Health inspection·August 15, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the environment was free of accident hazards for one of 12 residents reviewed (Resident 2). Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 14, 2023, indicated that the resident is cognitively impaired, does not speak, is totally dependent on two staff persons for all care needs, has a gastrostomy tube (g-tube - a tube inserted through the abdominal wall for the purpose of administering medications and nutrition), and had diagnoses that include hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke, affecting left non-dominant side. Observations on August 15, 2023, at 10:59 a.m. revealed that Nurse Aide 1 lowered the head of Resident 2's bed to a flat position while the enteral feeding continued to infuse, and rolled Resident 2 side to side without the assistance of a second staff person. Nurse Aide 1 stated that Resident 2 had an emesis and that her bed pad and shirt needed changed. Interview with the Director of Nursing on August 15, 2023, at 3:15 p.m. confirmed that Resident 2 should have been rolled from side to side by two staff members. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing services. Page 1 of 2 395435 395435 08/15/2023 Westmoreland Manor 2480 South Grand Blvd Greensburg, PA 15601

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to appropriately care for a gastrostomy tube (g-tube - a tube inserted through the abdominal wall for the purpose of administering medications and nutrition) for one of 12 residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 14, 2023, indicated that the resident is cognitively impaired, does not speak, is totally dependent on two staff for daily care needs, had a gastrostomy tube, and had diagnoses that include hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke, affecting left non-dominant side. Physician's orders for Resident 2 dated August 18, 2021, included an order to hold enteral feedings (infusing liquid nutrition via a pump directly into the stomach) for two hours after any episode of vomiting, as needed. Physician's orders for Resident 2, dated July, 7, 2023, included an order for the head of the bed to be elevated at least 30 degrees while the enteral feeding is infusing to decrease risk of aspiration (a condition in which stomach contents or fluids are breathed into the lungs through the wind pipe). Observations on August 15, 2023, at 10:59 a.m. revealed that Nurse Aide 1 lowered the head of Resident 2's bed to a flat position while the enteral feeding continued to infuse. Nurse Aide 1 stated the resident recently had an emesis and that her bed pad and shirt needed changed. Interview with Licensed Practical Nurse 1 on August 15, 2023, at 11:30 a.m. confirmed that it had been reported to her that Resident 2 had an emesis at 9:00 a.m. Licensed Practical Nurse 1 also confirmed that Resident 2 had an order to hold enteral feedings for two hours after an emesis and for the head of her bed to be elevated at least 30 degrees while the enteral feeding is infusing. Interview with the Director of Nursing on August 15, 2023, at 3:15 p.m. confirmed that the head of Resident 2's bed should have been elevated at least 30 degrees while the enteral feeding was infusing and that the feeding should have been placed on hold for two hours after the emesis. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing services. 395435 Page 2 of 2