Westmoreland Rehabilitation & Healthcare Center

In the surveyor’s words

From the most serious findings on record at Westmoreland Rehabilitation & Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF687Apr 22, 2025

  Based on clinical record review, staff, and family interviews, the facility failed to provide the necessary foot care and treatment to avoid complications from conditions such as diabetes, including referral and treatment by a qualified professional, for one (1) (Resident #5) of five (5) residents in the survey sample, which resulted in harm. The findings included: Resident #5 was admitted to the facility on [DATE] with a diagnosis of diabetes, cerebrovascular accident, dysphagia, aphasia, hypertension, cognitive communication deficiency, chronic ischemic heart disease, adult failure to thrive, malnutrition, hepatitis, and difficulty walking. […]

• No harm, potential for more than minimal, widespreadF880Jun 8, 2023

  Based on staff interview and facility documentation review, the facility staff failed to maintain an infection control and prevention program to help prevent the development and transmission of infections, which has the ability to affect all Residents residing at the facility. The findings included: 1. The facility staff failed to develop and implement a water management plan for Legionella with regards to a risk assessment to identify where Legionella and other waterborne bacteria could grow. On 6/7/23, during review of the facility water management program the facility Maintenance Director of [NAME] President of Plant Operations were present. […]

• No harm, potential for more than minimal, patternF689Jun 8, 2023

  Based on observation, interview, clinical record review and facility documentation the facility staff failed to 1) mitigate hazards for Residents that use slings, for 1 Resident (#33) in a survey sample of 26 Residents and 2) the facility staff failed to maintain water temperatures in a range to mitigate burns, scalding and other injuries. The findings included: 1) For Resident #33, the facility staff used a mechanical lift without the safety clips being on the hook to prevent the sling from backing out. On 6/7/23 at approximately 11:45 AM CNA's C and D were observed as they prepared to transfer Resident #33 from the bed to the shower stretcher. One CNA was on either side of the bed as they carefully rolled the Resident side to side to get the lift sling positioned under her correctly. […]

• No harm, potential for more than minimal, patternF727Jun 8, 2023

  Based on interview, and facility documentation the facility staff failed to maintain Registered Nurse coverage 7 days a week. This has the potential to affect Residents who need the services of a Registered Nurse (RN). The findings included: The facility staff failed to maintain RN coverage for at least 8 consecutive hours a day on 10/15/22. On 6/7/23 during entrance conference, the facility was asked if they had any kind of waivers and they stated that they did not. On 6/7/23, a review of Payroll Based Journal reports revealed that the facility lacked RN coverage on 10/8/22, 10/15/22, 10/22/22 and 10/23/22. On 6/7/23, the Human Resource director ran a report of the nursing staff scheduled for the months of September and October of 2022. […]

• No harm, potential for more than minimal, patternF755Jun 8, 2023

  Based on observation, interview, clinical record review, and facility documentation the facility staff failed to 1) ensure controlled substances were disposed of correctly and 2) failed to provide routine medications for 2 Residents (#28 and 16). The findings included: 1. The facility staff failed to ensure proper disposal of 24 controlled substances for Residents who no longer reside in the facility or who no longer use the controlled medication. On 6/7/23 at approximately 8 AM, during the medication pass it was discovered that there were 24 controlled substances, in various bottles and cards, to include liquid morphine, liquid Ativan, oxycodone, hydrocodone, gabapentin, Vimpat, morphine ER, and Ambien for Residents who no longer reside in the facility or who no longer use the medication. […]