Loyalhanna Care Center: Wrong Medication Dose Given - PA
The inspection report does not give the resident a name. It identifies him only as Resident 75. What it does give is a precise accounting of what he swallowed that morning: carvedilol for blood pressure, 75 mg of Plavix for heart disease, 5 mg of finasteride for difficulty with urination, 300 mg of gabapentin for pain, 40 mg of lisinopril for blood pressure, 50 mg of sertraline for mood stabilization, and 1 mg of Prograf, a drug used to prevent organ rejection after a transplant.
None of those medications had been prescribed to him.
He was assessed immediately after the error was discovered. A nursing note timed at 9:28 a.m. recorded what happened next: the resident said he felt lightheaded. His blood pressure was 108/58. A physician ordered him transferred to the local emergency room.
A blood pressure reading of 108/58 is low. Two of the medications he received, carvedilol and lisinopril, both lower blood pressure. He had taken a full dose of each.
Prograf, the organ rejection drug, is among the more consequential medications on that list. It is typically prescribed to transplant patients in carefully calibrated doses and monitored closely because its effects on the body are significant and its interaction with other drugs can be serious. The inspection report does not say whether Resident 75 had received a transplant or what his underlying medical conditions were. It says only that he was not the intended recipient of that drug.
He returned to the nursing home from the emergency room that same afternoon. A nursing note at 3:57 p.m. on August 20, 2024, recorded that he came back with no new orders.
The incident itself happened in August 2024. Federal inspectors did not arrive at Loyalhanna Care Center until March 2025. The Director of Nursing, interviewed on March 19 at 1:32 p.m., confirmed that the registered nurse involved had not followed the facility's policy when administering medications to the resident. The inspection report identifies the nurse only as Registered Nurse 2.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting few residents. That is the lower end of the federal harm scale. Whether that classification accounts for the full weight of receiving seven medications intended for another person, including an immunosuppressant, is not addressed in the report.
What the report does not contain is also notable. There is no description of how the error occurred. There is no account of whether Registered Nurse 2 was disciplined, retrained, or reassigned. There is no explanation of how a full medication pass for one resident was administered to another. The facility's plan of correction is not included in the inspection document; the form instructs anyone seeking that information to contact the nursing home or the state survey agency directly.
Loyalhanna Care Center is located at 535 McFarland Road in Latrobe. The inspection was completed March 20, 2025.
Resident 75 came back from the emergency room with no new orders. The report does not say what the emergency room found, what treatment he received while he was there, or whether the drugs he was given that morning caused any lasting effect. It closes the loop on his discharge and leaves the rest unanswered.
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 inspection report does not give the resident a name.
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.