Loyalhanna Care Center: Xanax Given Without Alternatives - PA
Nobody tried anything else first.
Resident 66, who has schizophrenia and depression and was already on both antipsychotic and antidepressant medications, had a standing order for 0.25 milligrams of Xanax every eight hours as needed for anxiety. The order dated to February 13, 2025, and was renewed on March 10. Between those two dates, staff administered the controlled sedative on February 14, 17, 21, 24, and 26, and again on March 11.
The facility's own psychotropic medication policy, updated as recently as January 13, 2025, required that non-pharmacological approaches be attempted before giving any psychotropic medication, unless a physician had specifically determined that such approaches were clinically inappropriate. Non-pharmacological interventions, in the language of federal nursing home oversight, means individualized, non-medication strategies, things like redirection, music, conversation, or environmental adjustments, tailored to the individual resident's history and preferences.
For Resident 66, on each of those six occasions, the medication administration record contained no documentation that any such approach was tried. Not a notation. Not a brief entry. Nothing.
The Director of Nursing, interviewed by inspectors on March 20, 2025, at 11:18 a.m., confirmed it directly: non-pharmacological interventions should have been attempted before the Xanax was given on each of those dates.
Xanax, the brand name for alprazolam, is a benzodiazepine, a class of sedative drugs associated with increased fall risk, cognitive dulling, and dependence, particularly in elderly and cognitively impaired patients. For nursing home residents already managing serious psychiatric diagnoses and multiple medications, the concern around unnecessary or insufficiently justified benzodiazepine use is well-documented in clinical literature. That concern is part of why federal oversight of psychotropic medication use in nursing homes exists at all, and why facilities are required to show that less risky options were considered first.
Resident 66's situation drew particular scrutiny from inspectors because the resident was cognitively impaired and required assistance with daily care needs, a profile that makes documented, individualized behavioral intervention both more important and more difficult to shortcut without notice.
The deficiency was cited at a level of minimal harm or potential for actual harm, and affected few residents, with only one of 36 residents reviewed identified in the findings. Inspectors cited the violation under Pennsylvania nursing services regulations.
What the inspection does not contain is any explanation for why the documentation was absent. Whether staff attempted non-pharmacological interventions and failed to record them, or whether the interventions were never tried at all, the record does not say. The Director of Nursing's confirmation that the attempts should have happened does not resolve which failure actually occurred.
For Resident 66, the distinction may matter less than it appears. A facility's obligation to try non-medication approaches before administering a controlled sedative is not satisfied by an undocumented attempt. The record is the care. When the record is empty, the care, as far as anyone can verify, did not happen.
The resident continued living at Loyalhanna Care Center as of the inspection date. The Xanax order remained active.
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.
Nobody tried anything else first.
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.