Loyalhanna Care Center: Oxygen Order Ignored - PA
The discrepancy at Loyalhanna Care Center, a nursing home at 535 McFarland Road, came to light during a federal inspection completed March 20, 2025. It involved one resident, identified in the report only as Resident 1, whose physician had written an order in November 2024 for continuous oxygen at a flow rate of zero to four liters per minute through a nasal cannula, with a target of keeping her blood oxygen levels above 89 percent. For a patient with congestive heart failure, a condition in which the heart cannot pump blood effectively enough to meet the body's needs, maintaining adequate oxygen levels is a basic and ongoing clinical concern.
When an inspector walked into her room on the morning of March 17, 2025, the concentrator was off. The resident explained that she had stopped using the oxygen after returning from a hospital stay.
That same morning, at 10:02 a.m., a nursing note documented that her respirations were even and unlabored, and that she was on supplemental oxygen at two liters per minute. Her medication administration record for March showed she had received oxygen that day on the day shift, the evening shift, and the night shift, at three liters per minute.
The machine was off.
The inspector returned the following afternoon, March 18, at 2:38 p.m. The concentrator was still off. The resident was still not receiving oxygen.
On March 19, the Director of Nursing confirmed what the inspector had already seen twice. The oxygen order was continuous. The resident was not receiving it. The order should have been clarified, the director said, after the resident returned from the hospital and decided on her own to stop using the equipment.
That clarification had not happened. Nobody had contacted the physician to revisit the order, to assess whether the resident's condition had changed enough to warrant adjusting or discontinuing it, or to document any clinical basis for the change in practice. The order on the books still said continuous oxygen. The concentrator sat in the corner, unplugged.
The inspection report rated the violation at the lowest level of harm, noting minimal harm or potential for actual harm. The facility's own oxygen therapy policy, updated in January 2025, required staff to document initial and ongoing assessments of any resident's condition warranting oxygen and to track the response to therapy. A quarterly assessment from February 2025 confirmed Resident 1 was cognitively intact and receiving oxygen therapy as part of her documented care needs.
What the records showed and what was actually happening in her room were two different things for at least two days.
The gap between a chart entry and a patient's actual condition is not a paperwork problem. For a resident with a failing heart, the question of whether she needs supplemental oxygen is a clinical one, and it belongs to a physician, not to a patient deciding on her own after a hospitalization that the machine was no longer necessary. That conversation, and whatever order might have followed it, never happened. Instead, the nursing staff kept marking the medication administration record as though it had.
Loyalhanna Care Center is a licensed skilled nursing facility in Westmoreland County. The inspection covered 36 residents. This was the only deficiency cited in the report.
The resident with congestive heart failure remained in her room, her concentrator off, her chart reading otherwise.
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 3, 2026 · Our methodology
LOYALHANNA CARE CENTER in LATROBE, PA was cited for violations during a health inspection on March 20, 2025.
The discrepancy at Loyalhanna Care Center, a nursing home at 535 McFarland Road, came to light during a federal inspection completed March 20, 2025.
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.