Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Loyalhanna Care Center during CMS and state inspections, most recent first.
A resident with cognitive impairment and dementia received PRN Ativan for restlessness/anxiety far beyond the 14-day order. The MAR showed repeated administrations over several months, but there was no physician order to continue the PRN med and no documented prescriber rationale for extending it.
A facility failed to follow physician orders for three residents: one resident with ESRD on dialysis did not have ordered lab results obtained from the dialysis center, one resident with dementia did not have the ordered bowel protocol initiated despite days without a BM, and one resident with arthritis and frequent pain received PRN Hydrocodone-Acetaminophen when pain ratings were below the ordered severe-pain threshold. The DON confirmed the orders were not followed.
Dialysis communication and collaboration were not adequately documented for two residents receiving HD, including a resident with ESRD who had ongoing dialysis orders and another resident with ESRD and diabetes who had limited dialysis clinic communication in the record. In addition, an observation found no hemodialysis emergency kit at one resident’s bedside, and the DON confirmed the missing kit and the limited communication documentation.
Failure to document administration of controlled pain meds: controlled drug records showed signed-out doses of hydrocodone-acetaminophen and oxycodone for several cognitively intact residents with pain-related diagnoses, but the MAR/clinical record did not show that the doses were actually given. The DON confirmed the missing documentation for the affected residents.
A facility failed to ensure residents received food at appetizing temperatures. Residents said meals served in the dining room were cold, and observation showed dietary staff plated food without lids or covers and left some trays sitting before delivery. A test tray showed pureed lasagna and peas and carrots at temperatures that tasted cold, and the RDM stated the items should have been warm when served.
A resident ordered a pureed diet was served pureed lasagna that was not prepared to the required texture. The menu directed staff to blend the lasagna until smooth and verify it with texture tests, but during meal observation the lasagna contained chunks that needed to be chewed. The Regional Dietary Manager confirmed the food had chunks and should not have.
A resident with an indwelling urinary catheter and neurogenic bladder was observed lying in bed with the catheter drainage bag hanging on the bed frame and visible from the hallway. Facility policy required privacy bags and covered drainage bags, and both a Nurse Aide and the DON confirmed the bag should have had a privacy cover.
Inaccurate MDS coding affected three residents. One resident's antipsychotic use and documented GDR contraindication were not coded correctly on the MDS despite MAR and psychiatry documentation; another resident's hearing was coded as adequate even though the care plan, resident interview, and family interview showed impaired hearing; and a third resident's MDS failed to reflect daily diuretic use documented in the orders and MAR. The RNAC, LPNAC, and DON each confirmed the coding errors.
A resident who was cognitively intact and independent for most daily care needs was frequently incontinent of bowel, with five incontinent episodes documented in the bowel record. However, there was no documented individualized care plan or interventions to address the resident’s bowel incontinence, and the DON confirmed the care plan had not been developed.
Failure to update care plans for changed resident needs: Two residents had care plans that were not revised when their treatment or care routines changed. One resident with an indwelling urinary catheter used a leg bag during the day and a large drainage bag at night, but the care plan was not updated to reflect that routine. Another resident with MS had a care plan that still included lymphedema pump therapy even though the order had been discontinued and there was no current documentation that the pumps were being used.
Failure to Provide Bowel Management and Follow Catheter Orders: A cognitively intact resident with worsening bowel incontinence did not have documented quarterly bowel assessments to identify restorative interventions, despite facility policy requiring individualized bowel management. In addition, a resident with neurogenic bladder and a suprapubic catheter did not have the catheter changed at the ordered 21-day interval, with TAR and nurse notes showing extended gaps and the DON confirming the missed documented changes.
QAPI committee failed to correct recurring deficiencies involving care plan creation and revision, quality care, pharm services, food consistency, and infection control. Prior POCs relied on audits and reporting to the QAPI committee, but the current survey found those plans were not successfully implemented, and the same issues remained cited under F656, F657, F684, F755, F805, and F880.
A nurse failed to follow the facility’s med administration policy when she removed pills from a medicine cup with her bare hands, placed them in a bag to be crushed, and then gave them to a resident. The RN later confirmed the error, and the DON confirmed staff were not to touch residents’ medications with bare hands.
A resident who required two-person assistance for transfers due to mobility limitations was assisted by a single nurse aide, contrary to care plan and physician orders. During the transfer after a shower, the aide slipped on water, causing both to fall and resulting in the resident sustaining a hip fracture that required surgery.
A resident who required two-person assistance for transfers was assisted by a single nurse aide after a shower. The aide, unaware of the updated transfer requirement, slipped on water on the floor, causing both herself and the resident to fall. The resident sustained a hip fracture that required surgery, as the care plan and physician's orders for two-person assistance were not followed.
A resident with a history of stroke and swallowing difficulties was not consistently provided with the prescribed mechanically altered or pureed diet. On two occasions, the resident was served food items—chicken and Brussel sprouts—not appropriate for her ordered diet, leading to choking episodes, one of which required hospital admission for hypoxia and aspiration. Staff failed to verify diet textures before serving meals, and the resident reported distress from these incidents.
The facility failed to follow physician's orders for medication administration for three residents. A resident with diabetes received insulin despite not meeting meal intake requirements. Two residents on Metoprolol Succinate did not have their vital signs checked as ordered, and one received the medication despite low blood pressure readings. These deficiencies were confirmed by the DON.
The facility failed to flush PICC/midline catheters with saline solution before and after administering IV medications for two residents, as per its policy. One resident required Vancomycin for neurogenic bladder, while another needed Cefepime for sepsis. The Director of Nursing confirmed the lack of documentation for catheter flushing, indicating non-compliance with the facility's intravenous therapy protocol.
The facility failed to label and discard insulin pens according to policy and did not secure controlled drugs in a locked compartment. An LPN confirmed that a Humalog insulin pen was not discarded after 28 days, and a Novolin insulin pen was not dated upon opening. Additionally, an unlocked box containing Ativan was found in the refrigerator, which the DON acknowledged should have been locked.
A resident with Multiple Sclerosis expressed dissatisfaction with her mechanical soft diet, preferring regular food despite having no teeth. The facility continued the prescribed diet based on a physician's order, and although a speech therapist noted the resident's preference, safety concerns were raised. The Medical Director required a waiver or MBS study before considering a diet change, but no waiver was offered. The Director of Nursing believed the resident should have her preferred diet, but the facility did not act to support her choice.
The facility failed to develop and implement individualized care plans for three residents, resulting in unaddressed medical needs. A resident with a history of thrombosis lacked a care plan for anticoagulant therapy. Another resident, with a history of falls, did not have a perimeter mattress as required. Additionally, a resident with an indwelling foley catheter had no care plan for catheter care or smokeless tobacco use. These deficiencies were confirmed by the DON.
A resident with a colostomy and moderate cognitive impairment was found digging at her stoma with silverware, causing an open area with bloody drainage. Despite physician's orders and facility policy requiring care plan updates, the care plan was not revised to prevent such behavior, as confirmed by the DON.
A facility failed to clarify physician's orders for a resident with a gastrostomy, leading to incorrect medication transcription. Additionally, a nurse administered the wrong medications to another resident, resulting in the resident feeling lightheaded and requiring emergency room evaluation. The DON confirmed these errors did not align with professional standards.
A resident with cognitive impairment and anoxic brain injury did not receive gastrostomy tube care as ordered by the physician. The tube was supposed to be flushed every four hours with 130 mL of water, but records showed it was often flushed with incorrect amounts or not at all. The DON confirmed these discrepancies.
