Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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WESTMORELAND MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a complaint survey completed on February 20, 2020, it was determined that Westmoreland Manor was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Based on the review of dietary cleaning records, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and prepared in accordance with professional standards for food service safety by failing to maintain a clean environment and an effective pest control program in the dietary department.

Findings include:

Undated dietary cleaning records provided by the facility on February 20, 2020, indicated that the floors in the front and back areas of the kitchen were cleaned seasonally, and there was no record that they were cleaned at any time in 2020. The facility's cleaning schedules for January and February 2020 revealed that there were specific items and/or areas of the kitchen that were to be cleaned after each use, once daily, weekly or monthly; however, all of the items and areas were signed daily with the same initials. The schedule did not include cleaning the floors in the food preparation and serving areas.

Observations in the kitchen on February 20, 2020, at 11:45 a.m. revealed that the kitchen floors were ceramic tiles that were approximately ten by ten inches square. There were multiple floor tiles that had no grout between them, which caused grooves and areas that were not level. There was food debris of various amounts and colors in the grooves between the tiles (where there was no grout). The floor area by the two fryers had a greasy build-up on the grout and tiles, and two tiles to the right of the fryers were not secured to the floor. The floor area between and under the fryers, steamer, tilt skillets and kettles had a large build-up of dark debris coating the tiles along with food debris of various colors. The drain to the left of the steamer had two drain pipes (approximately two inches in size) going into it and the drain was uncovered. One of the pipes had a flow of water coming from it, and there was various moist food debris all around the perimeter of the drain flanges. Observations of the area by the steamer at 11:45 a.m. revealed that there were five white/silver, crawling insects coming from underneath the steamer. Observations at 11:55 a.m. and 12:05 p.m. revealed that the insects were still present and coming from under the steamer.

Observations in the kitchen on February 20, 2020 at 4:20 p.m. revealed that the debris noted during the observations at 11:45 a.m. remained under the cooking units and between the floor tiles.

Interviews with Dietary Supervisor 1 on February 20, 2020, at 11:45 a.m. and 12:15 p.m. revealed that she was unaware of any "silverfish" reported recently but they did have them in the past. She indicated that the floors were mopped between each meal time and at the end of the day, and the heavy equipment was moved and pressure washed seasonally (four times a year), and she thought that the last time it was done was in November 2019.

Interview with Dietary Supervisor 2 on February 20, 2020, at 4:20 p.m. confirmed that the floor under the cooking units needed to be cleaned and that there was still food debris noted between the floor tiles. She indicated that the floor had just been mopped approximately one hour ago.

28 Pa. Code 207.2(a) Administrator's responsibility.

 Plan of Correction - To be completed: 03/20/2020

In preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
The facility will continue to ensure that food is stored and prepared in accordance with professional standards for food service safety by maintaining a clean environment and an effective pest control program in the dietary department.
Flooring was cleaned at time of exit and will continue to be cleaned between meals to ensure removal of debris and cleanliness. Outside vendor to provide professional grade cleaning the week of March 16th and replacement/repair of the floor is scheduled the same week. Pest Control Provider was in the 2-21-2020 and provided additional treatment, last professional treatment was 2 weeks earlier. Routine pest prevention is scheduled in the Dietary department.
Dietary and Maintenance will be re-educated on responsibilities for maintaining a clean environment by each Department Manager by 3/6/2020
Audits to ensure a cleanliness of the environment and effective pest control will be conducted three times a week for 4 weeks and then monthly times two months. Reports will be provided to Quality Assurance Improvement Performance Committee for trends.

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