
Summary
Resident 19 had a quarterly MDS assessment dated January 16, 2026 that identified severe cognitive impairment and documented use of psychotropic medications, including antidepressant, antianxiety, and antipsychotic medications, along with diagnoses of anxiety and dementia. On August 11, 2025, a CRNP assessed the resident and obtained new orders to increase clonazepam to 1 mg twice daily prior to morning and evening care. Physician orders that same day included Klonopin (clonazepam) 1 mg twice daily for anxiety and agitation. There was no documented evidence in the resident’s clinical record that the resident representative was informed in advance of the risks and benefits and treatment alternatives before the increased dose of Klonopin was started. During an interview on April 8, 2026, the Clinical Compliance CRNP confirmed that the record did not contain documentation showing the resident’s representative had been informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased clonazepam dose.
Damaged Wheelchair Armrests Not Maintained
Penalty
Summary
The facility failed to provide a clean and homelike environment for two residents whose wheelchairs had damaged armrests. One resident’s wheelchair was observed with a large piece of vinyl torn off the left armrest, exposing the foam padding, and the right armrest was taped with duct tape. The resident stated that the wheelchair was old and that she had asked for a new one. An LPN later confirmed the torn vinyl and taped armrest and said she believed maintenance repaired chair issues, then contacted maintenance and was told to submit a work order. A second resident’s wheelchair was observed with vinyl pieces peeling off the armrests, and a maintenance employee confirmed the condition at the time of observation. The maintenance employee stated that wheelchair repairs are normally handled through work orders from nursing or therapy and that he was not aware of routine wheelchair checks. The NHA acknowledged awareness of the first resident’s torn armrests and stated maintenance was working on them, and she was informed that there was no work order for the second resident’s wheelchair armrests and no specific repair request documented for the first resident’s armrests.
Care Plans Not Updated to Match Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated and revised to reflect residents’ specific care needs for three of 55 residents reviewed. Facility policies stated that care plans are to be reviewed and revised by the interdisciplinary team at least quarterly after each comprehensive and quarterly MDS assessment, or more often as changes occur. For Resident 98, a quarterly MDS dated March 12, 2026, showed the resident was cognitively intact, dependent on staff for care needs, and had diabetes mellitus, while physician orders dated January 15, 2026, directed blood glucose monitoring in the morning and evening. However, the care plan dated January 27, 2027, stated blood sugar checks were to be done every Wednesday morning. The NHA acknowledged on April 9, 2026, that the care plan should have been updated to reflect twice-daily blood glucose checks. For Resident 135, a significant change MDS dated January 15, 2026, showed the resident was cognitively intact, needed assistance with daily care needs, and had anxiety and bipolar disorder. The resident stated she was receiving showers on Tuesday evenings and wanted to return to morning showers before breakfast. Staff interviews confirmed the shower time had been changed to evening shift because the resident wanted it changed, and the DON confirmed the care plan was not revised to reflect the change in shower preference. For Resident 159, an annual MDS dated April 4, 2026, showed the resident was cognitively impaired, dependent on staff for all care needs, and not out of bed due to medical and safety concerns. Physician orders dated March 3, 2026, directed that the resident be non-weight bearing, not use hoyer lifts, and not be out of bed, yet care plans still described the resident as using a wheelchair, using bilateral assist bars for transfers, and being out of bed to an 18-inch specialty chair as tolerated. The DON confirmed the care plan was not updated to reflect the resident’s current status.
Failure to Follow Physician Orders for Medication and Blood Sugar Monitoring
Penalty
Summary
The facility failed to follow physician’s orders for Resident 9, who had impaired cognition and needed staff assistance with daily care needs. The resident had an order for Midodrine HCL 5 mg three times daily, with instructions to hold the medication if systolic blood pressure was less than 100. On April 4, 2026, the resident’s blood pressure was 119/75 mmHg, and on April 5, 2026, it was 139/81 mmHg, yet the medication was administered on both occasions instead of being held as ordered. The DON confirmed that Midodrine should have been held on those dates. The facility also failed to follow physician’s orders for Resident 10, who was cognitively intact, received insulin, and had diabetes. The resident had an order for accu-checks before meals and at bedtime, with instructions to re-check blood sugar in two hours if the result was over 300 mg/dL and notify the physician if it remained over 300 mg/dL after the re-check. The MARs showed multiple elevated blood sugar results, including 367 mg/dL, 360 mg/dL, 311 mg/dL, 369 mg/dL, and 400 mg/dL, but there was no documented evidence that staff re-checked the blood sugar in two hours as ordered. The DON confirmed that staff did not re-check the elevated blood sugars on the dates and times noted.