A facility failed to clarify a continuous oxygen order for a resident with congestive heart failure. Despite a physician's order for continuous oxygen to maintain blood oxygen levels, observations revealed the resident's oxygen concentrator was off, and she was not receiving oxygen. The DON confirmed the order should have been clarified.
A facility failed to maintain accountability for controlled medications for a resident with moderate cognitive impairment and frequent pain. Although Tramadol was signed out multiple times, there was no documented evidence in the MAR that it was administered. The DON confirmed the lack of documentation.
The facility failed to ensure timely physician responses to pharmacy recommendations for four residents. A pharmacist's monthly medication regimen reviews recommended actions for residents with various conditions, including dementia, depression, congestive heart failure, cancer, and COPD. However, there was no documented evidence that physicians responded to these recommendations, as confirmed by interviews with the DON.
A facility failed to obtain laboratory studies as ordered for a resident who was cognitively intact and received dialysis services. The resident had physician's orders for several tests, including a CBC with diff, CMP, Hgb A1C, lipid panel, and levetiracetam level every three months. However, there was no evidence that these tests were conducted after August 2024, as confirmed by the DON. The resident's medical history included seizures and kidney failure, and they were on levetiracetam.
The QAPI committee failed to address recurring deficiencies, as evidenced by repeated issues in a recent survey. Deficiencies included failures in developing care plans, care plan timing and revision, and ensuring services met professional standards. The facility also did not follow physician's orders, manage tube feeding properly, or provide oxygen therapy as ordered. Issues with controlled medications, drug labeling/storage, and infection control were also noted.
The facility did not follow infection control guidelines for implementing Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. A resident with a urinary catheter, another with a Foley catheter, and a third with a midline catheter were observed without EBP signage or PPE. Staff interviews confirmed these residents should have been on EBP, highlighting a lapse in infection control practices.
A resident who was cognitively intact and occasionally incontinent of bowel did not receive bowel medications as ordered by the physician. Despite extended periods without a bowel movement, staff delayed administering Milk of Magnesia and Bisacodyl suppository, and did not follow the prescribed sequence and timing of interventions. The facility confirmed that physician's orders for bowel management were not followed.
Two residents experienced significant weight loss and one had a decline in fluid intake, but the facility did not notify the physician or dietitian in a timely manner as required by policy. This resulted in delayed treatment and lack of updated care interventions, as confirmed by the DON.
Loyalhanna Care Center failed to comply with its water temperature safety policy, resulting in water temperatures exceeding the set limit in resident rooms. Maintenance staff did not complete required weekly checks or maintain documentation, as confirmed by interviews with staff and the Nursing Home Administrator.
Loyalhanna Care Center was found non-compliant with regulations for maintaining a clean and homelike environment. Observations revealed dirt, debris, and floor glue on the South hall floors, peeling wallpaper, and a brown substance on the walls. Transition strips in some rooms were broken, and a pink substance was noted in the North hall shower grout. Interviews with the Environmental Services and Maintenance Directors confirmed these issues, indicating a failure to provide a safe and comfortable environment.
A facility failed to provide scheduled showers for a resident who required assistance due to dementia. The resident was supposed to receive showers twice a week, but there was no documented evidence of showers being offered or refused on multiple occasions over a period of several weeks. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to promptly resolve resident grievances regarding slow response times to call bells, as evidenced by Resident Council meeting minutes and staff interviews. Despite the facility's grievance policy, there was no documented evidence of efforts to address these concerns until much later, leading to a deficiency finding.
The facility did not serve food items at appetizing temperatures during a lunch meal service. A test tray revealed that the iced tea, Mandarin oranges, and steak fries were not at the required temperatures, with the steak fries being particularly cold and unappetizing. The Dietary Director confirmed the deficiency.
The facility failed to maintain adequate water temperature during showers for three residents, leading to discomfort. Residents reported that the water was not warm enough, with observations confirming temperatures below the facility's policy range. Staff interviews indicated that the water temperature often required offering bed baths instead of showers, which residents refused. The Maintenance Director noted issues with the hot water supply affecting temperature regulation.
The facility failed to maintain a clean and homelike environment for several residents, as required by its policy. Observations revealed dust and debris in multiple rooms, including under beds and near doorways. The Director of Environmental Services confirmed the need for cleaning and cited workload issues as a reason for delayed deep cleaning.
The facility failed to provide scheduled showers for two residents, one with dementia and another with an artificial shoulder, as per their care plans. Despite being scheduled for specific days, records show missed showers without documentation of offers or refusals. The DON confirmed the lack of documentation for these missed showers.
A facility failed to protect residents from neglect and ensure proper medication administration. A resident with severe cognitive impairment was found with signs of neglect, including a urinary catheter indentation and pressure ulcers, after her daughter reported a lack of care. Additionally, three residents did not receive their nighttime medications as ordered, despite records indicating otherwise. The facility's investigation confirmed these deficiencies, highlighting issues in care documentation and medication administration.
A facility failed to ensure medications were administered as ordered for three residents. Despite being signed off as given, medications for residents with conditions like hypertension and atrial fibrillation were found discarded. The investigation confirmed the medications were not administered, and there was no documentation of refusal or inability to take them.
A facility failed to administer medications as ordered for three residents. An LPN discovered missing medication packs and false documentation of administration. Residents reported not receiving their medications, and an investigation found empty packets and pills in garbage bins. The residents had significant medical histories, and the failure to administer medications as ordered was confirmed by the Nursing Home Administrator.
A facility failed to administer and accurately document medications for three residents, leading to discrepancies between the MAR and actual medication administration. Residents reported not receiving their nighttime medications, and an investigation revealed empty medication packets and pills in garbage bins. The Nursing Home Administrator confirmed the failure to administer medications as ordered.
The facility failed to develop and implement a comprehensive care plan for a resident with moderate to severe tricompartmental osteoporosis and pain management needs, despite physician's orders and the resident's dependency on staff for care.
The facility failed to update a resident's care plan to reflect the resolution of a UTI and the completion of antibiotic therapy. Despite the resident completing a course of Cipro, the care plan still indicated ongoing antibiotic therapy.
The facility failed to clarify a physician's order for a resident receiving hemodialysis. The resident's dialysis schedule changed, but the order for Bumetanide was not updated accordingly. This oversight was confirmed by the Director of Nursing, indicating a lapse in following professional standards.
A facility failed to provide suprapubic urinary catheter care as ordered by the physician for a resident. The resident had an 18 French catheter instead of the ordered 16 French catheter, as confirmed by the resident, an LPN, and the Nursing Home Administrator.
The facility failed to ensure that gastrostomy tube care was provided as ordered by the physician for a cognitively impaired resident with an anoxic brain injury. The resident's clinical record showed missing documentation for required gastrostomy flushes on multiple occasions, which was confirmed by the DON.
The facility failed to provide oxygen therapy as ordered for a resident with cardiomyopathy and non-ST-elevation myocardial infarction. The resident did not have supplemental oxygen on multiple occasions, and staff confirmed that the oxygen should have been applied as per the physician's orders.
