Loyalhanna Care Center
LOYALHANNA CARE CENTER in LATROBE, PA — inspection on March 20, 2025.
Found 25 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
order.
She was going to check with the Nursing Home Administrator related to this and indicated that
Interview with the Director of Nursing on March 20, 2025, at 1:26 p.m. indicated that she spoke to the Nursing Home Administrator and that he indicated the new ownership did not do waivers.
However, she did indicate that if Resident 8 wanted a diet change, she should be able to have what she wanted and she would be speaking with the Medical Director. 28 Pa.
Code 201.29(j) Resident Rights.
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physician was notified, and the resident was transferred to the hospital for further evaluation.
minimal harm There was no documented evidence that a written notice of Resident 23's transfer to the hospital was provided to the resident and/or resident representative and the ombudsman regarding the reason for
An annual MDS assessment for Resident 32, dated November 2, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnosis that included dementia, high blood pressure, and heart failure.
Nursing note for Resident 32, dated May 26, 2024, at 7:20 p.m., revealed that the nurse was called to resident's room, assessed the resident, and noted a large amount of bright and dark red blood clots in the toilet.
She notified the physician and received orders to send her to the local emergency room.
The resident was admitted with a gastrointestinal bleed.
There was no documented evidence that a written notice of Resident 32's transfer to the hospital was provided to the resident and/or the resident's responsible party regarding the reason for transfer or that the ombudsman was notified of the resident's transfer.
A quarterly MDS assessment for Resident 33, dated February 24, 2025, revealed that the resident was moderately cognitively impaired and had a diagnosis of seizure disorder.
A nursing note for Resident 33, dated November 14, 2024, at 9:34 a.m., revealed that the resident had multiple seizures in the past two weeks and her seizure medication was increased twice.
The physician was notified, and the resident was transferred to the hospital for further evaluation.
There was no documented evidence that a written notice of Resident 33's transfer to the hospital was provided to the State Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's representative regarding the reason for transfer to the hospital.
Interview with the Director of Nursing on March 18, 2025, at 1:15 p.m. confirmed that there was no documented evidence that written notices were given as required. 28 Pa.
Code 201.14(a) Responsibility of Licensee. 28 Pa.
Code 201.25 Discharge Policy. 28 Pa.
Code 201.29(f)(g) Resident Rights.
tobacco measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while using smokeless tobacco, if indicated.
Supervision will be provided as per the resident's care plan. If a resident is capable of independent smokeless tobacco use, this will be indicated in the plan of care.
Observations during the facility tour on March 17, 2025, at 10:50 a.m. revealed that Resident 75 was lying in bed and had two cans of smokeless tobacco on his bedside table.
Interview with Licensed Practical Nurse 1 on March 19, 2025, at 11:17 a.m. confirmed that Resident 75 had smokeless tobacco on his bedside.
Interview with the Director of Nursing on March 19, 2025, at 1:32 p.m. confirmed that Resident 75 did not have a care plan that addressed the care and services needed for an indwelling foley catheter or the use of smokeless tobacco. 28 Pa.
Code 201.24(e)(4) admission Policy. 28 Pa.
Code 211.12(d)(5) Nursing Services.
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reviewed, and revised by a team of health professionals.
that the facility failed to ensure that a resident's care plan was updated/revised to reflect the
Findings include: The facility's policy regarding care plans, dated January 13, 2025, indicated that the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated February 26, 2025, indicated that the resident was moderately cognitively impaired, required staff assistance with care, and had a colostomy (an artificial opening in the bowel).
Physician's orders, dated January 28, 2025, included orders for the resident to have a colostomy bag and wafer every shift.
The resident's current care plan indicated that the resident had a colostomy and also had a history of placing silverware into her vagina and rectum.
A nursing note for Resident 46, dated February 8, 2025, at 9:16 p.m. revealed that the resident had an open area on the end of her colostomy/stoma (an opening in the abdomen that allows waste to exit the body).
The note indicated that the resident did dig at her stoma with silverware and had been witnessed by staff doing this.
The area had a bright red center and a small amount of bright red, bloody drainage.
There was no documented evidence that the resident's care plan was updated to include interventions to prevent Resident 46 from digging at her colostomy/stoma with silverware.
Interview with the Director of Nursing on March 20, 2025, at 11:15 a.m. confirmed that Resident 46's care plan was not updated following the incident on February 8, 2025. 28 Pa.
Code 211.12(d)(5) Nursing Services.
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carvedilol (medication for blood pressure), 75 mg of Plavix (medication for heart disease), 5 mg of
mood stabilization), and 1 mg of Prograf (medication used for preventing organ rejection).
The
felt lightheaded, and blood pressure was taken and was 108/58 mmHg.
The physician ordered for the resident to be transferred to the local emergency room.
A nursing note, dated August 20, 2024, at 3:57 p.m., revealed that Resident 75 returned to the nursing home from the emergency room with no new orders.
