Loyalhanna Care Center

resident's ability to function.

determined that the facility failed to ensure that residents medication regimen was free from

behavior) for one of 35 residents reviewed (Resident 8).Findings include:The facility's policy regarding psychotropic medication use, dated January 1, 2026, indicated that psychotropic medications used on a PRN (as needed) basis must have a diagnosed specific condition and indication for use documented in the resident's medical record.

Orders for PRN psychotropic medications, excluding antipsychotics, were to be limited to no more than 14 days, unless the attending physician or prescribing practitioner believed it was appropriate to extend the order beyond the 14 days.

The medical record was to include documentation from the physician or prescriber for the rationale for the extended time period and was to indicate a specific duration.A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 8 dated February 28, 2026, indicated that the resident had cognitive impairment, required assistance from staff for daily care needs, received an anti-anxiety medication, and had a diagnosis of dementia.Physician's orders for Resident 8 dated November 27, 2025, included an order for the resident to receive 0.50 milligrams (mg) of Ativan (an antianxiety medication) every four hours as needed for restlessness/anxiety for 14 days.

Review of the Medication Administration Records (MAR) for Resident 8 dated December 2025, and January, February and March 2026 revealed that 0.50 mg of Ativan was administered to the resident on December 2, 5-7, 9, 18, 19, 23, 24, and 27, 2025; January 2, 4, 9, 11, 22, 24, 25, 28, and 30; February 4, 5, 7, 9-11, 13, 17, 20, 21, 23-25; and March 2, 4-6, 8, 10, 12, 14, 15, 18-21, and 23, 2026.

There was no evidence of a physician's order to continue the as needed Ativan beyond the 14 days ordered on November 27, 2025, and there was no documentation by a practitioner that included the rationale for extending the as needed Ativan beyond 14 days.Interview with the Director of Nursing on April 1, 2026, at 10:02 a.m. confirmed that there was no physician's order to continue the as needed Ativan beyond the initial order of 14 days or documented evidence from a physician or prescriber to indicate the rationale to extend the as needed Ativan for Resident 8 beyond 14 days.28 Pa.

Code 211.12(d)(5) Nursing Services.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

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period.

Physician's orders for Resident 35, dated February 28, 2026, included orders for the resident

the assessment period.

However, an admission MDS assessment for Resident 35, dated March 2,

diuretic medication.

Interview with the Director of Nursing on April 2, 2026, at 12:34 p.m. confirmed that MDS assessment for Resident 35 was coded inaccurately. 28 Pa.

Code 211.5(f) Clinical records

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Loyalhanna Care Center 535 McFarland Road Latrobe, PA 15650

Review of Resident 3's bowel record dated March 3, 2026, through April 1, 2026, indicated that the resident was incontinent of bowel five times.There was no documented evidence that a care plan was developed to address Resident 3's specific and individualized care needs related to being frequently incontinent of bowel.Interview with the Director of Nursing on April 2, 2026, at 10:32 a.m. confirmed that an individualized care plan and interventions was not developed related to Resident 3 being incontinent of bowel and should have been. 28 Pa.

Code 211.12(d)(5) Nursing Services.

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Loyalhanna Care Center 535 McFarland Road Latrobe, PA 15650

Review of physician's orders revealed that the order for Resident 76's lymphedema pumps was discontinued on August 23, 2025, and there was no documented evidence in the Resident's treatment administration record that she was currently using the lymphedema pumps.

Interview with the Director of Nursing on April 2, 2026, at 10:32 a.m. confirmed that Resident 76's care plan was not revised when the lymphedema pumps were discontinued, and it should have been. 28 Pa.

Code 211.11(d) Resident care plan.

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February 20 at 9:08 a.m., February 23 at 7:39 a.m., February 25 at 12:02 a.m., February 26 at 1:52 a.m.

a.m., March 14 at 7:48 p.m., March 17 at 8:59 p.m., and March 18, 2026 at 2:05 p.m. when the

confirmed that staff did not administer Resident R9's pain medication as ordered by the physician.28 Pa.

