Loyalhanna Care: Catheter Care Failures - PA
Federal inspectors found these failures at Loyalhanna Care Center during an April inspection that revealed the facility wasn't following its own policies for basic bladder and bowel care.
Resident 4, who has neurogenic bladder from nerve damage, required catheter changes every 21 days according to physician orders from June 2025. The suprapubic catheter, inserted through an incision in the lower abdomen, provides drainage when normal bladder function is compromised.
Treatment records showed no evidence the catheter was changed between October 18, 2025, and November 29, 2025 — a 42-day gap. An even longer lapse occurred between February 8, 2026, and March 28, 2026, when 48 days passed without documented catheter maintenance.
The Director of Nursing confirmed to inspectors on April 2 that there was no evidence the catheter changes occurred as ordered during either period.
Meanwhile, Resident 3's bowel continence deteriorated dramatically over six months without intervention. The cognitively intact resident with schizoaffective disorder went from being "always continent" in September 2025 to "occasionally incontinent" by December, then "frequently incontinent" by March 2026.
Despite this clear decline, staff completed no quarterly bowel assessments as required by facility policy. The facility's own policy, updated January 1, 2026, specifically called for bowel assessments "quarterly, with a significant change, or post hospitalization" to identify interventions that could restore continence and maintain dignity.
The policy emphasized using "the least restrictive and most restorative interventions" first, utilizing diet, fluids, activity, positioning, and medications as needed. It aimed to prevent complications like skin breakdown and maintain resident dignity through individualized care.
None of that happened for Resident 3.
The resident's care needs also shifted during this period. In September, she required only supervision or light assistance for toileting hygiene. By December, she needed partial to moderate assistance. Yet no one assessed why her bowel function was failing or what could be done to help.
The Director of Nursing acknowledged to inspectors that no quarterly bowel assessments had been completed for Resident 3, despite the facility's written commitment to such evaluations.
Both violations represent failures in fundamental nursing care. Catheter maintenance prevents blockages, infections, and other serious complications. Regular assessment of bowel function can identify treatable causes of incontinence and preserve residents' dignity and quality of life.
For Resident 4, the missed catheter changes created risk of blockage, displacement, or infection. Suprapubic catheters require precise maintenance schedules because complications can develop rapidly when drainage is compromised.
For Resident 3, the lack of assessment meant no one investigated whether her declining continence stemmed from medication changes, dietary factors, mobility issues, or other treatable causes. The facility's policy recognized that bowel training programs could restore function through systematic intervention.
Instead, both residents experienced what the inspection classified as "minimal harm or potential for actual harm" — regulatory language that understates the daily impact of sitting in waste or dealing with catheter complications.
The violations occurred despite the facility housing just 35 residents during the review period, a manageable census for implementing basic care protocols. Only two residents among the 35 reviewed experienced these specific failures, suggesting the problems weren't systemic but reflected individual care planning breakdowns.
Loyalhanna Care Center's January policy update demonstrated awareness of proper bowel and bladder management standards. The gap between written policy and actual practice left two vulnerable residents without the individualized care they needed and deserved.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Loyalhanna Care Center from 2026-04-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
LOYALHANNA CARE CENTER in LATROBE, PA was cited for violations during a health inspection on April 2, 2026.
Resident 4, who has neurogenic bladder from nerve damage, required catheter changes every 21 days according to physician orders from June 2025.
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.
Frequently Asked Questions
- What happened at LOYALHANNA CARE CENTER?
- Resident 4, who has neurogenic bladder from nerve damage, required catheter changes every 21 days according to physician orders from June 2025.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in LATROBE, PA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from LOYALHANNA CARE CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 395860.
- Has this facility had violations before?
- To check LOYALHANNA CARE CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.