Westmoreland Manor: Catheter Care Failures - PA
Westmoreland Manor failed to provide straight catheterization for Resident 16 as ordered by doctors, according to a state inspection completed April 9. The 55-resident facility's treatment records showed gaps in care on March 17, March 18, March 22, and March 24.
The resident had benign prostatic hyperplasia, a condition where the prostate gland enlarges and blocks normal urination. His care plan from December 5, 2025, specified he needed straight catheterization per physician order.
Doctor's orders from March 6 were explicit: catheterize the resident every 12 hours after he attempted to urinate, but only if a bladder scan showed more than 300 milliliters of retained urine. Staff were required to record all amounts on a paper flowsheet.
The orders changed slightly on March 25. The resident was to be catheterized before bed, again only after attempting to void naturally, and only if bladder scans revealed retention over 300 milliliters.
Treatment administration records and paper flowsheets revealed the missed care. On March 17, evening shift staff failed to catheterize the resident. The next morning, March 18, day shift staff also skipped the procedure.
Four days later, evening staff again missed the catheterization on March 22. Two days after that, on March 24, evening shift workers failed to provide the treatment once more.
The resident was cognitively intact, according to his March 18 quarterly assessment. He required assistance with care needs but could understand what was happening to him.
Straight catheterization involves inserting a thin, flexible tube into the bladder to drain urine. For men with enlarged prostates, the procedure prevents painful and potentially dangerous urine retention that can lead to infections, kidney damage, or bladder rupture.
The facility's nursing home administrator confirmed the care failures during an interview with state inspectors on April 7 at 2:32 p.m. There was no documented evidence that Resident 16 received straight catheterization on any of the four dates when treatment records showed it was missed.
Inspectors found no indication that staff performed bladder scans on the missed dates to determine if catheterization was needed. The physician's orders required these scans before deciding whether to proceed with the procedure.
The March quarterly assessment revealed Resident 16 was one of the facility's more independent residents despite his medical condition. Unlike many nursing home patients, he retained his cognitive abilities and could communicate his needs to staff.
His care plan had been in place since December, giving staff more than three months to establish routines for his specialized urinary care. The treatment wasn't new or unexpected.
State inspectors reviewed records for 55 residents during their visit. Resident 16 was the only patient whose catheter care failed to meet physician orders, though inspectors classified the violation as affecting "few" residents.
The missed treatments occurred during both day and evening shifts, suggesting the problem wasn't isolated to one work crew or time of day. Evening shift workers missed three of the four treatments.
Pennsylvania regulations require nursing homes to provide nursing services according to physician orders and accepted standards of practice. The catheter care failures violated these requirements.
Westmoreland Manor's administrator acknowledged the documentation gaps but inspectors found no evidence that the facility had identified or corrected the problem before the state visit.
The inspection classified the harm level as "minimal harm or potential for actual harm." However, untreated urine retention in men with enlarged prostates can escalate quickly from discomfort to serious medical complications.
For Resident 16, the missed catheterizations meant potentially sitting with a full bladder for hours, unable to empty it naturally because of his enlarged prostate. The exact consequences of each missed treatment remain unclear from facility records.
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 13, 2026 · Our methodology
Westmoreland Manor in GREENSBURG, PA was cited for violations during a health inspection on April 9, 2026.
Westmoreland Manor failed to provide straight catheterization for Resident 16 as ordered by doctors, according to a state inspection completed April 9.
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?
- Westmoreland Manor failed to provide straight catheterization for Resident 16 as ordered by doctors, according to a state inspection completed April 9.
- 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.