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

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Loyalhanna Care Center 535 McFarland Road Latrobe, PA 15650

Based on assessments findings and resident goals, the least restrictive and most restorative interventions are used first. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3 dated September 12, 2025, indicated the resident was cognitively intact, required supervision or touch assist for toileting hygiene, was always continent of bowel and had diagnoses that included Schizoaffective disorder, bipolar type (a chronic mental health condition combining schizophrenia symptoms (hallucinations, delusions) with severe mood episodes (mania and sometimes depression)).A quarterly MDS for Resident 3 dated December 13, 2025, indicated the resident was cognitively intact, required partial to moderate assistance for toileting hygiene, and was occasionally incontinent of bowel. An annual MDS assessment for Resident 3 dated March 13, 2026, indicated the resident was cognitively intact, was independent for most of her daily care needs, and was frequently incontinent of bowel.

There was no documented evidence that a bowel assessment was completed quarterly to identify restorative interventions to promote bowel continence and maintain resident dignity.

Interview with the Director of Nursing on April 2, 2026, at 10:32 a.m. confirmed that there was no documented evidence that bowel assessments were completed quarterly for Resident 3 per the facility policy. A quarterly MDS assessment for Resident 4, dated January 17, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had an indwelling urinary catheter, had diagnoses that included neurogenic bladder (loss of bladder control caused by damage to the nerves, spinal cord, or brain).Physician's orders for Resident 4 dated June 15, 2025, included for staff to change the Resident's suprapubic catheter (an indwelling urinary catheter inserted through a small incision in the lower abdomen/suprapubic area) every 21 days and as needed for blockage or displacement.

Review of the Treatment Administration Record and nurses' notes for Resident 4 dated October 2025 through March 2026, revealed there was no documented evidence that the suprapubic catheter was changed in the 42 days between October 18, 2025, and November 29, 2025, and no documented evidence it was changed during the 48 days between February 8, 2026, and March 28, 2026.

Interview with the Director of Nursing on April 2, 2026, at 8:22 a.m. confirmed that there was no documented evidence that suprapubic catheter was changed as ordered by the physician on the above-mentioned dates. 28 Pa.

Code 211.12(d)(1)(5) Nursing services.

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assistance for daily care needs, and was receiving dialysis.Review of Resident 86's clinical record

every Tuesday, Thursday, and Saturday at 11:00 a.m.Review of Resident 86's clinical record revealed

documentation included January 15, and 21, 2026.

Observations on April 2, 2026, at 12:10 p.m. revealed that there was no hemodialysis emergency kit located in the resident's room.Interview with the Director of Nursing on April 2, 2026, at 12:34 p.m. confirmed that Residents 6 and 86 had no or limited evidence of ongoing communication and collaboration between the facility and dialysis clinic, and also confirmed that Resident 86 should have had an emergency hemodialysis kit at bedside.28 Pa.

Code 211.5(f)(viii) Medical Records.28 Pa.

Code 211.12(d)(1)(3)(5) Nursing Services.

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that 5 mg of oxycodone was signed out on February 26, 2026, at 4:23 p.m. and February 28, 2026, at

dates and times.

Interview with the Director of Nursing on April 1, 2026, at 2:12 p.m. confirmed that

the signed-out doses of controlled medications mentioned above were administered. 28 Pa.

Code 211.9(a)(1) Pharmacy Services. 28 Pa.

Code 211.12(d)(1)(3)(5) Nursing Services.

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Loyalhanna Care Center 535 McFarland Road Latrobe, PA 15650

appetizing temperatures.

Findings include:The facility's policy regarding Food Temperatures, dated

the proper serving temperatures.Interview with a group of residents on March 31, 2026 at 11:00 a.m. revealed that their food is served cold when eating in the dining room.

They stated that the food comes from the kitchen to the dining room and it is cold.Observations of tray line on March 31, 2026 at 12:08 p.m. revealed that the dietary staff were preparing the plates for the dining room.

