Loyalhanna Care Center

F-F656, revealed that the QAPI committee was ineffective in correcting deficient practices related to the development of a comprehensive person-centered care plan.

The facility's plan of correction for a deficiency regarding care plan timing and revision, cited during the survey ending April 11, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F657, revealed that

the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding care plan timing and revision.

The facility's plan of correction for a deficiency regarding services provided meet professional standards, cited during the surveys ending April 11, 2024, and May 22, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F658, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding services provided meet professional standards.

The facility's plan of correction for a deficiency regarding following physician's orders, cited during the survey ending April 11, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F684, revealed that the QAPI committee was ineffective in correcting deficient practices related to following physician's orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 23 395860 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395860 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Loyalhanna Care Center 535 McFarland Road Latrobe, PA 15650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 The facility's plan of correction for a deficiency regarding tube feeding management, cited during the survey ending April 11, 2024, revealed that the facility would complete audits and report the results of the audits to Level of Harm - Minimal harm or the QAPI committee for review. The results of the current survey, cited under

F-F693, revealed that the potential for actual harm facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding tube feeding management. Residents Affected - Few

The facility's plan of correction for a deficiency regarding a failure to provide oxygen therapy as ordered by

the physician, cited during the survey ending April 11, 2024, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under

F-F695, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding providing oxygen therapy as ordered by the physician.

The facility's plans of correction for deficiencies regarding the failure to account for controlled medications, cited during the survey ending April 11, 2024, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under

F-F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.

The facility's plan of correction for a deficiency regarding label/store drugs and biologicals, cited during the survey ending April 11, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F761, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding label/store drugs and biologicals.

The facility's plans of correction for deficiencies regarding infection control practices, cited during the survey ending April 11, 2024, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under

F-F880.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(e)(1) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 395860 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395860 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Loyalhanna Care Center 535 McFarland Road Latrobe, PA 15650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 19102 potential for actual harm Based on review of established infection control guidelines, facility policy, and residents' clinical records, as Residents Affected - Few well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for three of 36 residents reviewed (Residents 6, 75, 283).

Findings include:

CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP

during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.

The facility's policy regarding EBP, dated January 13, 2025, indicated that the facility will have the discretion

in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is currently targeted by CDC may be considered epidemiologically important.

An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e. g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated January 27, 2025, revealed that the resident had moderate cognitive impairment, had a urinary tract infection, and received an antibiotic.

Physician's orders for Resident 6, dated February 17, 2025, included orders for the resident to have an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine).

Observations of Resident 6 on July 18, 2025, at 12:14 p.m. revealed that the resident was in his room, and there was no signage or notification of the resident being on EBP posted at the resident's room, and there was no PPE observed in or around the resident's room. Interview with Registered Nurse 4 on March 18, 2025, revealed that a sign was usually put up when a resident was on EBP but she was not sure if the resident was on EBP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 395860 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395860 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Loyalhanna Care Center 535 McFarland Road Latrobe, PA 15650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Interview with the Director of Nursing on March 18, 2024, at 2:14 p.m. confirmed that the resident should have been on EBP due to having an indwelling urinary catheter. Level of Harm - Minimal harm or potential for actual harm A significant change MDS assessment for Resident 75, dated January 20, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had an indwelling foley catheter (a Residents Affected - Few soft, flexible plastic tube inserted in the bladder), and had diagnosis that included heart failure, obstructive uropathy, and diabetes mellitus.

Observations during the facility tour on March 17 2025, at 10:50 a.m. revealed that Resident 75 was lying in bed. There was no signage or notification of the resident being on EBP posted at the resident's room, and there was no PPE observed in or around the resident's room.

Interview with Licensed Practical Nurse 5 on March 17, 2025, at 11:07 a.m. confirmed that Resident 75 had

an indwelling Foley catheter and should have had an EBP sign on his door.

Interview with the Director of Nursing on March 19, 2025, at 2:55 p.m. confirmed that Resident 75 should have had an EBP sign on his door.

An admission MDS assessment for Resident 283, dated March 16, 2025, revealed that the resident was cognitively intact, was independent with her daily care needs, had a midline catheter (flexible tube inserted into a vein in the upper arm for administering fluids and medication), and had a diagnosis that included sepsis due to pseudomonas (a life threatening condition that occurs when the immune system overreacts to

an infection caused by bacteria).

Observations during the facility tour on March 17, 2025, at 12:40 p.m. revealed that Resident 283 was sitting

on the side of her bed. There was no signage or notification of the resident being on EBP posted at the resident's room, and there was no PPE observed in or around the resident's room.

Interview with the Director of Nursing on March 19, 2025, at 1:52 p.m. confirmed that Resident 283 should have an EBP sign on her door as well as PPE for staff to utilize.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(e)(1) Management.

28 Pa. Code 211.12(d)(1)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 395860