Westmoreland Manor: Blood Pressure Medication Errors - PA
The medication errors affected two of 55 residents reviewed during an April inspection at the 2480 South Grand Boulevard facility.
Resident 9 required daily help from staff and had impaired cognition, according to her January assessment. Her doctor ordered 5 milligrams of Midodrine hydrochlorothiazide three times daily, but with a crucial caveat: hold the blood pressure medication if her systolic pressure dropped below 100.
Staff ignored that order twice in two days.
On April 4 at 5:00 p.m., the resident's blood pressure measured 119/75. The medication should have been held. Staff gave it anyway.
The next day at 2:00 p.m., her pressure was 139/81. Again, the medication should have been held. Staff administered it a second time.
The Director of Nursing confirmed during an April 8 interview that the Midodrine should have been withheld on both occasions.
The second case involved a cognitively intact diabetic resident whose blood sugar monitoring fell apart for months.
Resident 10's doctor ordered blood sugar checks before meals and at bedtime. If results exceeded 300 mg/dL, staff were to recheck in two hours. If still over 300 after the second check, they were to notify the physician.
The resident's blood sugar spiked repeatedly between January and March, reaching levels that demanded immediate attention.
On January 15 at 4:00 p.m., the reading hit 367 mg/dL. No documented recheck.
February 13 brought two dangerous readings: 360 mg/dL at 4:00 p.m. and 311 mg/dL at 9:00 p.m. No rechecks for either.
The next evening, February 14, another spike to 369 mg/dL. Still no follow-up testing.
The worst reading came March 8 at 4:00 p.m.: 400 mg/dL. Again, no documented recheck within two hours as ordered.
During her April 9 interview, the Director of Nursing acknowledged that staff failed to perform the required follow-up blood sugar checks on all the dates inspectors identified.
The facility's medication administration records provided no evidence that staff ever conducted the two-hour rechecks, despite the doctor's explicit orders and multiple instances of blood sugar levels well above the 300 mg/dL threshold.
For Resident 9, receiving blood pressure medication when it should be held could cause her pressure to drop too low, potentially leading to dizziness, falls, or fainting. The doctor's parameters were designed to prevent exactly this scenario.
For Resident 10, the failure to monitor and report persistently elevated blood sugar levels of 300 mg/dL and above could delay necessary medical intervention. Blood sugar at 400 mg/dL represents a serious medical situation requiring prompt physician notification and potential treatment adjustments.
Both violations represented failures to follow physician orders, a fundamental nursing responsibility that directly impacts resident safety and medical outcomes.
The inspection found that Westmoreland Manor failed to ensure physician orders were followed, affecting the medication safety and diabetes management of residents who depended on staff to carry out their prescribed care plans accurately.
State inspectors classified the violations as causing minimal harm or potential for actual harm, but noted they affected few residents during their comprehensive review of the facility's practices.
The Director of Nursing's acknowledgment of both failures during separate interviews confirmed that the medication errors and monitoring lapses were not disputed by facility leadership.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westmoreland Manor from 2026-04-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 14, 2026 · Our methodology
Westmoreland Manor in GREENSBURG, PA was cited for violations during a health inspection on April 9, 2026.
The medication errors affected two of 55 residents reviewed during an April inspection at the 2480 South Grand Boulevard facility.
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.
Frequently Asked Questions
- What happened at Westmoreland Manor?
- The medication errors affected two of 55 residents reviewed during an April inspection at the 2480 South Grand Boulevard facility.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in GREENSBURG, PA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Westmoreland Manor or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 395435.
- Has this facility had violations before?
- To check Westmoreland Manor's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.