Loyalhanna Care Center: Care Plan Update Failures - PA
Federal inspectors found that Loyalhanna Care Center didn't revise care plans for three residents despite significant changes in their treatment needs during a April inspection.
Resident 28 had used a urinary catheter for years due to an enlarged prostate that made normal urination difficult. His daughter explained during an inspector interview that staff put a leg bag on her father each morning and removed it at bedtime, replacing it with a larger drainage bag overnight.
"The leg bag makes it easier for him to move about during the day," she told inspectors on April 1.
The routine had been in place for months. Physician orders from January confirmed the catheter prescription. Inspectors observed the resident wearing the leg bag during multiple visits between March 30 and April 2.
But his care plan contained no mention of the daily leg bag routine.
The Director of Nursing confirmed during an April 1 interview that "Resident 28's care plan should have been updated to reflect that he utilizes a leg bag from the time he gets up until he goes to bed at night, and it was not."
A second resident faced the opposite problem. Resident 76, who has Multiple Sclerosis, had a care plan that called for lymphedema pump treatments on both legs for one hour each. The pumps reduce chronic swelling by moving lymphatic fluid out of affected limbs.
Her care plan, dating to February 2023, still included detailed instructions for the pump treatments. But physicians had discontinued the order for the pumps eight months earlier, on August 23, 2025.
Treatment records showed no evidence that staff had used the pumps recently. The Director of Nursing acknowledged on April 2 that "Resident 76's care plan was not revised when the lymphedema pumps were discontinued, and it should have been."
The facility's own policy, updated January 1, required staff to revise care plans whenever residents experience status changes. The policy stated that care plans "will be updated with the new or modified interventions" to ensure consistent care.
Resident 28 was moderately cognitively impaired but usually understood staff and could communicate his needs, according to his January assessment. He required assistance with daily activities and had lived with his prostate condition and catheter for an extended period.
Resident 76 remained cognitively intact despite her Multiple Sclerosis diagnosis, which causes the immune system to attack protective nerve coatings in the brain and spinal cord. She also required staff assistance for daily care needs.
The inspection found that care plan failures affected few residents overall. Inspectors reviewed 35 resident files and identified problems with three cases. But the violations demonstrated how outdated care plans can leave staff without accurate guidance for routine medical care.
Federal regulations require nursing homes to develop comprehensive care plans that reflect each resident's current condition and treatment needs. The plans guide daily care decisions and ensure all staff members understand how to properly assist residents.
When care plans become outdated, staff may continue unnecessary treatments or fail to provide required care. In Resident 28's case, staff were performing the correct routine but lacked written protocols. For Resident 76, her plan still referenced discontinued treatments.
The inspection classified the violations as causing minimal harm or potential for actual harm to residents. No residents suffered injuries from the care plan failures, but the lack of current documentation created risks for inconsistent care.
Resident 28's daughter had no complaints about her father's actual care. Staff continued the leg bag routine she described as helpful for his mobility. The problem was administrative rather than clinical, but federal standards require both accurate care and accurate documentation.
The facility must submit a plan of correction explaining how it will ensure care plans reflect residents' current conditions and treatment orders.
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 28 had used a urinary catheter for years due to an enlarged prostate that made normal urination difficult.
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 28 had used a urinary catheter for years due to an enlarged prostate that made normal urination difficult.
- 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.