Loyalhanna Care Center: IV Catheter Safety Failures - PA
Nobody flushed it.
The resident, identified in inspection records only as Resident 283, was receiving two grams of Cefepime intravenously twice daily, at 8:00 a.m. and 8:00 p.m., from March 11 through March 19, 2025. Cefepime is a broad-spectrum antibiotic used to treat serious bacterial infections, the kind that lands someone in a nursing facility with a PICC line or midline catheter in the first place. The drug was going in. The saline flushes, which clear the line before and after each infusion, were not.
The inspection report documents eighteen separate administrations of the antibiotic across those nine days. There is no documented evidence that the line was flushed before or after any of them.
When federal inspectors interviewed the Director of Nursing on March 19 at 1:54 p.m., she confirmed it. There was no documented evidence that Resident 283's PICC or midline catheter had been flushed with saline prior to or after Cefepime administration on any of the dates in question.
A PICC line, a peripherally inserted central catheter, runs from a vein in the arm to a position near the heart. A midline catheter is shorter but still reaches deep into the upper arm. Both require saline flushes to maintain patency, meaning to keep the line clear and functional, and to prevent blood from backing up into the catheter and clotting. A clotted line can fail mid-treatment. A line that isn't properly cleared between uses can also become a site for infection, and infections tied to central venous catheters can turn fatal.
The facility is located at 535 McFarland Road in Latrobe, a small city in Westmoreland County roughly 40 miles southeast of Pittsburgh. Inspectors completed the survey on March 20, 2025.
CMS rated the harm level as minimal harm or potential for actual harm, the lower end of the deficiency scale. That classification reflects what inspectors could document, not necessarily what the resident experienced. The inspection record does not describe Resident 283's diagnosis, their current condition, or whether the catheter remained functional throughout the nine days.
What it does describe is a gap that stretched more than a week. Not a single missed flush, not an isolated oversight on a busy night shift. Eighteen administrations of an intravenous antibiotic, and the surrounding safety steps were absent each time.
The deficiency was cited under 28 Pa. Code 211.12(d)(1)(5), the Pennsylvania nursing services regulation governing the quality of care residents receive from nursing staff.
The inspection report does not name the nurses or aides who administered the Cefepime on the days in question. It does not explain whether the flushes were performed but not charted, or whether they were not performed at all. The Director of Nursing's confirmation addresses only the documentation, which is itself the standard of proof in a facility where a resident cannot independently verify what was or wasn't done to their own catheter.
Resident 283 was dependent on staff to manage a line running to a vein near their heart. For nine days, the people responsible for that line left no evidence they were taking care of it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Loyalhanna Care Center from 2025-03-20 including all violations, facility responses, and corrective action plans.
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.
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Last verified: November 2, 2026 · Our methodology
LOYALHANNA CARE CENTER in LATROBE, PA was cited for violations during a health inspection on March 20, 2025.
The resident, identified in inspection records only as Resident 283, was receiving two grams of Cefepime intravenously twice daily, at 8:00 a.m.
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.