Unnecessary PRN psychotropic medication
Penalty
Summary
The facility failed to ensure that one resident’s medication regimen was free from unnecessary psychotropic medication. Resident 8 had cognitive impairment, required staff assistance with daily care needs, received an anti-anxiety medication, and had a diagnosis of dementia. The facility’s policy stated that PRN psychotropic medications had to have a diagnosed specific condition and indication documented in the medical record, and PRN psychotropic orders excluding antipsychotics were limited to 14 days unless the prescriber documented the rationale for extending the order and a specific duration. Resident 8 was ordered Ativan 0.50 mg every four hours as needed for restlessness/anxiety for 14 days. The MAR showed the medication was administered repeatedly over December 2025 through March 2026. There was no evidence of a physician’s order to continue the PRN Ativan beyond the initial 14-day order, and there was no documentation from a physician or prescriber stating the rationale for extending the PRN Ativan beyond 14 days. The DON confirmed that no such order or documented rationale existed.
Failure to Follow Physician Orders for Labs, Bowel Protocol, and Pain Medication
Penalty
Summary
The facility failed to obtain laboratory results as ordered for a resident with end-stage renal disease who was receiving dialysis. The resident was cognitively intact and required staff assistance with daily care needs. A physician order directed staff to call the dialysis center to obtain the most recent lab results, but there was no documented evidence that the results were obtained, and the DON confirmed the order was not followed. The facility also failed to follow bowel protocol orders for a resident with dementia who was frequently incontinent of bowel movements. The physician ordered Milk of Magnesia as needed if no bowel movement by the third day, followed by Bisacodyl suppository if ineffective, and then a Fleets enema if needed after those measures. Review of bowel records and MARs showed no documented bowel movement during two separate multi-day periods, and staff did not initiate or follow the ordered bowel protocol. In addition, the facility failed to administer pain medication as ordered for a resident with moderate cognitive impairment, arthritis, and pain almost constantly. The resident had an order for Hydrocodone-Acetaminophen every six hours as needed for severe pain or per resident preference, but MAR review showed multiple administrations when the documented pain ratings were below the ordered threshold, and the DON confirmed staff did not administer the medication as ordered.
Dialysis Communication and Bedside Emergency Kit Deficiencies
Penalty
Summary
The facility failed to maintain records of dialysis communication and collaboration for two residents receiving hemodialysis. Resident 6 had end-stage renal disease, was cognitively intact, required assistance with daily care, and had an order for dialysis on Monday, Wednesday, and Friday. Review of the clinical record showed limited evidence that resident assessments or communication about the resident’s condition before and after dialysis were being shared between the facility and the dialysis center, despite the facility policy and dialysis contract calling for ongoing assessment and communication. Resident 86 was cognitively intact, required extensive assistance with daily care, had end-stage renal disease and diabetes, and had an order for dialysis every Tuesday, Thursday, and Saturday at 11:00 a.m. Review of the clinical record showed limited evidence of communication between the facility and the dialysis clinic, with dialysis communication documentation only on January 15 and 21, 2026. In addition, observation on April 2, 2026, at 12:10 p.m. revealed that there was no hemodialysis emergency kit located in the resident’s room. The DON confirmed that Residents 6 and 86 had no or limited evidence of ongoing communication and collaboration with the dialysis clinic, and confirmed that Resident 86 should have had an emergency hemodialysis kit at bedside.
Failure to Document Administration of Controlled Pain Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for four residents. Facility policy required staff to sign the MAR after medication administration and to sign the narcotic book for controlled substances, but review of clinical records and controlled drug records showed signed-out doses of hydrocodone-acetaminophen and oxycodone without documented evidence that the medications were actually administered. The DON confirmed that the clinical records for the affected residents did not contain documentation showing the signed-out doses were given. Resident 2 was cognitively intact, independent for most daily care needs, had fibromyalgia, and was receiving scheduled and PRN pain medication; controlled drug records showed multiple signed-out doses of hydrocodone-acetaminophen with no corresponding administration documentation. Resident 4 was cognitively intact, needed staff assistance with daily care, had multiple sclerosis, and was receiving scheduled and PRN pain medication; controlled drug records showed multiple signed-out doses of oxycodone without documentation of administration. Resident 76 was cognitively intact, needed staff assistance with daily care, had multiple sclerosis, and was receiving scheduled and PRN pain medication; controlled drug records showed multiple signed-out doses of oxycodone without documentation of administration. Resident 86 was cognitively intact, needed assistance with personal care, had a left hip fracture and chronic renal failure, and had an order for PRN oxycodone; controlled drug records showed two signed-out doses of oxycodone without documentation of administration.
Cold Food Served in Dining Room
Penalty
Summary
The facility failed to ensure that residents received foods served at appetizing temperatures. The facility policy dated January 1, 2026 stated that food temperatures would be monitored daily to ensure proper serving temperatures. During a group interview on March 31, 2026, residents stated that food served in the dining room was cold and that it came from the kitchen cold. Observations of the tray line at 12:08 p.m. showed dietary staff preparing plates for the dining room, placing the plates on trays without lids or covers, and allowing some plates to sit on the tray line for about five minutes before being taken to the dining room. A test tray obtained from the kitchen after residents had been served showed pureed lasagna at 114.9 degrees Fahrenheit and peas and carrots at 120.5 degrees Fahrenheit; both items tasted cold and were not appetizing. The Regional Dietary Manager stated that the pureed lasagna and peas and carrots should have been warm and not cold when served.
Pureed Diet Food Consistency Not Met
Penalty
Summary
The facility failed to ensure that food was prepared in the proper consistency for residents ordered a pureed diet by the physician. The facility’s policy for Therapeutic Diet Orders stated that residents would be provided food in the appropriate form as prescribed by the physician. The menu for pureed lasagna served at lunch required the lasagna to be placed into a food processor, blended until smooth, and checked with the fork drip test and spoon tilt test to confirm the texture met specifications. During lunch meal observation, the pureed lasagna was observed to have chunks that needed to be chewed. The Regional Dietary Manager confirmed that the pureed lasagna had chunks in it and that it should not have.
Failure to Maintain Privacy for Catheter Drainage Bag
Penalty
Summary
The facility failed to maintain the dignity of Resident 94, who was admitted with an indwelling urinary catheter and had a diagnosis of neurogenic bladder. A facility policy dated January 1, 2026 stated that residents with indwelling catheters should receive appropriate catheter care and that privacy bags would be available and catheter drainage bags would be covered at all times while in use. On March 30, 2026, the resident was observed lying in bed with the urinary catheter drainage bag containing urine hanging on the bed frame and visible from the hallway. A Nurse Aide stated the resident should have had a privacy bag for the catheter drainage bag, and the DON later confirmed that the drainage bag should have had a privacy cover.
Inaccurate MDS Coding for Antipsychotic Use, Hearing, and Diuretic Medication
Penalty
Summary
The facility failed to complete accurate MDS assessments for three residents by incorrectly coding assessment items related to antipsychotic medication use, hearing status, and diuretic administration. For one resident, the clinical record showed routine bedtime antipsychotic medication administration throughout the month, a care plan noting antipsychotic use, and psychiatry documentation that a GDR was clinically contraindicated, yet the quarterly MDS was coded to show no GDR and no physician documentation that a GDR was clinically contraindicated. The RN Assessment Coordinator confirmed the MDS was coded inaccurately regarding the GDR of antipsychotic medications. For another resident, the care plan identified a communication problem related to hearing deficit, and survey interviews with the resident and the resident's daughter indicated the resident had significant difficulty hearing and had never used a hearing aid, yet the quarterly MDS coded hearing as adequate. The LPN Assessment Coordinator confirmed the resident's hearing was impaired during the review period and that the MDS should have been coded as moderately impaired. For a third resident, physician orders and the MAR showed daily Furosemide administration during the assessment period, but the admission MDS coded that no diuretic medication had been received. The DON confirmed that this MDS was coded inaccurately.
