Westmoreland Manor: Feeding Tube Orders Ignored - PA
The violations affected two of the facility's most vulnerable residents — both severely cognitively impaired and completely dependent on staff for daily care.
Resident 12 received the wrong feeding schedule for weeks. On March 24 and 25, physicians ordered the resident to receive tube feedings only at 9 a.m., 2 p.m., and 7 p.m., and only if the resident ate less than half their regular meals. The midnight feeding was specifically discontinued.
But staff kept giving the 10 p.m. feeding anyway.
Medication records show staff administered tube feedings at 10 p.m. on March 24, 30, and 31, and April 2, 4, 5, and 7. The Clinical Compliance Certified Registered Nurse Practitioner confirmed during an April 8 interview that "staff were not following the current physician's order for tube feedings and the resident should not have been receiving the feeding at 10:00 p.m."
The feeding tube delivers Jevity 1.2 RTH formula directly into the stomach through a surgically implanted device. Each feeding provides 240 milliliters of nutrition for residents who cannot eat or drink by mouth.
Resident 66 faced a different but equally serious problem. This resident received continuous tube feeding of Peptamen formula at 35 cubic centimeters per hour for 20 hours daily through a feeding pump. The feeding was scheduled to run from 12:01 a.m. to 8 p.m. each day.
On April 8, the resident's physician examined them and ordered staff to immediately halt the tube feeding for six hours and check for residual before resuming. Residual checks determine if food is backing up in the stomach rather than digesting properly — a potentially dangerous condition.
The physician wrote the order at 2:03 p.m. April 8. The formal physician's orders that day included explicit instructions to "hold his tube feeding for six hours then resume, and to check for residual before resuming the feeding."
Staff ignored it completely.
Medication records for April show no evidence that anyone halted Resident 66's feeding as ordered. The Director of Nursing confirmed during an April 9 interview that there was "no documented evidence that Resident 66's tube feeding was held as ordered."
The facility's own policy, dated February 1, required all tube feedings to follow physician orders exactly. The policy mandated that feeding orders be documented on order recaps, electronic medication records, and the tube feeding container itself.
Both residents required feeding tubes because they could not safely eat or drink by mouth. Resident 12's January assessment showed complete dependence on staff for daily care tasks. Resident 66's assessment revealed severe cognitive impairment and similar total dependence on staff.
For Resident 12, the incorrect feeding schedule meant receiving nutrition at times when physicians had determined it was unnecessary or potentially harmful, given the resident's ability to consume some regular food during the day.
For Resident 66, the failure to halt feeding and check for residual could have prevented detection of serious digestive complications. When tube feeding backs up in the stomach instead of moving through the digestive system, it can cause aspiration, infection, or other life-threatening conditions.
The violations occurred despite clear documentation requirements. Nutrition notes for Resident 12 from April 6 specifically outlined the correct feeding schedule: 240 cubic centimeters of Jevity formula at 9 a.m., 2 p.m., and 7 p.m., administered only if meal intake was less than fifty percent.
Staff had access to current physician orders, facility policies, and electronic medication records that should have prevented both violations. Yet they continued administering feedings according to outdated orders for Resident 12 and completely ignored urgent medical orders for Resident 66.
Both residents remained entirely dependent on staff to follow medical orders correctly for their most basic nutritional needs.
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.
Resident 12 received the wrong feeding schedule for weeks.
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?
- Resident 12 received the wrong feeding schedule for weeks.
- 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.