Westmoreland Manor

F-F689 on March 24, 2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 13 395435 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395435 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westmoreland Manor 2480 South Grand Blvd Greensburg, PA 15601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 28 Pa. Code 201.18(b)(1) Management.

Level of Harm - Actual harm 28 Pa Code 211.12(d)(5) Nursing Services.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 395435 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395435 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westmoreland Manor 2480 South Grand Blvd Greensburg, PA 15601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Level of Harm - Minimal harm or 19102 potential for actual harm Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to Residents Affected - Few ensure that a peripherally-inserted central catheter (PICC - a long, thin tube that is inserted through a vein in

the arm and passed through to the larger veins near the heart) was flushed as ordered by the physician for two of 58 residents reviewed (Residents 77, 207).

Findings include:

The facility's policy regarding flushing intravenous catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated February 1, 2025, indicated that the catheter was to be flushed with 0.9 percent sodium chloride (sterile salt water solution) before and after medication administration.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 77, dated April 2, 2025, revealed that the resident was cognitively impaired, required assistance for daily care needs, and had diagnoses that included heart failure, high blood pressure, and extended spectrum beta lactamase in the urine (an infection in urine).

Physician's orders for Resident 77, dated April 28, 2025, included an order for the resident to receive 500 milligrams of Invanz (intravenous antibiotic medication) for urinary tract infection.

Review of the April and May 2025 Medication Administration Record (MAR) for Resident 77 revealed no documented evidence that the resident's PICC line was flushed after the antibiotic was administered as per facility policy.

An interview with the Clinical Compliance Officer on May 8, 2025, at 9:41 a.m. confirmed that there was no documented evidence that Resident 77's PICC line was flushed after the antibiotic was administered as per facility policy.

A quarterly MDS assessment for Resident 207, dated April 23, 2025, revealed that the resident was cognitively intact, required assistance for daily care needs, received antibiotics, received IV medications, and had diagnoses that included peripheral vascular disease (poor circular of the extremities), and diabetes.

A nursing note, dated April 17, 2025, revealed the resident returned from the hospital following amputation of her left big toe and had a PICC line in her right arm.

Physician's orders for Resident 207, dated April 18, 2025, included an order for the resident to receive 1500 mg of Vancomycin (antibiotic) intravenously (IV) daily until April 23, 2025, and the IV access site was to be flushed with 10 ml of normal saline solution before and after medication administration at bedtime. Physician's order for Resident 207, dated April 22, 2025, included an order for the resident to receive 1750 mg of Vancomycin intravenously daily until April 24, 2025. A care plan, dated April 21, 2025, indicated that IV flushes were to be provided as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 395435 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395435 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westmoreland Manor 2480 South Grand Blvd Greensburg, PA 15601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Resident 207's MAR's for April 2025 indicated that the resident received IV Vancomycin intravenously daily at 10:00 a.m., and not at bedtime, from April 18 through 24, 2025; however, there was no documented Level of Harm - Minimal harm or evidence that staff flushed the resident's IV catheter with saline solution before and after any of the IV potential for actual harm administrations of Vancomycin.

Residents Affected - Few Interview with the Clinical Corporate Officer on May 7, 2025, at 12:44 p.m. confirmed that there was no documented evidence that Resident 207's PICC line was flushed with saline solution before and after every administration of antibiotics.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 395435 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395435 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westmoreland Manor 2480 South Grand Blvd Greensburg, PA 15601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 42079 potential for actual harm Based on review of manufacturer's instructions, facility policies, and clinical records, as well as observations Residents Affected - Few and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent.

Findings include:

The facility's policy regarding medication administration: rights, dated February 1, 2024, indicated that when administering the medication, the electronic medical record should be checked against the prescription label for each resident. To ensure accountability and the six 'rights' (right resident, right drug, right dose, right time, right route, right dosing form), guidelines were set for medication administration.

Observations during medication administration on August 21, 2024, revealed that two medication administration errors were made during 30 opportunities for error, resulting in a medication administration error rate of 6.67 percent.

An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 106, dated April 23, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included renal failure (kidney failure) and peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain).

Physician's orders for Resident 106, dated April 21, 2024, included an order for the resident to be administered 250 milligrams (mg) of calcium citrate twice a day for Vitamin D deficiency.

Observations of medication administration on May 7, 2025, at 8:20 a.m. revealed that Resident 106 was administered 950 mg of calcium citrate.

Interview with Licensed Practical Nurse 2 on May 7, 2025, at 2:23 p.m. confirmed that the physician's order was to administer 250 mg of calcium citrate, but the card dispensed from the pharmacy was for 950 mg of calcium citrate.

A quarterly MDS assessment for Resident 147, dated April 2, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included multiple sclerosis (a chronic, progressive disease of the central nervous system that can affect the brain, optic nerves, and spinal cord).

Physician's orders for Resident 147, dated July 18, 2022, included an order for the resident to be administered two drops into each eye of artificial tears solution one percent (carboxymethylcellulose sodium) three times a day for dry eyes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 395435 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395435 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westmoreland Manor 2480 South Grand Blvd Greensburg, PA 15601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Observations of medication administration on May 7, 2025, at 8:40 a.m. revealed that Resident 147 was administered one drop of artificial tears solution one percent (carboxymethylcellulose sodium). Interview with Level of Harm - Minimal harm or Licensed Practical Nurse 2 at that time confirmed that she was finished with her medication administration to potential for actual harm Resident 147, and that she instilled one drop into each eye. At 8:44 a.m. Licensed Practical Nurse 2 confirmed that she should have administered two drops in each eye. Residents Affected - Few

Interview with the Director of Nursing on May 8, 2025, at 8:32 a.m. confirmed that the current physician's order did not match the medication that was administered to Resident 106, and that the correct number of eye drops were not administered to Resident 147 and should have been.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 395435