Failure to Develop Individualized Care Plan for Bowel Incontinence
Penalty
Summary
The facility failed to develop comprehensive care plans with specific, individualized interventions to address the care needs of Resident 3. The facility’s policy required a person-centered care plan with measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs, and to include services identified in the comprehensive assessment. Resident 3’s annual MDS assessment showed the resident was cognitively intact, independent for most daily care needs, and frequently incontinent of bowel. Review of the bowel record from March 3, 2026, through April 1, 2026, showed the resident was incontinent of bowel five times, but there was no documented evidence that a care plan was developed to address this specific need. The DON confirmed in interview that an individualized care plan and interventions had not been developed related to the resident’s bowel incontinence and should have been.
Failure to Update Care Plans for Changed Resident Needs
Penalty
Summary
The facility failed to revise and update care plans for two residents whose care needs had changed. Review of policies, clinical records, observations, and staff interviews showed that the care plan for Resident 28 was not updated to reflect that he used a leg bag during the day and a large drainage bag at night for his indwelling urinary catheter. Resident 28’s quarterly MDS dated January 24, 2026, showed moderate cognitive impairment, need for assistance with daily care, diagnoses including benign prostatic hyperplasia, and an indwelling urinary catheter. Physician’s orders dated January 21, 2026, included a 16 French Foley catheter, and observations on multiple dates in late March and early April 2026 showed the resident wearing a leg bag. The resident’s daughter stated that staff applied the leg bag in the morning and removed it at bedtime, and the DON confirmed the care plan should have been updated to reflect this routine but was not. The facility also failed to revise Resident 76’s care plan after lymphedema pump therapy was discontinued. Resident 76’s quarterly MDS dated January 11, 2026, showed that she was cognitively intact, required assistance with daily care, and had multiple sclerosis. Her care plan dated February 28, 2023, included a potential for impaired skin integrity with an intervention for lymphedema pumps to be applied to both lower extremities, but physician’s orders showed the lymphedema pump order was discontinued on August 23, 2025, and there was no documented evidence in the treatment administration record that she was currently using the pumps. The DON confirmed that the care plan was not revised when the pumps were discontinued and that it should have been.
Failure to Provide Bowel Management and Follow Catheter Orders
Penalty
Summary
The facility failed to ensure that a resident with bowel incontinence received appropriate treatment and services to restore as much normal bowel function as possible. Resident 3 was cognitively intact and had diagnoses including schizoaffective disorder, bipolar type. A quarterly MDS dated September 12, 2025, showed the resident was always continent of bowel and needed supervision or touch assist for toileting hygiene. A later quarterly MDS dated December 13, 2025, showed the resident was occasionally incontinent of bowel and required partial to moderate assistance with toileting hygiene. An annual MDS dated March 13, 2026, showed the resident was frequently incontinent of bowel and independent for most daily care needs. The facility policy dated January 1, 2026, required individualized bowel assessments and restorative interventions, but there was no documented evidence that bowel assessments were completed quarterly to identify interventions to promote continence and maintain dignity. The facility also failed to follow physician's orders for Resident 4's indwelling urinary catheter. Resident 4 was cognitively intact, required staff assistance for daily care needs, had an indwelling urinary catheter, and had diagnoses including neurogenic bladder. A physician's order dated June 15, 2025, directed staff to change the resident's suprapubic catheter every 21 days and as needed for blockage or displacement. Review of the treatment administration record and nurses' notes from October 2025 through March 2026 showed no documented evidence that the suprapubic catheter was changed during a 42-day period between October 18, 2025, and November 29, 2025, and no documented evidence it was changed during a 48-day period between February 8, 2026, and March 28, 2026. The DON confirmed there was no documented evidence that the catheter was changed as ordered on those dates.
QAPI Committee Failed to Correct Recurring Deficiencies
Penalty
Summary
The facility's QAPI committee failed to correct repeated quality deficiencies identified in prior and current surveys. Based on review of the facility's plans of correction for the survey ending March 20, 2025, and the current survey ending April 2, 2026, the same areas remained deficient, including care plan creation, care plan revision, quality care, pharmaceutical services, food served in a form to meet an individual's needs, and infection control. The report states that the facility had developed plans of correction that included quality assurance systems and audits to be reported to the QAPI committee, but those measures did not successfully address the recurring deficiencies. For the prior survey deficiencies, the facility's plans of correction for care plan creation, care plan revision, quality care, pharmaceutical services, food served in a form to meet an individual's needs, and infection control all included audits and reporting to the QAPI committee for review. The current survey found that the QAPI committee failed to successfully implement those plans to ensure care plans were created and revised timely, quality care was provided, pharmaceutical services were appropriately maintained, food was served to meet individuals' needs, and infection control was properly maintained. The cited regulations included F656, F657, F684, F755, F805, and F880, along with 28 Pa. Code 201.14(a) and 201.18(e)(1).
Improper Hand Contact With Medications During Administration
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during medication administration for one resident. The facility policy dated January 1, 2026 stated that staff were to remove medication from the source without touching it with bare hands. During observation of medication administration on April 1, 2026, Registered Nurse 2 prepared medications for Resident 67 and removed pills from the medicine cup with her bare hands, placed them in a bag to be crushed, and then administered the medications to the resident. The nurse confirmed she should not have touched the medication with her bare hands, and the Director of Nursing confirmed that staff were not to touch residents' medications with their bare hands.
Failure to Follow Transfer Protocols Results in Resident Fall and Hip Fracture
Penalty
Summary
The facility failed to ensure that a resident was protected from neglect, resulting in a fall with a fractured hip. The resident, who was cognitively intact and required substantial to maximum assistance for transfers due to chronic obstructive pulmonary disease and other diagnoses, had a care plan and physician's orders specifying that two staff members were required for all transfers using a wheeled walker. Despite these orders and care plan interventions, a nurse aide assisted the resident alone during a transfer after showering, without a second staff member present. During this process, the nurse aide slipped on water on the floor, causing both herself and the resident to fall. The resident sustained a visibly shortened and externally rotated right leg, and was subsequently diagnosed with a hip fracture requiring surgery. Documentation revealed that the nurse aide was unaware of the change in the resident's transfer status to a two-person assist, despite having received prior education on abuse and neglect. The nurse aide's failure to follow the care plan and physician's orders directly led to the resident's fall and injury. The incident was confirmed through review of clinical records, staff interviews, and investigative documents.
Failure to Follow Transfer Protocols Results in Resident Fall and Hip Fracture
Penalty
Summary
The facility failed to provide an environment free from accident hazards for a resident at risk for falls, resulting in a fall with a hip fracture. The resident, who was cognitively intact but required substantial to maximum assistance for transfers and used a walker, had a care plan and physician's orders specifying that two staff members were required for all transfers. Despite these orders, a nurse aide assisted the resident alone during a transfer after a shower. During this process, the nurse aide slipped on water on the floor, causing both herself and the resident to fall. The resident sustained a hip fracture that required surgical intervention. Documentation revealed that the nurse aide was unaware of the updated transfer status requiring two-person assistance. The incident occurred when the resident was standing at the bars and the aide attempted to assist her alone, contrary to the care plan and physician's orders. The event was confirmed through staff interviews and review of clinical records, which indicated that the required level of supervision and adherence to fall prevention protocols were not maintained at the time of the incident.
