Loyalhanna Care Center: Transfer Notice Failures - PA
That finding was not isolated. Inspectors reviewing records at Loyalhanna Care Center documented the same failure for three separate residents, each sent to a hospital under urgent circumstances, none of their families or representatives properly notified in writing about the reason for the transfer. The state long-term care ombudsman, whose role is to advocate for nursing home residents, was not notified either.
The inspection, completed March 20, 2025, identified the pattern across resident files spanning several months.
Resident 32, who had dementia, high blood pressure, and heart failure, and required staff assistance for her daily needs, was the patient found with blood clots in the toilet. A nursing note from May 26, 2024, recorded that the nurse was called to her room at 7:20 p.m., assessed her, and immediately contacted the physician. Orders came back to send her to the local emergency room. She was admitted with a gastrointestinal bleed. No written transfer notice was documented for the resident, her responsible party, or the ombudsman.
Resident 33 had been having multiple seizures over a two-week stretch. Her seizure medication had already been increased twice. A nursing note from November 14, 2024, recorded that the physician was notified and the resident was transferred to the hospital for further evaluation. She was moderately cognitively impaired, meaning her ability to understand or ask questions about what was happening to her was limited. No written notice was documented for her, her representative, or the ombudsman.
The third resident, Resident 23, was also transferred to the hospital after the physician was notified. The inspection report does not describe the medical circumstances in detail, but documents the same outcome: no written notice provided to the resident, the resident representative, or the ombudsman.
All three residents were cognitively impaired to some degree. That detail matters. A family member or legal representative who receives a written transfer notice has a record of why their loved one was moved, what the stated reason was, and when it happened. Without it, they are left to reconstruct events through phone calls, nursing staff recollections, and whatever the hospital records eventually show. The ombudsman, similarly, cannot intervene or investigate what they are never told about.
When inspectors interviewed the Director of Nursing on March 18, 2025, she confirmed there was no documented evidence that written notices had been given as required. She did not dispute the finding.
The violations were cited under Pennsylvania regulations governing licensee responsibility, discharge policy, and resident rights.
Loyalhanna Care Center is a long-term care facility in Latrobe, in Westmoreland County. The residents described in the inspection report were not short-term visitors passing through. Resident 32's annual assessment, dated November 2024, reflects a person with a complex medical picture requiring ongoing staff support. Resident 33 was managing a seizure disorder that had already required two medication adjustments in the weeks before her transfer. These were people whose families had reason to expect the facility would keep them informed.
The written transfer notice requirement exists precisely because nursing home residents are often unable to speak for themselves in a crisis. When someone with dementia is loaded into an ambulance at 7:20 on a Sunday night, the person best positioned to ask questions, to follow up with the hospital, to make sure nothing falls through the cracks, is the family member or representative who was supposed to receive that notice.
For at least three families at Loyalhanna Care Center, that notice never came.
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 2, 2026 · Our methodology
LOYALHANNA CARE CENTER in LATROBE, PA was cited for violations during a health inspection on March 20, 2025.
The state long-term care ombudsman, whose role is to advocate for nursing home residents, was not notified either.
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.