Interview with the Director of Nursing on March 19, 2025, at 1:32 p.m. confirmed that the Registered Nurse 2 did not follow the facility's policy when administering medications to a resident. 28 Pa.
Code 211.12(d)(1)(3)(5) Nursing Services.
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was no documented evidence that the resident's blood pressure or heart rate was obtained prior to
no documented evidence that Resident 21's blood pressure or heart rate was obtained per physician's orders prior to the administration of Metoprolol Succinate from September 27, 2024, through March 18,
- 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 soft, flexible plastic tube inserted in the bladder), and had diagnosis that included heart failure, obstructive uropathy, and diabetes mellitus.
Physician's order for Resident 75, dated January 12, 2025, included an order for the resident to receive 50 milligrams of Metoprolol Succinate (a medication for high blood pressure) daily and to hold medication if blood pressure systolic is less than 110 mmHg and heart rate is less than 60 beats per minute.
A review of Residents 75's January and February 2025 Medication Administration Record revealed that on January 25 the resident's blood pressure was 98/70 mmHg; on January 27 it was 106/65 mmHg; on January 31 it was 102/55 mmHg; on February 2 it was 106/68 mmHg; on February 10 it was 102/62 mmHg; and on February 18, 2025, it was 101/67 mmHg.
An interview with the Director of Nursing on March 20, 2025, at 12:31 p.m. confirmed that physician's orders for Resident 75 were not followed and that the medication should have been held. 28 Pa.
Code 211.12(d)(1)(5) Nursing Services.
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Review of Resident 17's clinical record, including the Treatment Administration Record and progress notes for February and March 2025, revealed that on February 1, 2025, at 1:00 a.m. and 5:00 a.m. the gastrostomy was flushed with 60 ml of free water; March 4, 2025, at 1:00 a.m. the gastrostomy tube was not flushed; March 9, 2025, at 1:00 a.m. and 5:00 a.m. was flushed with 180 ml of free water; March 10, 2025, at 1:00 a.m. was not flushed and at 5:00 a.m. was flushed with 150 ml of free water; March 14 at 1:00 a.m. and 5:00 a.m. was flushed with 120 ml and at 5:00 p.m. was flushed with 60 ml of free water; March 18, 2025, at 1:00 a.m. was not flushed and at 5:00 a.m. was flushed with 180 ml of free water.
Interview with the Director of Nursing on March 18, 2025, at 1:44 p.m. confirmed that the gastrostomy tube was not flushed every four hours with 130 mL (milliliters) of free water as ordered by the physician on the dates and times listed above. 28 Pa.
Code 211.12(d)(5) Nursing Services.
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staff administered two gm of Cefepime intravenously on March 11 thru 19, 2025, at 8:00 a.m. and 8:00
documented evidence that Resident 283's PICC/midline was flushed with saline solution prior to and/or after the Cefepime administration on the above-mentioned dates. 28 Pa.
Code 211.12(d)(1)(5) Nursing Services.
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Review of Resident 1's Medication administration record (MAR) for March 2025 revealed documentation that she received oxygen on March 17, 2025, at a flow rate of 3 liters/minute on the day, evening and night shifts.
Observations of Resident 1 on March 18, 2025, at 2:38 p.m. revealed that her oxygen concentrator remained off and she was not receiving oxygen at that time.
Interview with the Director of Nursing on March 19, 2025, at 1:07 p.m. confirmed that Resident 1's oxygen was ordered continuous, and that she was not receiving it.
She also confirmed that the order for continuous oxygen should have been clarified. 28 Pa.
Code 211.12(d)(1)(3)(5) Nursing Services.
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services of a licensed pharmacist.
determined that the facility failed to maintain accountability for controlled medications (drugs with
Findings include: The facility's policy regarding medication administration, dated January 13, 2025, indicated that staff were to sign the Medication Administration Record (MAR) after administering medications to residents.
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 frequent pain, received pain medication as needed, and received an opioid (a controlled pain medication).
Physician's orders, dated February 17, 2025, included an order for the resident to receive 50 milligrams (mg) of Tramadol (narcotic pain reliever) every six hours as needed for moderate pain.
A controlled drug accountability record for February and March 2025 revealed that 50 mg of Tramadol was signed out on February 24 at 11:54 a.m.; February 28 at 10:00 p.m.; March 7 at 7:56 a.m.; and March 14, 2025, at 8:30 p.m.; however, there was no documented evidence in the MAR that the Tramadol was actually given to the resident.
Interview with the Director of Nursing on March 19, 2025, at 1:28 p.m. confirmed that there was no evidence of the Tramadol being administered to Resident 6 and that the nurse was to document on the MAR when the medication was given. 28 Pa.
Code 211.9(a)(h) Pharmacy Services. 28 Pa.