Failure to Provide Prescribed Diet Texture Results in Resident Choking and Hospitalization
Penalty
Summary
The facility failed to provide food in the proper consistency as ordered by the physician for a resident with a history of stroke and swallowing difficulties. The resident was prescribed a mechanically altered diet, later changed to a pureed texture, but was served food items inconsistent with these orders on multiple occasions. On one occasion, the resident was served a piece of chicken that was not ground as required, leading to a choking incident that resulted in hypoxia, aspiration, and hospital admission. Documentation shows that the nurse aide delivered the meal tray without verifying the correct diet texture, and the resident's husband had to cut the chicken into small pieces before the resident began choking. Subsequently, the resident experienced another choking episode after being served Brussel sprouts, which are not permitted on a mechanical soft diet due to their tough texture. Despite recent staff education on appropriate diet modifications, the dietary manager confirmed that Brussel sprouts were served to the resident, contrary to guidelines. The resident reported that these incidents were frightening and that she avoids certain foods due to a history of choking. These events demonstrate a failure by both dietary and nursing staff to ensure that prescribed diet textures were consistently provided, resulting in significant adverse outcomes for the resident.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders for medication administration for three residents. Resident 1, who was cognitively intact and diagnosed with diabetes, was ordered to receive 16 units of Humalog insulin only if she consumed more than 50% of her meal. However, records show that the insulin was administered on multiple occasions despite her meal intake being below the required threshold. This was confirmed by the Director of Nursing during an interview. Resident 21, who was cognitively impaired and had hypertension, was ordered to have her blood pressure and heart rate checked before administering Metoprolol Succinate. The facility did not document these vital signs before medication administration from the time the order was given. Similarly, Resident 75, who had heart failure and diabetes, was given Metoprolol Succinate despite having blood pressure readings below the threshold specified in the physician's order. The Director of Nursing confirmed that the medication should have been withheld on these occasions.
Failure to Flush Catheters Before and After IV Medication Administration
Penalty
Summary
The facility failed to adhere to its policy on intravenous therapy, which requires flushing a peripherally-inserted central catheter (PICC) or midline catheter with saline solution before and after medication administration. This deficiency was identified for two residents. Resident 1, who was cognitively intact and required substantial assistance with care needs, had a PICC/midline catheter for intravenous administration of Vancomycin. Despite physician orders for the medication, there was no documented evidence that the catheter was flushed with saline solution as required by the facility's policy. Similarly, Resident 283, who was cognitively intact and independent with daily care needs, had a PICC/midline catheter for the administration of Cefepime due to a diagnosis of sepsis. The facility's records showed no evidence of catheter flushing with saline solution before and after medication administration, as per the physician's orders. Interviews with the Director of Nursing confirmed the lack of documentation for both residents, indicating a failure to follow the established protocol for safe intravenous therapy.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to its medication labeling and storage policies, resulting in several deficiencies. An opened Humalog insulin Kwik pen for a resident was not discarded after the recommended 28 days, as it was labeled as opened on February 3, 2025. Additionally, a Novolin 70/30 insulin Kwik pen for another resident was opened but not dated, contrary to the facility's policy that requires dating upon opening. These actions were confirmed by an LPN during an observation of the medication cart on the North Hall. Furthermore, the facility did not provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs. During an observation, an unlocked box containing two unopened stock bottles of Ativan was found in the North Hall medication room refrigerator. The LPN confirmed the box was broken and could not be locked. The Director of Nursing acknowledged these issues, confirming the Humalog pen should have been discarded, the Novolin pen should have been dated, and the Ativan box should have been locked.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination regarding diet consistency. Resident 8, who is cognitively intact and has a diagnosis of Multiple Sclerosis, expressed dissatisfaction with her prescribed mechanical soft, ground meat texture diet. Despite her ability to eat regular food without issues, the facility continued to provide the mechanical diet based on a physician's order from December 2023. The resident's concerns were noted in a speech therapy note from August 2024, which indicated that the resident had been unhappy with her diet textures for the past 10 months. Although the speech therapist expressed safety concerns about changing the diet, they acknowledged that the resident's quality of life could be improved by allowing her to choose her diet. The Medical Director required a waiver form or a modified barium swallow (MBS) study before considering a diet change. The MBS, initially scheduled for October 2024, was rescheduled to December 2024, and the results suggested that a soft diet with thin liquids might be appropriate. However, there was no documented evidence that the resident was offered the option to sign a waiver. Interviews with the Therapy Director and the Director of Nursing revealed that the facility's new ownership did not use waivers, and the Medical Director was reluctant to change the diet order. Despite the Director of Nursing's belief that the resident should have the diet she wanted, the facility did not take action to honor the resident's choice, resulting in a failure to support resident self-determination.
Failure to Implement Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident 12, who was cognitively intact and required assistance with care needs, had a history of thrombosis and embolism and was on an anticoagulant medication. However, there was no documented care plan to address these conditions and the need for anticoagulant therapy. The Director of Nursing confirmed the absence of such a care plan. Resident 21, who was cognitively impaired and had a history of falls, did not have a perimeter mattress on her bed as required by her fall care plan. This was confirmed by observations and an interview with the Director of Nursing. Additionally, Resident 75, who was cognitively intact and had an indwelling foley catheter, lacked a care plan addressing the catheter care and the use of smokeless tobacco, despite having smokeless tobacco on his bedside table. The Director of Nursing confirmed the absence of a care plan for these needs.
Failure to Update Care Plan for Resident with Colostomy
Penalty
Summary
The facility failed to update the care plan of a resident, identified as Resident 46, to reflect specific care needs following an incident. The resident, who was moderately cognitively impaired and required staff assistance, had a colostomy and a history of placing silverware into her vagina and rectum. A quarterly Minimum Data Set (MDS) assessment indicated these needs, and physician's orders required a colostomy bag and wafer every shift. However, after an incident on February 8, 2025, where the resident was found digging at her stoma with silverware, resulting in an open area with bright red, bloody drainage, the care plan was not updated to include interventions to prevent such behavior. The deficiency was confirmed during an interview with the Director of Nursing on March 20, 2025, who acknowledged that the care plan had not been revised following the incident. The facility's policy, dated January 13, 2025, required that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, which was not adhered to in this case.
Medication Administration Errors and Physician Order Clarification Failures
Penalty
Summary
The facility failed to clarify physician's orders for a resident who was cognitively impaired and required assistance for personal care needs. This resident had a gastrostomy and was ordered to be NPO, yet the medications were incorrectly transcribed to be administered orally instead of through the feeding tube. The Director of Nursing confirmed the transcription error, which did not align with the professional standards of medication administration. Additionally, a registered nurse administered the wrong medications to another resident who was cognitively intact and required assistance for daily care needs. The nurse entered the wrong room and gave the resident a series of medications intended for another individual. This error was identified when the resident reported feeling lightheaded, and the blood pressure was found to be low. The resident was subsequently transferred to the emergency room for evaluation. The Director of Nursing confirmed that the nurse did not follow the facility's medication administration policy.
Failure to Follow Physician's Orders for Gastrostomy Tube Care
Penalty
Summary
The facility failed to provide gastrostomy tube care as ordered by the physician for a resident with significant cognitive impairment and anoxic brain injury. The resident was dependent on staff for daily care and had a physician's order for the gastrostomy tube to be flushed every four hours with 130 mL of free water. However, the clinical records for February and March 2025 revealed multiple instances where the tube was either not flushed at all or flushed with incorrect amounts of water. Specific discrepancies included instances where the tube was flushed with only 60 mL or 180 mL of water instead of the prescribed 130 mL, and occasions where the tube was not flushed at all. These deviations from the physician's orders were confirmed by the Director of Nursing during an interview, indicating a failure to adhere to the prescribed care plan for the resident's gastrostomy tube management.