Failure to Complete Ordered Straight Catheterization
Penalty
Summary
The facility failed to ensure that straight catheterization was completed as ordered for one resident who was cognitively intact, required assistance with care needs, had benign prostatic hyperplasia, and received intermittent catheterization. The resident’s care plan indicated straight catheterization per order, and physician orders directed straight catheterization every 12 hours after an attempted void if bladder scan showed a residual volume over 300 ml, with all amounts recorded on a paper flowsheet. A later physician order directed straight catheterization before bed after an attempted void if residual volume was over 300 ml. Review of the resident’s March 2026 TAR and paper flowsheet showed no documented straight catheterization on several shifts, including an evening shift, a morning shift, and two additional evening shifts. The Nursing Home Administrator confirmed there was no documented evidence that the straight catheterization was completed as ordered on those dates and shifts.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse by another resident with a history of aggressive behaviors. According to the facility's abuse policy, staff were required to monitor, assess, and implement care planning interventions for residents with behaviors that could lead to conflict or harm. Resident 2, who had diagnoses including dementia, anxiety, and depression, exhibited multiple behavioral issues such as agitation, paranoia, and hostility, and was to be closely monitored and redirected as needed. Despite these interventions being outlined in the care plan, Resident 2 was able to push another resident, resulting in harm. On the day of the incident, Resident 3, who was also cognitively impaired and had a history of behavioral issues, approached Resident 2 and tapped him on the shoulder. Resident 2 responded by forcefully pushing Resident 3, causing her to fall and sustain a right hip fracture. The facility's investigation, supported by video evidence and staff interviews, substantiated that abuse occurred, as Resident 3 suffered significant injury as a result of the altercation.
Failure to Investigate Resident Grievance Regarding Staff Conduct
Penalty
Summary
The facility failed to conduct a thorough investigation into a resident's grievance regarding the actions and behaviors of a specific LPN. The resident, who had a history of cerebral vascular accident with right side hemiplegia and diabetes, submitted a grievance form detailing multiple incidents over the course of a year. These included the LPN preparing the wrong insulin, making upsetting comments, and engaging in behaviors perceived as passive-aggressive or intended to distress the resident. The resident also reported that the LPN made statements about her hallucinating and expressed a desire not to have this LPN involved in her care. Upon review, it was found that the facility's investigation did not include documentation addressing the resident's specific concerns about the LPN's conduct, nor was there evidence that a statement was obtained from the LPN in question. The facility's grievance policy required a thorough investigation with supporting documentation, but these steps were not completed or recorded in this case. The DON confirmed the absence of documented evidence addressing the resident's concerns or obtaining a statement from the LPN.
Failure to Ensure Hot Liquid Safety Results in Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident with a history of cerebral vascular accident resulting in left-side hemiplegia. The resident, who was alert, oriented, and able to communicate preferences, requested a cup of coffee using his own K-Cup and specified that he did not want a lid on the cup. The coffee was prepared by a nurse aide using a Keurig machine and delivered to the resident's bedside table without the temperature being checked, as was the usual practice at the time. Shortly after receiving the coffee, the resident attempted to drink from the open cup, which slipped from his hand and spilled onto his left thigh. The incident resulted in the formation of blisters and redness on the resident's thigh, as documented in the nursing note. The resident reported mild pain, and the affected area was treated by staff. There was no evidence that the temperature of the coffee was measured prior to serving, and the facility's hot liquid safety policy was not applied to nursing staff, only to kitchen staff. Interviews with staff confirmed that the temperature of hot liquids from the Keurig was not routinely checked before serving to residents. The nurse aide involved in the incident stated that she followed the resident's request for no lid and did not measure the temperature of the coffee. The DON confirmed the lack of documentation regarding temperature checks and clarified that the policy was not extended to nursing staff at the time of the incident.