Code 211.12(d)(3)(5) Nursing Services.
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cognitively impaired, required assistance with care needs, and had a diagnosis of cancer.
recommendations to discontinue the as needed loperamide (medication used to treat diarrhea) due to
pharmacist's recommendation.
A quarterly MDS assessment for Resident 68, dated February 7, 2025, revealed that the resident was cognitively impaired, required assistance with care needs, and had a diagnosis of chronic obstructive pulmonary disease.
A monthly pharmacy medication regimen review for Resident 68, dated October 18, 2024, revealed recommendations to document the continued necessity/benefit for fluoxetine (medication used to treat depression) or attempt a dosage reduction.
There was no documented evidence that the physician responded to the pharmacist's recommendation.
An interview with the Director of Nursing on March 20, 2025, at 10:30 a.m. confirmed that there was no documented evidence that the physician responded to the pharmacist's October 2024 recommendations for Residents 23, 66, and 68. 28 Pa.
Code 211.12(d)(3) Nursing Services.
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Based on review of facility policies and clinical records, as well as staff interviews, it was
medications, by failing to ensure that non-pharmacological (non-medication) behavioral interventions (individualized, non-pharmacological approaches to care), were attempted prior to the administration of as needed antianxiety medications for one of 36 residents reviewed (Resident 66).
Findings include: The facility's policy regarding psychotropic medications (any medication that affects brain activities associated with mental processes and behavior), dated January 13, 2025, indicated that non-pharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 66, dated January 21, 2025, revealed that the resident was cognitively impaired, required assistance with care needs, was administered antipsychotic (used to treat mental health disorders) and antidepressant (used to treat depression) medications and had diagnoses including Schizophrenia (a serious mental disorder that affects how people interpret reality) and depression.
Physician's orders for Resident 66, dated February 13, 2025, included an order for the resident to receive 0.25 milligrams (mg) of Xanax (a controlled antianxiety medication) every eight hours as needed for anxiety.
Physician's orders for Resident 66, dated March 10, 2025, included an order for the resident to receive 0.25 mg of Xanax every eight hours as needed for anxiety.
Review of the Medication Administration Record (MAR) for Resident 66 for February and March 2025 revealed that the resident was administered 0.25 mg of Xanax on February 14 at 11:19 a.m.; February 17 at 11:45 a.m.; February 21 at 6:46 p.m.; February 24 at 7:05 p.m.; February 26 at 11:41 a.m.; and March 11 at 9:25 a.m.
There was no documented evidence that non-pharmacological behavioral interventions were attempted prior to administering Xanax on the above-mentioned dates and times.
Interview with the Director of Nursing on March 20, 2025, at 11:18 a.m. confirmed that non-pharmacological interventions should have been attempted prior to the administration of as needed Xanax to Resident 66 on the above-mentioned dates and times. 28 Pa.
Code 211.12(d)(5) Nursing Services.
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the results.
the facility failed to obtain laboratory studies as ordered by the physician for one of 36 residents
Findings include: The facility's policy regarding laboratory specimens, dated January 13, 2025, revealed that the facility would provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law.
The facility would provide or obtain laboratory services to meet the needs of its residents.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated December 18, 2024, revealed that the resident was cognitively intact, received dialysis services, received an anticonvulsant medication, and had diagnoses that included seizures and kidney failure.
Physician's orders for Resident 53, dated September 5, 2021, included an order for staff to obtain a complete blood count with differential (CBC with diff - blood test that measures various components of the blood), complete metabolic panel (CMP - blood test that provides information about your body's chemical balance), Hemaglobin A1C (Hgb A1C- blood test that measures blood sugar over the past 2-3 months), lipid panel (blood test that measures the amount of fats in the blood), and levetiracetam level every three months. A physician's order, dated August 31, 2021, included an order for the resident to receive 500 milligrams (mg) of levetiracetam (anticonvulsant medication used to prevent seizures) daily on Monday, Tuesday, Wednesday, Thursday, Friday and Saturday.
There was no documented evidence that staff obtained Resident 53's ordered laboratory tests after August 2024.
Interview with Director of Nursing on March 19, 2025, at 1:28 p.m. confirmed that there was no evidence that Resident 53's laboratory studies were obtained as ordered every three months after August 2024. 28 Pa.
Code 211.12(d)(1)(3)(5) Nursing Services.
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would complete audits and the results would be reviewed as part of quality assurance.
The results of
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, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to infection control.
Refer to F-F656, F-F657, F-F658, F-F684, F-F693, F-F695, F-F755, F-F761, F-F880. 28 Pa.
Code 201.14(a) Responsibility of Licensee. 28 Pa.
Code 201.18(e)(1) Management.
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resident was cognitively intact, required assistance from staff for daily care needs, had an indwelling
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.
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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.
395860
Form Approved OMB
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
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.
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.
395860
Form Approved OMB
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.