The plates were made and then placed on the trays for delivery into the dining room.

There were no lids or covers placed over the food to keep it warm and there were times that the plate of food sat on the tray line for approximately five minutes before going to the dining room.

The plates were then carried into the dining room with no lid or cover over the food. A test tray was requested from the kitchen on March 31, 2026 at 12:28 p.m. after the last of the residents in the dining room had been served.

The test tray was served from the steam tables in the kitchen. At 12:34 p.m. the test tray temperature of the pureed lasagna was 114.9 degrees Fahrenheit and tasted cold, the temperature of the peas and carrots was 120.5 degrees F and tasted cold.

The temperature of these items were cold to taste and not appetizing. An interview with the Regional Dietary Manager on March 31, 2026 at 12:30 p.m. revealed that the pureed lasagna and the peas and carrots should have been warm and not cold when served.28 Pa.

Code 201.18(b)(1)(e)(1) Management.

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individual needs.

facility failed to ensure that the proper food consistency was prepared for residents receiving a

Diet Orders, dated January 1, 2026, revealed that residents would be provided food in the appropriate from as prescribed by the physician.The facility's menu for pureed lasagna for the meal served on March 31, 2026, revealed that the pureed lasagna should be placed into a food processor, blended until smooth and then staff should use the fork drip test and the spoon tilt test to confirm the texture is within the specifications.Observations during the lunch meal on March 31, 2026 at 12:28 p.m. revealed that the pureed lasagna had chunks in it that needed to be chewed.

Interview with the Regional Dietary Manager on March 31, 2026 at 12:30 p.m. confirmed that the pureed lasagna had chunks in it and that it should not have.28 Pa.

Code 211.12(d)(3) Nursing services. 28 Pa.

Code 211.12(d)(5) Nursing services.

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corrective plans of action.

current survey, it was determined that the facility's Quality Assurance Performance Improvement

of care and services effectively addressed recurring deficiencies.

Findings include:The facility's deficiencies and plan of corrections for an annual survey ending March 20, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations.

The results of the current survey, ending April 2, 2026, identified repeated deficiencies related to care plan creation, care plan revisions, quality care, pharmaceutical services, food in a form to meet an individuals needs, and infection control.The facility's plan of correction for a deficiency regarding care plan creation, cited during the survey ending March 20, 2025, 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-F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that care plans were created timely.The facility's plan of correction for a deficiency regarding care plan revision, cited during the survey ending March 20, 2025, 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 that care plans were revised timely.The facility's plan of correction for a deficiency regarding quality care, cited during the survey ending March 20, 2025, 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-F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that quality care was provided.The facility's plan of correction for a deficiency regarding pharmaceutical services, cited during the survey ending March 20, 2025, 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-F755, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that pharmaceutical services were appropriately maintained.The facility's plan of correction for a deficiency regarding food served in a form to meet an individual's needs, cited during the survey ending March 20, 2025, 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-F805, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that food was served to meet an individuals needs.The facility's plan of correction for a deficiency regarding infection control, cited during the survey ending March 20, 2025, 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-F880, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that infection control was properly maintained.Refer to F-F656, F-F657, F-F684, F-F755, F-F805, F-F880.28 Pa.

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

Code 201.18(e)(1) Management.

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while providing medications for one of 35 residents reviewed (Resident 67).Findings include:The

to remove the medication from the source, taking care not to touch the medication with their bare hand.

Observations during medication administration on April 1, 2026, at 8:08 a.m. revealed that Registered Nurse 2 prepared to administer medications to Resident 67 and took out pills from the medicine cup with her bare hands and placed them in a bag to be crushed.

She then administered the medications to Resident 67.

Interview with Registered Nurse 2 on March 11, 2025, at 8:10 a.m. confirmed that she should not have touched the medication with her bare hands.

Interview with the Director of Nursing on April 1, 2026, at 3:04 p.m. confirmed that staff were not to touch residents' medications with their bare hands. 28 Pa.

Code 211.12(d)(1)(5) Nursing services.