Failure to Follow Physician Orders for Blood Pressure Medications
Penalty
Summary
The facility failed to ensure that physician's orders were followed for two residents, resulting in care and treatment not being provided in accordance with professional standards of practice. For one resident with a history of congestive heart failure and hypertension, physician's orders required Hydralazine to be held if the systolic blood pressure was less than 120 mmHg. However, review of the Medication Administration Record (MAR) showed that the medication was administered on multiple occasions when the resident's systolic blood pressure was below the specified threshold, with no documentation that the medication was held as ordered. Similarly, another resident with hypertension and dementia had a physician's order for metoprolol tartrate to be held if the systolic blood pressure was less than 130 mmHg or if the heart rate was less than 60 beats per minute. The MAR indicated that the medication was not held on several occasions when the resident's systolic blood pressure was below the ordered threshold, and there was no documentation to show compliance with the physician's order. These findings were confirmed in an interview with Clinical Compliance staff.
Inaccurate Completion of MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for four residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For one resident with a seizure disorder and cerebral palsy, the MDS did not accurately reflect the administration of an anticonvulsant medication during the seven-day look-back period, despite physician orders and medication administration records confirming its use. Another resident with coronary artery disease and a history of heart attack was not accurately coded for receiving an antiplatelet medication, even though both physician orders and the medication administration record indicated the medication was given during the assessment period. These inaccuracies were confirmed by the Director of Case Management. Additionally, a resident who was readmitted to the facility after a hospital stay for a hip fracture was not properly coded in the MDS to indicate this was the first assessment since reentry, which prevented the documentation of a recent fall and fracture. Another resident's discharge status was incorrectly recorded in the discharge tracking MDS, with the record indicating a discharge to the hospital instead of a personal care home, as documented in the nursing notes. These errors were also confirmed by the Director of Case Management.
Failure to Clarify Provider Order After Pharmacy Medication Substitution
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by not clarifying a provider's order for a resident. Specifically, a physician's order directed that a resident with renal failure and peripheral vascular disease receive 250 mg of calcium citrate twice daily for Vitamin D deficiency. However, during medication administration, the resident was given 950 mg of calcium citrate containing 200 mg of calcium, which did not match the original order. The pharmacy had substituted the medication due to a backorder but did not notify the facility or ensure the substitution was equivalent. Nursing staff, including an LPN, were unaware of the reason for the substitution and did not clarify the change with the physician. There was no documentation in the resident's clinical record indicating that the order was clarified, and the DON confirmed that the medication administered did not match the physician's order. The facility's policy required that such substitutions be communicated and orders updated, but this process was not followed, resulting in the administration of a non-equivalent medication without proper provider clarification.
Failure to Document PICC Line Flushing as Ordered
Penalty
Summary
The facility failed to ensure that peripherally-inserted central catheters (PICCs) were flushed as ordered by physicians for two residents. Facility policy required that intravenous catheters be flushed with 0.9% sodium chloride before and after medication administration. For one resident with cognitive impairment and multiple diagnoses, including heart failure and a urinary tract infection, physician orders specified administration of intravenous antibiotics. However, review of the medication administration records showed no documented evidence that the resident's PICC line was flushed after antibiotic administration, as required by policy. Another resident, who was cognitively intact and had diagnoses including peripheral vascular disease and diabetes, returned from the hospital with a PICC line and orders for daily intravenous Vancomycin, with instructions to flush the IV access site with saline before and after medication administration. The medication administration records indicated that the resident received the IV antibiotics, but there was no documentation that the PICC line was flushed with saline before and after each administration. Staff interviews confirmed the lack of documentation for both residents.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy and regulation. During medication administration observations, two errors were identified out of 30 opportunities, resulting in a 6.67 percent error rate. The facility's policy required staff to verify the electronic medical record against the prescription label and adhere to the six rights of medication administration. However, these procedures were not followed in the observed instances. One cognitively intact resident with renal failure and peripheral vascular disease was ordered to receive 250 mg of calcium citrate twice daily but was instead administered 950 mg. Another cognitively intact resident with multiple sclerosis was ordered to receive two drops of artificial tears in each eye three times daily but was only given one drop per eye. Both errors were confirmed by the LPN involved and the Director of Nursing, who acknowledged that the medications administered did not match the physician's orders.