Failure to Clarify Continuous Oxygen Order
Penalty
Summary
The facility failed to clarify a resident's continuous oxygen order when it was not in use, which was identified during a review of facility policies, clinical records, observations, and staff interviews. The facility's policy on oxygen therapy required that oxygen be administered to residents in need, consistent with professional standards, care plans, and resident preferences, with documentation of assessments and responses to therapy. Resident 1, who was cognitively intact and had a diagnosis of congestive heart failure, had a physician's order for continuous oxygen at a flow rate of 0-4 liters per minute to maintain blood oxygen levels above 89 percent. Observations on March 17 and 18, 2025, revealed that Resident 1's oxygen concentrator was turned off, and she was not receiving oxygen, despite the continuous order. A nursing note indicated that the resident's respirations were even and unlabored while on supplemental oxygen, but the medication administration record showed documentation of oxygen administration at different flow rates on March 17, 2025. An interview with the Director of Nursing confirmed that the continuous oxygen order was not being followed and should have been clarified.
Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident. The facility's policy required staff to sign the Medication Administration Record (MAR) after administering medications. An admission Minimum Data Set (MDS) assessment for the resident revealed moderate cognitive impairment and frequent pain, for which the resident received pain medication as needed, including an opioid. Physician's orders included 50 mg of Tramadol every six hours as needed for moderate pain. However, the controlled drug accountability record showed that Tramadol was signed out on several occasions, but there was no documented evidence in the MAR that the medication was administered to the resident. The Director of Nursing confirmed the lack of documentation for the administration of Tramadol to the resident.
Failure to Ensure Timely Physician Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely physician responses to pharmacy recommendations for four residents. The facility's policy required a monthly comprehensive medication regimen review by a consultant pharmacist, with recommendations to be acted upon by the prescriber. However, for Resident 2, who was cognitively impaired and on antidepressant and antipsychotic medications, there was no documented evidence that the physician responded to a recommendation to evaluate the necessity of the current medication dosage. Similarly, for Resident 23, who had congestive heart failure, the physician did not respond to a recommendation to discontinue a medication due to nonuse. Additionally, Resident 66, who was cognitively impaired and diagnosed with cancer, had a recommendation to discontinue a medication due to nonuse, which also lacked a physician's response. Resident 68, with chronic obstructive pulmonary disease, had a recommendation to document the necessity of a medication or attempt a dosage reduction, but again, there was no documented physician response. Interviews with the Director of Nursing confirmed the absence of documented responses to these recommendations, indicating a failure in the facility's process for addressing pharmacy recommendations.
Failure to Obtain Ordered Laboratory Tests for a Resident
Penalty
Summary
The facility failed to obtain laboratory studies as ordered by the physician for a resident, identified as Resident 53. The facility's policy, dated January 13, 2025, mandates that laboratory services be provided or obtained when ordered by a physician or other qualified practitioners. Resident 53, who was cognitively intact and received dialysis services, had physician's orders for several laboratory tests to be conducted every three months, including a complete blood count with differential, complete metabolic panel, Hemoglobin A1C, lipid panel, and levetiracetam level. These orders were dated September 5, 2021. However, there was no documented evidence that the facility obtained the required laboratory tests for Resident 53 after August 2024. This deficiency was confirmed during an interview with the Director of Nursing on March 19, 2025, who acknowledged the lack of evidence for the ordered laboratory studies. The resident's medical history included seizures and kidney failure, and they were receiving an anticonvulsant medication, levetiracetam, as part of their treatment plan.
QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated issues identified in a survey ending March 20, 2025. These deficiencies included failures in developing comprehensive person-centered care plans, care plan timing and revision, and ensuring services met professional standards. Additionally, the facility did not follow physician's orders, manage tube feeding properly, or provide oxygen therapy as ordered. There were also issues with the accountability of controlled medications, labeling and storing drugs and biologicals, and maintaining proper infection control practices. The facility had previously developed plans of correction for these deficiencies, which included completing audits and reporting results to the QAPI committee. However, the current survey revealed that these plans were not effectively implemented, as the same deficiencies were cited again. The QAPI committee's ineffectiveness in correcting these practices indicates a failure to maintain compliance with nursing home regulations, as evidenced by the repeated citations under various F-tags.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to adhere to infection control guidelines from CMS and CDC, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Resident 6, who had an indwelling urinary catheter, was observed without any signage or notification of being on EBP, and no PPE was available in or around the resident's room. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed that Resident 6 should have been on EBP due to the presence of the catheter. Similarly, Resident 75, who also had an indwelling Foley catheter, was found without EBP signage or PPE in their room. Staff interviews confirmed the oversight. Additionally, Resident 283, with a midline catheter and a diagnosis of sepsis due to pseudomonas, was observed without EBP signage or PPE. The Director of Nursing confirmed that EBP should have been implemented for Resident 283 as well. These deficiencies indicate a failure to follow established infection control protocols for residents with indwelling medical devices.
Failure to Follow Physician's Orders for Bowel Management
Penalty
Summary
The facility failed to follow physician's orders regarding bowel management for a resident who was cognitively intact and occasionally incontinent of bowel. According to the physician's orders, the resident was to receive 30 mL of Milk of Magnesia (MOM) as needed for constipation if no bowel movement occurred by the third day, followed by a Bisacodyl suppository if MOM was ineffective, and then a Fleets enema if there was still no result. Clinical records showed that the resident went without a bowel movement for seven days on one occasion and eleven days on another, with staff only administering MOM and a Bisacodyl suppository late in each episode. Review of the Medication Administration Record (MAR) confirmed that the prescribed sequence and timing of interventions were not followed as ordered. The Nursing Home Administrator acknowledged that the physician's orders for bowel medications were not adhered to for this resident. This failure was identified through clinical record review and staff interviews.
Failure to Notify Physician and Dietitian of Significant Weight Loss and Decreased Fluid Intake
Penalty
Summary
The facility failed to ensure timely notification of the dietitian and physician regarding significant weight loss and decreased fluid intake for two residents, resulting in a delay in treatment. According to facility policy, any resident with a weight change of five percent or more should have their weight rechecked and, if confirmed, the dietitian and physician must be notified immediately. For one resident, a significant weight loss of 6.9 percent (10.5 pounds) in one month was confirmed, but there was no documented evidence that the physician was notified as required by the care plan. Another resident, who was at risk for fluid volume deficit due to diuretic use and had a history of swallowing difficulties, experienced a decline in daily fluid intake over several days, with intake consistently below the recommended amount. Despite laboratory results indicating worsening dehydration and electrolyte imbalances, there was no documentation that the physician was notified of the low fluid intake or that the care plan was updated with new interventions to address the issue. The resident also experienced a 9.6 percent weight loss over two months, but neither the physician nor the dietitian was notified until a supplement was ordered. Interviews with the Director of Nursing confirmed that the required notifications to the physician and dietitian regarding significant weight loss and decreased fluid intake were not made in a timely manner for both residents. This lack of timely communication resulted in delays in implementing appropriate interventions for the affected residents.
