Loyalhanna Care Center: Feeding Tube Care Failures - PA
The resident, identified in inspection records only as Resident 17, has an anoxic brain injury, meaning her brain was deprived of oxygen at some point before she came to live at the facility. She is cognitively impaired and totally dependent on staff for every aspect of her daily care. She does not speak.
Her physician ordered, in June 2024, that her gastrostomy tube be flushed every four hours with exactly 130 milliliters of free water. The order had been in place for months before inspectors arrived in March 2025.
What the records showed was something different.
On February 1, at 1:00 a.m. and again at 5:00 a.m., staff flushed the tube with 60 milliliters, less than half the ordered amount. On March 4, at 1:00 a.m., the tube was not flushed at all. On March 9, at 1:00 a.m. and 5:00 a.m., staff used 180 milliliters, nearly 40 percent more than ordered. On March 10, the 1:00 a.m. flush did not happen; the 5:00 a.m. flush was done with 150 milliliters. On March 14, two overnight flushes were done with 120 milliliters each, and a late afternoon flush used only 60 milliliters. On March 18, the 1:00 a.m. flush was skipped again, and the 5:00 a.m. flush was administered at 180 milliliters.
The pattern held across two months: wrong volumes, missed flushes, and no apparent correction between incidents.
The facility's own policy, updated as recently as January 13, 2025, stated that gastrostomy tube flushes would be provided as ordered by the physician. The policy was written. The physician's order was written. Neither one translated into consistent care for this resident during the overnight and early morning hours when the failures were concentrated.
When inspectors interviewed the Director of Nursing on March 18, 2025, at 1:44 p.m., she confirmed that the tube had not been flushed every four hours with 130 milliliters of free water as ordered. She did not dispute the record.
The inspection, completed March 20, 2025, classified the violation as causing minimal harm or potential for actual harm. It affected few of the 36 residents whose records were reviewed.
Gastrostomy tubes are common in nursing home residents who cannot swallow safely or reliably. Regular flushing at prescribed volumes keeps the tube clear and helps maintain hydration in residents who receive little or no fluid by mouth. For a resident like Resident 17, who cannot communicate discomfort, cannot ask for water, and cannot tell a nurse that something feels wrong, the tube and the schedule attached to it are not optional components of her care. They are her care.
The facility is located at 535 McFarland Road in Latrobe and operates under the provider identification number 395860.
Resident 17 had no way to report what was happening during those overnight hours. She had no way to ask why the flush was short, or late, or missing. The records show the gaps. She could not.
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.
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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.
She is cognitively impaired and totally dependent on staff for every aspect of her daily care.
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.