Obstructed Electrical Panels in Storage Room
Penalty
Summary
The facility failed to maintain electrical equipment in accordance with NFPA 70, National Electric Code, as required by NFPA 101 (2012 Ed.). During an observation on April 30, 2025, at 9:20 a.m., it was noted that two electrical panels were obstructed by wheelchairs in the B-2 storage room on the second floor of the B wing. This deficiency affected one out of 27 smoke compartments in the facility. An interview with the Facility Administrator and Maintenance Director on May 1, 2025, at 11:00 a.m., confirmed the presence of the electrical equipment deficiency. The obstruction of the electrical panels by wheelchairs indicates a failure to ensure clear access to electrical equipment, which is necessary for safety and compliance with the relevant codes.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. Maintenance removed the wheelchairs in the second-floor b-wing storage room that were obstructing the electrical panels on 5/1/2025. The Director of Maintenance/designee will conduct random weekly audits throughout the facility two times per week for two weeks then weekly for two weeks to ensure there are no electrical panels obstructed by wheelchairs. The results of these audits will be brought to the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions.
Improper Use of Extension Cord in Maintenance Room
Penalty
Summary
The facility failed to maintain electrical wiring systems and equipment, as evidenced by the use of an electrical extension cord as a fixed power source for a small electric or mechanical pump. This deficiency was observed in the Maintenance/Shop Storage room located in the basement of the facility. The observation was made on April 30, 2025, at 10:35 a.m. During an interview conducted on May 1, 2025, at 11:00 a.m., both the Facility Administrator and the Maintenance Director confirmed the deficiency related to the electrical wiring systems.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. Maintenance removed the electrical extension cord in the Maintenance/Shop Storage room in the basement on 5/2/2025. The Director of Maintenance/designee will conduct random weekly audits in the facility two times per week for two weeks, then weekly for two weeks to ensure there are no extension cords. The results of these audits will be brought to the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions.
Unsafe Dining Room Environment
Penalty
Summary
The facility failed to provide a safe and comfortable homelike environment in the A1 dining room, as required by their policy dated February 4, 2024. During an interview with a group of residents, concerns were raised about the condition of the dining room tables, which were described as peeling and rough, posing a risk of skin tears. Observations confirmed that all eight tables in the A1 dining room were peeling and had sharp edges. The Maintenance Director and the Director of Nursing both confirmed the poor condition of the tables, acknowledging that the environment was neither safe nor comfortable for the residents.
Failure to Implement Non-Pharmacological Interventions Before Administering Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, as evidenced by the lack of documented non-pharmacological interventions prior to administering Lorazepam. The facility's policy, dated February 4, 2024, mandates the use of non-pharmacological interventions when clinically indicated to reduce the need for psychotropic medication. However, for one resident, there was no evidence that such interventions were attempted before administering Lorazepam on multiple occasions in January and February 2024. The resident in question had cognitive impairment and required assistance with transfers, with diagnoses including dementia and anxiety. Despite a psychiatric evaluation recommending the continuation of positive psychosocial and non-pharmacological approaches, the Medication Administration Records showed repeated administration of Lorazepam without prior attempts at non-pharmacological interventions. The Director of Nursing confirmed the absence of these interventions during an interview, highlighting a failure to adhere to the facility's policy and regulatory requirements.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling of medications for a resident and did not label multi-dose containers of insulin with the date they were opened. Specifically, for one resident, the label on their Lantus insulin did not reflect the correct dosage and timing as per the physician's orders. The label indicated 25 units at bedtime, while the resident was administered 20 units in the morning. This discrepancy was confirmed by an LPN during an interview, who acknowledged that a 'Change in Direction' label should have been applied. Additionally, the facility did not adhere to its policy of dating multi-dose vials upon opening. During an inspection of a medication cart, it was observed that insulin vials for several residents were opened but not dated, contrary to the manufacturer's instructions which require vials to be discarded after a specific period. This was confirmed by another LPN and the Director of Nursing, who acknowledged that the vials should have been labeled with the opening and discard dates.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to ensure that food was served under sanitary conditions, as evidenced by a violation of their policy on feeding with dignity. During a lunch meal observation in the A3 unit dining room, a nurse aide was seen handling a resident's food without using gloves or a barrier. Specifically, the nurse aide used his bare hand to place a mechanical soft prepared hamburger onto a bun for a resident, who then consumed the food. This action was in direct violation of the facility's policy, which mandates that staff cleanse hands between residents, avoid touching food with bare hands, and use gloves or barriers when handling food. The nurse aide confirmed the breach of protocol during an interview, and the Corporate Compliance/Certified Registered Nurse Practitioner corroborated the requirement for using gloves or barriers when touching residents' food items.
Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two residents receiving hospice services. Resident 97, who was cognitively impaired and diagnosed with malnutrition, had a care plan indicating hospice services due to a terminal illness. However, as of May 9, 2023, there was no documented evidence of updated hospice nurse aide charting in the resident's clinical record or the hospice provider's clinical record since January 2024. This was confirmed by an interview with the Director of Nursing. Similarly, Resident 228, who was cognitively intact and diagnosed with a cerebrovascular accident, had a care plan for hospice services due to terminal cerebrovascular disease. As of May 9, 2023, there was no documented evidence of updated hospice registered nurse or nurse aide charting in the resident's clinical record or the hospice provider's clinical record since the admission notes dated April 27, 2024. This deficiency was also confirmed by the Director of Nursing.
QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to effectively address recurring deficiencies identified in multiple surveys. These deficiencies included issues with the accuracy of assessments, tube feeding management, labeling and storage of drugs and biologicals, and infection prevention and control. Despite having developed plans of correction in response to previous surveys, the QAPI committee was unable to maintain compliance with the relevant regulations, as evidenced by the repeated citations in the current survey. The deficiencies were initially identified in surveys conducted on June 13, 2023, August 15, 2023, and August 29, 2023. The facility's plans of correction included monitoring by the QAPI committee to ensure compliance. However, the current survey, ending May 9, 2024, revealed that the QAPI committee was ineffective in addressing these issues, leading to repeated citations under F641, F693, F761, and F880. The facility's inability to correct these deficiencies indicates a failure in the QAPI committee's role in maintaining regulatory compliance.
Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to prevent the misappropriation of medication for one resident, identified as Resident 34. The resident was cognitively intact, required extensive assistance for daily care needs, and had a diagnosis of chronic pain. The physician's orders included Norco for pain management. On a specific date, narcotics were delivered to the B3 nursing unit, and Registered Nurse Supervisor 1 documented the receipt of five narcotic cards. However, during a shift change, it was discovered that only four cards were delivered to the unit, despite five being documented on the accountability form. An investigation revealed that Registered Nurse 2 was the last person in possession of the narcotics card, as confirmed by video footage. The footage showed Registered Nurse 2 entering the medication room alone, and there was no evidence that all five narcotic cards were delivered to the B3 unit. The investigation concluded that misappropriation of Resident 34's medication occurred, as only four cards were documented and delivered, leading to the determination that one card was missing.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to update the care plan of Resident 66 to reflect changes in her care needs. The resident's Medication Administration Record for May 2024 showed that she was receiving medications at 6:00 a.m., despite her care plan from January 21, 2020, indicating a preference for no medications or care before 7:00 a.m. An interview with Resident 66 on May 6, 2024, revealed that she had switched to early dialysis and did not mind receiving medications early, but her care plan was not updated to reflect this change. The Director of Nursing confirmed on May 9, 2024, that the care plan was outdated and should have been revised to accommodate the resident's new preferences.
