Westmoreland Manor: Wound Care Violations - PA
Westmoreland Manor failed to follow wound consultation orders for Resident 15, who had a severe pressure ulcer on her left ischial tuberosity — the pelvic bone that bears weight when sitting — along with an open wound on her right buttocks caused by moisture damage.
The resident was cognitively intact but completely dependent on staff for care, with limited range of motion in her arms and legs. Her January assessment revealed she had multiple pressure ulcers.
A February 3 wound consultation documented the Stage 4 pressure sore measuring 2.0 x 0.3 x 0.1 centimeters on her left side, along with the smaller moisture-damaged area on her right buttocks measuring 0.1 x 0.1 x 0.1 centimeters. The wound specialist ordered calcium alginate with silver dressing applied to both wound beds every two days.
By March 3, the Stage 4 ulcer had shrunk to 0.5 x 0.5 x 0.1 centimeters, suggesting the treatment was working when applied correctly. The specialist continued the same treatment plan: calcium alginate with silver every two days for both wounds.
But staff weren't following the orders.
Treatment records from February and March showed nursing staff applied treatments to the left pressure sore daily from February 5 through March 30 — not every two days as ordered. For the right buttocks wound, there was no documented evidence that the recommended calcium alginate with silver treatment was applied at the correct frequency at all.
The facility's own wound management policy, updated February 1, required staff to provide evidence-based treatments according to current standards and physician orders, including specific cleansing methods, dressing types, and frequency of changes.
Stage 4 pressure ulcers represent full-thickness tissue loss with exposed bone, tendon, or muscle. They typically develop when residents remain in the same position too long, cutting off blood flow to vulnerable areas like the tailbone region where Resident 15's wound appeared.
Calcium alginate with silver dressings are specifically designed to absorb wound drainage while providing antimicrobial protection. The frequency of application matters because too-frequent changes can disrupt healing tissue, while insufficient changes allow bacteria to accumulate.
The Director of Nursing confirmed during an April 9 interview that treatments for both the pressure ulcer and the moisture-associated dermatitis were not completed as the wound consultant recommended. The director acknowledged they should have been.
This wasn't a case of unclear orders or missing documentation. The wound specialist provided specific measurements, treatment plans, and schedules. The nursing staff had written policies requiring them to follow physician orders exactly. Treatment records showed they were doing something — just not what was ordered.
The violation affected one of 55 residents reviewed during the inspection, but it highlighted a fundamental breakdown in following medical recommendations for serious wounds.
Pressure ulcers that reach Stage 4 can become life-threatening if not properly managed. They often require months of careful treatment to heal, and improper care can lead to bone infections, sepsis, or the need for surgical intervention.
Resident 15's wounds were showing signs of improvement by March, despite the treatment errors, but the inconsistent care potentially delayed healing and increased infection risk during the two-month period when staff weren't following the specialist's orders.
The facility must now develop a plan to correct the deficiency and demonstrate that wound treatments will be administered exactly as ordered by consulting specialists.
For Resident 15, the Stage 4 pressure sore that once measured two centimeters across had shrunk to half a centimeter by March. But she spent two months receiving daily treatments when the wound specialist had determined every-other-day care would promote better healing.
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: August 5, 2026 · Our methodology
Westmoreland Manor in GREENSBURG, PA was cited for violations during a health inspection on April 9, 2026.
The resident was cognitively intact but completely dependent on staff for care, with limited range of motion in her arms and legs.
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.