Westmoreland Manor: Meds Injected Into Bloodstream - PA
The resident, identified in inspection records only as Resident 2, had a midline catheter, a thin tube inserted into a vein in the arm used to deliver intravenous medications. Her oral medications were ordered to be swallowed. The nurse, a licensed practical nurse employed through a staffing agency, crushed them and pushed them into the catheter with a syringe instead.
The error came to light because of the resident's daughter. On April 28, 2026, at 5:58 p.m., she told another nurse on the floor that she had watched the agency nurse put medications into her mother's midline catheter and wanted to know if that was appropriate. It was not.
Licensed Practical Nurse 4, the nurse who received the daughter's concern, already had reason to be suspicious. She had seen the agency nurse, identified in the report as Licensed Practical Nurse 2, giving an as-needed pain medication by mouth and had wondered whether he was crushing other medications and giving them orally. She asked him directly. He told her he was.
What happened next showed the damage had already been done. Licensed Practical Nurse 4 tried to walk Licensed Practical Nurse 2 through the correct procedure for administering Resident 2's antibiotics through the midline. The medication would not infuse. The catheter would not flush. Licensed Practical Nurse 2 had told her he had just flushed the line. The line was blocked.
Licensed Practical Nurse 4 reported the incident up the chain, first to Registered Nurse 1, then to Registered Nurse 3. Later that same evening, Licensed Practical Nurse 2 admitted to Licensed Practical Nurse 4 that he had crushed Resident 2's 6:00 p.m. medications and put them in her midline catheter.
The facility's Director of Nursing, Nursing Home Administrator, and Clinical Compliance Certified Registered Nurse Practitioner confirmed the following afternoon what the nurses had already established: the medications were ordered by mouth, they were given by vein, and they should not have been.
Licensed Practical Nurse 2 was removed from duty and reported both to the staffing agency that employed him and to the Pennsylvania State Board of Nursing.
The facility moved quickly after that. A full audit of every resident with an intravenous access device was completed. Staff received education on the six rights of medication administration, with specific focus on route, and on the Pennsylvania scope of practice for licensed practical nurses, which does not permit them to administer intravenous push medications. Competency evaluations followed the training. Audits of medication administration were scheduled three times a week going forward, with results to be reviewed at monthly quality assurance meetings. Inspectors found the facility in compliance with the relevant federal standard by April 27, two days before the inspection concluded.
The speed of the corrective response did not change what had happened to Resident 2. A nurse who did not understand, or did not follow, the most basic principle of medication administration, that the route ordered is the route required, had pushed crushed pills into her vein. Her midline catheter, the line through which she was supposed to be receiving antibiotics, was blocked. Whether and how that affected her treatment for the infection the antibiotics were meant to address, the inspection report does not say.
Her daughter had been in the room. She had watched it happen and known enough to ask whether it was right. Without that question, asked at 5:58 on a Tuesday evening, it is not clear when anyone else would have.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westmoreland Manor from 2026-04-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
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 7, 2026 · Our methodology
Westmoreland Manor in GREENSBURG, PA was cited for violations during a health inspection on April 29, 2026.
Her oral medications were ordered to be swallowed.
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.