Loyalhanna Care Center: Care Plan Failures Found - PA
Inspectors visited the facility on March 17, 2025, and found Resident 75 lying in bed with the tobacco cans in plain sight at 10:50 in the morning. When they came back two days later and asked a licensed practical nurse about it, she confirmed what they had seen. The tobacco was there. No one disputed that.
What the facility could not produce was any documentation showing it had thought through what that meant for this particular resident. Its own policy, dated January 12, 2025, said exactly what was supposed to happen: safe smokeless tobacco use had to be addressed in each resident's care plan, communicated to staff, visitors, and volunteers, and if a resident needed supervision while using it, that supervision would be spelled out. If he could manage it independently, that too would be written down.
None of it was written down.
The Director of Nursing confirmed as much in an interview on March 19, 2025, at 1:32 in the afternoon. Resident 75 did not have a care plan for his smokeless tobacco use. He also did not have a care plan for his indwelling foley catheter, a device that carries infection risk and requires monitoring.
That second gap matters. A foley catheter is not a passive piece of equipment. It requires attention to placement, hygiene, and signs of complications. A care plan is how a nursing facility organizes who does what, when, and what to watch for. Without one, the coordination that prevents harm depends on individual staff members remembering, or noticing, or happening to ask. That is not a system. It is a guess.
The facility's own smokeless tobacco policy acknowledged the stakes clearly enough to require documentation. The gap between what that policy demanded and what the Director of Nursing confirmed existed is not a paperwork technicality. Care plans are how facilities communicate across shifts, across staff turnover, across the ordinary chaos of a building where many people need many things at once. A resident who uses smokeless tobacco and has a catheter is a resident with specific needs. Loyalhanna's policy recognized that. Its records did not reflect it.
Inspectors cited the facility under Pennsylvania Department of Health regulations governing nursing services and admission policy. The deficiency was rated as minimal harm, meaning inspectors did not find evidence that Resident 75 had been hurt. That rating reflects what the record showed at the time of inspection. It does not mean the gaps carried no risk.
Loyalhanna Care Center is located at 535 McFarland Road in Latrobe. The inspection was completed March 20, 2025.
The two cans of tobacco were still on the nightstand when inspectors walked through. The care plan had not been written. The Director of Nursing, when asked, said so plainly. What happens on the next shift, or the one after that, when a staff member who doesn't know this resident's situation walks into that room, is a question the facility's records still could not answer.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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.
Inspectors visited the facility on March 17, 2025, and found Resident 75 lying in bed with the tobacco cans in plain sight at 10:50 in the morning.
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.