Westmoreland Manor: IV Safety Violation in PA
GREENSBURG, PA - State health inspectors documented multiple violations at Westmoreland Manor nursing facility during a May 2025 inspection, including improper medication administration and failures to follow critical intravenous therapy protocols.
IV Line Protocol Failures Put Residents at Risk
During the inspection, investigators found that nursing staff at Westmoreland Manor failed to properly maintain intravenous catheters for two residents requiring critical antibiotic treatments. The violations centered on the facility's failure to flush PICC lines (peripherally-inserted central catheters) according to physician orders and established protocols.
Resident 77, who was receiving treatment for a urinary tract infection, had physician orders for 500 milligrams of Invanz antibiotic administered through a PICC line. However, medication administration records showed no documentation that staff flushed the IV line after antibiotic administration, despite facility policy requiring this critical step.
Similarly, Resident 207, who had recently undergone amputation of her left big toe and required IV antibiotics, received daily doses of Vancomycin from April 18-24, 2025. Physician orders specifically required the IV access site to be flushed with 10 ml of normal saline solution before and after each medication administration. Documentation revealed staff failed to perform these required flushes during any of the antibiotic administrations.
The Clinical Compliance Officer confirmed during interviews that proper flushing protocols were not followed for either resident, representing a significant departure from standard medical practice.
Medical Significance of IV Line Maintenance
PICC lines require meticulous care to prevent serious complications. Proper flushing serves multiple critical functions: it prevents blood clots from forming in the catheter, reduces the risk of medication incompatibilities, and helps maintain catheter patency (keeping the line open and functional).
When IV lines are not properly flushed, several dangerous complications can occur. Blood can back up into the catheter and form clots, potentially blocking the line entirely or breaking loose to cause embolisms. Medication residue can build up inside the catheter, creating a breeding ground for bacteria that can lead to bloodstream infections. These infections, known as central line-associated bloodstream infections (CLABSIs), can be life-threatening, particularly for elderly residents with compromised immune systems.
For residents requiring extended antibiotic therapy, maintaining proper IV access is essential for treatment success. A blocked or infected PICC line may require surgical removal and replacement, subjecting residents to additional medical procedures and interrupting their treatment regimen.
Medication Administration Errors Exceed Federal Standards
The inspection revealed that Westmoreland Manor's medication error rate reached 6.67 percent, exceeding the federal requirement that facilities maintain error rates below 5 percent. This violation was documented through direct observation of medication administration practices.
During observations on August 21, 2024, surveyors identified two medication errors among 30 administration opportunities. Resident 106 was prescribed 250 milligrams of calcium citrate twice daily for Vitamin D deficiency, but staff administered 950 milligrams instead - nearly four times the prescribed dose. The Licensed Practical Nurse confirmed during interviews that while the physician's order specified 250 mg, the pharmacy had dispensed 950 mg cards, and staff failed to catch the discrepancy.
Resident 147, who has multiple sclerosis and requires artificial tears for dry eyes, was prescribed two drops in each eye three times daily. However, nursing staff administered only one drop per eye. The Licensed Practical Nurse initially stated she had completed the administration correctly but later acknowledged the error when questioned.
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: September 19, 2026 · Our methodology
Westmoreland Manor in GREENSBURG, PA was cited for violations during a health inspection on May 8, 2025.
Physician orders specifically required the IV access site to be flushed with 10 ml of normal saline solution before and after each medication administration.
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.