Failure to Provide Weekly Showers Due to COVID-19
Penalty
Summary
The facility failed to ensure that a resident was provided with weekly showers, as required by their policy. The policy, dated February 4, 2024, stated that residents should be offered a shower at least once a week. An annual Minimum Data Set (MDS) assessment for the resident, dated April 26, 2024, indicated that the resident was alert and oriented, and it was important for them to choose their preferred method of bathing. The resident's care plan, dated July 7, 2023, specified that they were to receive a shower in the morning. However, the resident's bathing records for April 2024 showed that they did not receive a weekly shower on April 5 and 12, instead receiving a bed bath. This was confirmed by the Director of Nursing, who stated that the resident was not showered on those dates due to testing positive for COVID-19.
Failure to Follow Feeding Tube Labeling Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the management of feeding tubes for one resident, identified as Resident 159. The policy, dated February 4, 2024, mandates that the formula and tubing used for feeding tubes must be labeled with the date and time they were started and should not be used for more than 24 hours. However, during an observation on May 8, 2024, it was noted that the bag of Isosource 1.5 formula being used for Resident 159 did not have the required date and time label. This was confirmed by a Registered Nurse at the time of observation. Resident 159, who is cognitively impaired and requires staff assistance, has a feeding tube for nutrition due to diagnoses including stroke and dementia. The resident's care plan and physician's orders specify the administration of Isosource 1.5 at a rate of 38 mL/hr for 21 hours. Despite these orders being followed as per the Medication Administration Record for May 2024, the lack of proper labeling on the feeding bag represents a failure to comply with the facility's established procedures. The Director of Nursing confirmed that staff are responsible for ensuring that feeding tube labels contain the necessary information.
Infection Control Deficiencies in Hand Hygiene and Linen Handling
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for a resident with multiple ulcers and infections. During an observation, two nurses were seen performing wound care on a resident with a Stage 3 and Stage 4 pressure ulcer on the right great toe and a venous ulcer on the right lower leg. Despite the facility's policy requiring hand washing and glove changes at specific intervals during wound care, the nurses did not wash their hands after removing soiled gloves and before applying clean ones. This lapse occurred multiple times during the treatment process, including between handling soiled and clean dressings and between treating different wound sites. Additionally, the facility did not adhere to proper infection control practices while handling soiled linens. A nurse aide was observed throwing a soiled towel and washcloth on the floor during a bed bath for another resident who required extensive assistance with daily care. The facility's protocol dictates that soiled linens should be placed in bags and taken to the dirty utility room, which was not followed in this instance. Interviews with the involved staff and the Director of Nursing confirmed the failure to follow hand hygiene protocols during wound care. Similarly, the Clinical Coordinator confirmed that the handling of soiled linens did not comply with the facility's infection control practices. These deficiencies highlight lapses in adherence to established infection prevention and control measures, as outlined in the facility's policies.
Failure to Notify Responsible Parties and Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to provide written notification of emergency hospital transfers to the responsible parties and the State Ombudsman for three residents. Resident 63, who had end-stage renal disease and required hemodialysis, was transferred to the hospital after a traumatic removal of her dialysis catheter led to uncontrollable bleeding. There was no documented evidence that a written notice of this transfer was provided to the resident's responsible party or the State Ombudsman. Similarly, Resident 82, who had cognitive impairment and dementia, was transferred to the hospital following a fall that resulted in shoulder pain. Additionally, Resident 118, who was nonverbal and had Huntington's disease, was transferred due to hypoxemia and a possible ileus. In both cases, there was no documented evidence of written notification to the responsible parties or the State Ombudsman. The Nursing Home Administrator confirmed the lack of notification and was unaware of the requirement for written notices in such situations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 794 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hempfield Manor | 1.2 mi | ★★★★★ | 20 | 0 |
| Rehab & Nursing Ctr Greater Pittsburgh | 1.3 mi | ★★★★★ | 11 | 0 |
| Saint Anne Home | 1.4 mi | ★★★★★ | 2 | 0 |
| Redstone Highlands Health Care | 1.9 mi | ★★★★★ | 15 | 1 |
| Oak Hill Rehabilitation & Healthcare Center | 3.3 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.