Loyalhanna Care Center: Care Plan Failures - PA
The incident was documented in a nursing note dated February 8, 2025, at 9:16 p.m. Staff had witnessed Resident 46 digging at her stoma, the surgically created opening in her abdomen through which waste exits her body, with silverware. The note described what they found: an open area at the end of the colostomy, a bright red center, and a small amount of bright red, bloody drainage.
The facility already knew this was a risk. Her care plan, in place before the February incident, noted that she had a history of placing silverware into her vagina and rectum. She was moderately cognitively impaired and required staff assistance with her care. A physician had ordered her colostomy bag and wafer changed every shift. The risk was documented. The history was documented.
Nobody added anything to her care plan after she hurt herself.
When inspectors arrived on March 20, 2025, more than six weeks after the bleeding was recorded, the care plan for Resident 46 still contained no interventions aimed at keeping her from digging at her stoma again. No documented strategy. No added precaution. The wound had been noted, the cause had been witnessed, and the response, on paper at least, was nothing.
The Director of Nursing confirmed it directly during an interview with inspectors that morning. The care plan had not been updated following the February 8 incident.
The facility's own policy, revised as recently as January 13, 2025, stated that the interdisciplinary team would review and revise a resident's comprehensive care plan after each quarterly assessment. A quarterly assessment for Resident 46, completed February 26, 2025, documented her cognitive impairment, her need for staff assistance, and her colostomy. That assessment came and went eighteen days after the stoma injury. The care plan still was not updated.
Inspectors cited the deficiency under Pennsylvania nursing services regulations and classified the level of harm as minimal harm or potential for actual harm. One resident was affected out of 36 reviewed.
The classification of minimal harm is a regulatory determination. What it describes is a woman with moderate cognitive impairment and a documented history of self-injury who wounded herself with silverware, bled, was observed by staff, and then remained in a facility where no written plan existed to stop her from doing it again.
A colostomy stoma is exposed tissue. It has no nerve endings to signal pain the way intact skin does, which means a cognitively impaired resident may not register what she is doing to herself or the damage being caused. Infection at a stoma site can escalate quickly.
None of that context appears in the inspection report. What does appear is a gap of more than six weeks between a documented injury and the moment federal inspectors arrived to find the care plan unchanged.
Loyalhanna Care Center is located at 535 McFarland Road in Latrobe. The inspection was completed March 20, 2025.
For residents with cognitive impairment, a care plan is not administrative paperwork. It is the written record of what staff are supposed to do, and when, and why. When a resident's behavior puts her at risk of harm, the care plan is where the response lives. Without it, the next shift starts without instruction. So does the one after that.
Resident 46's care plan knew about the silverware. It did not know about the blood.
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 incident was documented in a nursing note dated February 8, 2025, at 9:16 p.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.