Non-compliance with Water Temperature Safety Policy
Penalty
Summary
Loyalhanna Care Center was found to be non-compliant with federal and state regulations regarding accident hazards and supervision. The facility failed to maintain a safe environment by not adhering to its policy on water temperature control. The policy, dated January 13, 2025, required water temperatures to be set at no more than 110 degrees Fahrenheit, with weekly checks and documentation of water temperatures in all hot water circuits. However, during a complaint survey, it was observed that water temperatures in several resident rooms exceeded this limit, with temperatures recorded at 125, 121.6, and 119.4 degrees Fahrenheit. Interviews with Maintenance Worker 1 revealed a lack of adherence to the policy, as he admitted to not completing water temperature logs in the past week and was unable to provide documentation of weekly checks. The Nursing Home Administrator confirmed the absence of documented evidence for these checks and acknowledged that the water temperatures should not have been as high as observed. This failure to monitor and document water temperatures as per policy resulted in the facility's non-compliance with the requirements to ensure a safe environment for residents.
Plan Of Correction
Plan of Correction: In preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. IDENTIFIED: Residents identified were not in any immediate harm. Residents have been checked for any skin issues; no skin issues identified. LIKE: No other residents have been identified to have any issues. SYSTEM CORRECTION AND EDUCATION: The Nursing Home Administrator has educated the maintenance staff on the weekly water temp checks to include a sample of resident rooms. Any issues will be reported and handled accordingly. They have also been educated on the Safe Water Temperatures Policy and F689. Water temperature audits will be done weekly x 2 weeks and then monthly x 2 months. Results of audits will be reviewed at the facility's Quality Assurance Performance Improvement (QAPI) meetings. Date of Compliance: 26 March 2025.
Environmental Deficiencies at Loyalhanna Care Center
Penalty
Summary
Loyalhanna Care Center was found to be non-compliant with the requirements for providing a safe, clean, comfortable, and homelike environment as per 42 CFR Part 483, Subpart B. Observations made during a complaint survey revealed several deficiencies in the facility's environment. The floors in the South hallways were noted to have scattered dirt, debris, and clumps of brown dust, along with black markings identified as floor glue. The carpeting in Corridor A had varying amounts of dust and debris, and the wallpaper was peeling, with tape attempting to hold it in place. Additionally, a brown, clumpy substance was observed on the wall above a kiosk. Transition strips in the doorways of rooms 114, 111, and 220 were missing pieces, and the shower in the North hall had a pink substance in the grout. Interviews with the Environmental Services Director and the Maintenance Director confirmed these observations. The Environmental Services Director acknowledged the presence of dirt and debris, the difficulty in removing floor glue, and the inappropriate presence of a pink substance in the shower, which is typically removed weekly with bleach. The Maintenance Director confirmed the broken transition strips, the persistent floor glue, and the peeling wallpaper, all contributing to the facility's unkempt appearance. These findings indicate a failure to maintain a clean and homelike environment for the residents, as required by federal and state regulations.
Plan Of Correction
In preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F584 All items identified during visit have been addressed. Environmental rounds are on-going weekly in order to identify any further issues to be addressed in a timely manner. Education provided by administrator to the maintenance director and environmental services director F584 with a focus on ensuring that residents have a clean and homelike environment. Environmental audits will be completed by administrator/designee weekly X2 weeks and then monthly x2 months. Results of audits will be reviewed at the facility's Quality Assurance Performance Improvement (QAPI) meetings.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to carry out activities of daily living independently, received the necessary services to maintain personal hygiene. Specifically, the facility did not provide showers or baths as scheduled for a resident who required assistance due to dementia. The resident was cognitively intact and had a care plan that included receiving showers every Sunday and Wednesday evening. However, there was no documented evidence that the resident was offered or refused a shower on multiple occasions between December 2024 and January 2025. This was confirmed by the Nursing Home Administrator during an interview, indicating a lapse in adhering to the resident's care plan and preferences.
Plan Of Correction
R2 was interviewed by a registered nurse (RN) and verbalized she does refuse showers. Educated on benefits vs. risks. Skin assessment complete and no concerns identified. Shower was provided once R2 agreed. Resident preferences for showers/bathing reviewed and tasks in point of care updated to reflect preferences for all current residents and is completed upon admission for new admissions with interdisciplinary team follow up in clinical meetings. Re-education on F677 with nursing staff on F677 with a focus on providing residents with showers/baths as scheduled and proper documentation for refusals. Audits to be completed by director of nursing/designee weekly x 2 weeks, then monthly x 2 months. Results of audits will be reviewed at the facility's Quality Assurance Performance Improvement (QAPI) meetings.
Failure to Promptly Resolve Resident Grievances
Penalty
Summary
The facility failed to make ongoing efforts to resolve grievances for the residents, as evidenced by the review of clinical records, Resident Council meeting minutes, and grievance records, along with staff interviews. The facility's grievance policy, dated October 28, 2024, stated that the facility would support each resident's right to voice grievances and make prompt efforts to resolve them. However, the Resident Council meeting minutes from September 11, October 16, and November 5, 2024, revealed that residents reported staff were slow in answering call bells, indicating a lack of prompt resolution to their grievances. Interviews with the Director of Nursing and the Clinical Coordinator on December 6, 2024, confirmed that there was no documented evidence of prompt efforts to resolve the residents' grievances following the Resident Council meetings on September 11 and October 16, 2024. The Clinical Coordinator further confirmed that there were no prompt efforts to resolve the residents' grievance regarding the response to call bells to their satisfaction until November 5, 2024, which should have been addressed sooner. The deficiency was cited as past non-compliance, indicating that the facility did not adhere to its grievance policy and failed to ensure that residents' grievances were promptly addressed and resolved. This lack of action in addressing the grievances related to the slow response to call bells contributed to the deficiency finding.
Failure to Serve Food at Appetizing Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing temperatures, as evidenced by observations during a lunch meal service. The facility's policy, dated October 28, 2024, mandates that all hot food items must be cooked, held, and served at a temperature of at least 135 degrees Fahrenheit, while cold food items must be stored and served at 41 degrees Fahrenheit or below. During the observation on December 6, 2024, a test tray from the second North unit cart was found to have food items not meeting these temperature requirements. Specifically, the iced tea was at 60 degrees Fahrenheit, the Mandarin oranges at 50 degrees Fahrenheit, the bratwurst on a bun at 134.6 degrees Fahrenheit, the green beans at 145.5 degrees Fahrenheit, and the steak fries at 55 degrees Fahrenheit. The steak fries were notably cold and not at a palatable or appetizing temperature, a fact confirmed by the Dietary Director during the observation.
Plan Of Correction
No residents reported that the steak fries were cold and not at a palatable or appetizing temperature. Test trays include different types of fried potato dishes to determine proper temperatures that are palatable. Education with dietary staff by the administrator on F804 with a focus on serving food at an appetizing/palatable temperature. Audits will be completed 3 X week by the Dietary Director/Designee X4 weeks then weekly X4 weeks. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time substantial compliance has been met.
