Loyalhanna Care Center: Medication Safety Failures - PA
The resident's physician had been explicit. The order, written September 27, 2024, directed staff to administer Metoprolol Succinate, a drug used to treat high blood pressure, and to hold the dose if the patient's systolic blood pressure fell below 110 or heart rate dropped below 60 beats per minute. Those are the numbers at which the medication stops being treatment and starts being a hazard.
Nobody checked. Not on September 27. Not in October, November, or December. Not in January, February, or the first weeks of March 2025.
When inspectors reviewed the medication administration records for Resident 21 during their March 20 visit, they found no documented evidence that blood pressure or heart rate had been obtained before any dose since the order was written. The Director of Nursing confirmed it that morning.
A second resident had it worse.
Resident 75 was cognitively intact, according to a January 2025 assessment, and aware of his surroundings. He had heart failure, obstructive uropathy, and diabetes. He used an indwelling catheter. He needed staff help for daily care. His physician ordered the same drug, Metoprolol Succinate, 50 milligrams daily, starting January 12, 2025, with the same instruction: hold the dose if systolic pressure fell below 110.
On January 25, his blood pressure was 98/70.
On January 27, it was 106/65.
On January 31, it was 102/55.
The medication records show he received the drug anyway. Staff documented the readings and gave the pills.
On February 2, his pressure was 106/68. On February 10, it was 102/62. On February 18, it was 101/67. Six separate readings across less than four weeks, every one of them below the threshold the physician had set. Six times the drug should have been held. Six times it wasn't.
A systolic blood pressure in the high 90s or low 100s in a patient with heart failure is not a minor fluctuation. Metoprolol slows the heart rate and lowers blood pressure further. Giving it to a patient already running that low compounds the risk of the blood pressure dropping to a point where the heart and brain aren't getting adequate flow.
The Director of Nursing confirmed at 12:31 p.m. on March 20 that the physician's orders for Resident 75 had not been followed and that the medication should have been held on those dates.
CMS classified the violations under the harm category of minimal harm or potential for actual harm, and noted that some residents were affected. The citation referenced Pennsylvania nursing services regulations.
What the records don't show is whether anyone noticed the pattern as it was happening. Six low readings across less than a month, all logged in the same medication administration record, all followed by the same drug. Resident 75 was cognitively intact. He could speak for himself. Whether he knew the medication was supposed to be withheld when his pressure ran low, whether he felt the effects of receiving it anyway, the inspection report doesn't say.
What it does say is that his physician set a clear line, and the nurses crossed it six times in writing, with the numbers right there on the page.
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 3, 2026 · Our methodology
LOYALHANNA CARE CENTER in LATROBE, PA was cited for violations during a health inspection on March 20, 2025.
The resident's physician had been explicit.
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.