Inadequate Water Temperature During Showers
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for three residents, as evidenced by issues with water temperature during showers. The facility's policy requires maintaining a comfortable and safe temperature range, but residents reported discomfort due to inadequate water temperature. Resident 1, who is cognitively intact and requires assistance with daily care, reported that the water temperature during her scheduled showers was not warm enough, making her uncomfortable. Similarly, Resident 2, also cognitively intact and needing assistance, experienced fluctuating water temperatures during her showers, which were not comfortable. Resident 3 expressed a desire for warmer water during her showers. Observations in the North side shower room confirmed that the water temperature did not exceed 80°F, which is below the facility's policy range of 100-110°F. Interviews with nurse aides revealed that they often had to offer bed baths due to the cooler water temperature, but residents preferred their scheduled showers. The Maintenance Director explained that the water temperature is regulated by a valve, but if the hot water is insufficient, the desired temperature range is not achieved. The Nursing Home Administrator acknowledged that the water temperature should be within the normal limits to ensure a comfortable environment for residents.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the rooms of 10 out of 14 residents reviewed. The facility's policy, dated April 10, 2024, required daily dust mopping and inspections by housekeepers to ensure cleanliness. However, observations on July 25, 2024, revealed significant dust and debris accumulation in multiple residents' rooms, including under beds and near doorways. Specific findings included empty plastic cracker wrappers, crumbs, dust, and paper debris in various rooms, indicating a lack of adherence to the cleaning policy. Interviews with staff, including the Director of Environmental Services, confirmed that the rooms were supposed to be cleaned daily and deep cleaned monthly. However, the Director acknowledged that the rooms needed cleaning and that staff should report when additional cleaning is necessary. The Director also mentioned that a deep clean was delayed due to other work responsibilities, such as laundry duties, further contributing to the deficiency in maintaining a clean environment.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that residents were provided with showers as scheduled, affecting two residents. Resident 2, who has dementia and requires assistance with showering, was scheduled to receive showers every Monday and Thursday during the morning shift. However, records from June 26, 2024, to July 25, 2024, show that the resident only received three showers in that 30-day period, with no documentation of showers being offered and refused. This indicates a failure to adhere to the resident's care plan, which specified a preference for morning showers. Similarly, Resident 5, who has an artificial left shoulder and requires assistance due to fatigue and limited range of motion, was scheduled to receive showers every Tuesday and Friday during the p.m. shift. The records for June and July 2024 show no documented evidence of showers being provided or offered and refused on several scheduled days, including June 28, July 5, 9, 12, 19, and 23. An interview with the Director of Nursing confirmed the lack of documentation explaining why the showers were not provided as scheduled for both residents.
Neglect and Medication Administration Failures
Penalty
Summary
The facility failed to protect residents from neglect, as evidenced by the case of Resident 1, who was severely cognitively impaired and required extensive assistance with all care needs. On May 19, 2024, Resident 1's daughter observed that her mother had not received care since the previous evening, as indicated by a six-inch indentation from the urinary catheter tubing, red and mushy heels, and a bruise on her arm. Despite the daughter's complaints and the observations made by the Director of Nursing, the facility's investigation concluded that there was no neglect, citing that night shift staff chart care once per shift and may provide care later without additional charting. Additionally, the facility failed to administer medications as ordered by the physician for Residents 2, 3, and 4. On May 11, 2024, Resident 2 reported not receiving her nighttime medications, which was confirmed by the discovery of empty medication packets and whole pills in the garbage. Similarly, Residents 3 and 4 also reported not receiving their medications, and further investigation revealed that their medication packets were found in the trash, with some medications still intact. Despite the MAR indicating that the medications were administered, the Nursing Home Administrator confirmed that the residents did not receive their medications as ordered. The facility's failure to ensure proper care and medication administration resulted in neglect for the residents involved. The investigation into these incidents revealed discrepancies in care documentation and medication administration, highlighting a lack of adherence to the facility's abuse policy, which mandates that residents be free from neglect. The facility's management and nursing services were found to be deficient in ensuring the residents' rights and well-being, as outlined in the relevant state codes.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a registered nurse administered medications as ordered by the physician for three residents. This deficiency was identified through a review of Pennsylvania's Nursing Practice Act, job descriptions, clinical records, and staff interviews. The registered nurse was responsible for supervising day-to-day nursing activities, including monitoring medication passes and treatment schedules to ensure medications were administered as ordered. However, it was found that medications were not administered to Residents 2, 3, and 4 as per the physician's orders. Resident 2, who had multiple diagnoses including hypertension, end-stage renal disease, and diabetes, reported not receiving her nighttime medications. The medications included Melatonin, Rosuvastatin, Trazodone, Ronpinirole, Cranberry, and Mirtazapine, which were signed off as administered by Registered Nurse 4. However, upon investigation, it was discovered that the medication packets were empty, and some medications were found discarded in the garbage. Similarly, Resident 3, with a history of coronary artery disease and atrial fibrillation, did not receive her Metoprolol, as evidenced by the packet found in the trash, despite it being signed off as administered. Resident 4, diagnosed with cancer, atrial fibrillation, and schizophrenia, also reported not receiving her nighttime medications, which included Atorvastatin, Divalproex, Apixaban, and Metoprolol. The investigation revealed that the medications were not administered as ordered, and there was no documentation of refusal or inability to take the medications. The Nursing Home Administrator confirmed that the medications were not administered as ordered, and Registered Nurse 4 had incorrectly signed them off as given.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the physician for three residents. On May 11, 2024, a Licensed Practical Nurse overheard a resident expressing concerns about not receiving her nighttime medications. Upon investigation, it was discovered that the medication packs for the evening administration were missing, and the computer system falsely indicated that the medications had been administered. Further investigation revealed that other residents also reported not receiving their medications. The investigation uncovered that empty medication packets and random pills were found in various garbage bins, including a medication cup with crushed medications labeled for a specific room. The Medication Administration Records (MAR) falsely indicated that the medications had been administered, despite evidence to the contrary. Interviews with the residents confirmed that they did not receive their medications as scheduled. The residents involved had significant medical histories, including conditions such as hypertension, diabetes, coronary artery disease, and schizophrenia. The failure to administer medications as ordered could have serious implications for their health. The Nursing Home Administrator confirmed that the medications were not administered as required, and the responsible nurse had inaccurately documented the administration of these medications.
Medication Administration and Documentation Failure
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for three residents. On May 11, 2024, a Licensed Practical Nurse (LPN) overheard a resident expressing concerns about not receiving her nighttime medications. Upon investigation, it was discovered that the medication packs for the evening administration were missing, and the computer system falsely indicated that the medications had been administered. Further investigation revealed that other residents also reported not receiving their medications. The investigation uncovered that empty medication packets and random pills were found in various garbage bins, including a medication cup with crushed medications labeled for a specific room. This indicated that the medications were not administered as recorded. The Medication Administration Record (MAR) falsely showed that the medications were given, despite evidence to the contrary. Interviews with the residents confirmed that they did not receive their medications as prescribed. The residents involved had significant medical conditions, including hypertension, diabetes, and coronary artery disease, which required consistent medication management. The failure to administer medications as ordered and the inaccurate documentation of medication administration were confirmed by the Nursing Home Administrator. This deficiency violated the accepted professional standards for maintaining accurate clinical records and safeguarding resident-identifiable information.
Failure to Develop Comprehensive Care Plan for Pain Management
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that included specific and individualized interventions to address the specialized care needs of a resident. The resident, who was cognitively intact and dependent on staff for care needs, was administered opioid medication and had a physician's order for an x-ray due to increased knee pain, which revealed moderate to severe tricompartmental osteoporosis. Despite these findings and a physician's order for Tramadol to manage the resident's pain, the facility did not create a care plan to address the resident's pain management needs. This deficiency was confirmed during an interview with the Registered Nurse Assessment Coordinator.
Failure to Update Care Plan for Resolved UTI
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated to reflect the resolution of a urinary tract infection (UTI) and the completion of antibiotic therapy. The facility's policy requires care plans to be reviewed and revised as necessary when residents experience a status change. However, for one resident, the care plan was not updated even after the UTI was resolved and the antibiotic course was completed. The resident was initially prescribed Keflex for a UTI, which was later changed to Cipro based on culture results. The course of Cipro was completed, but the care plan still indicated ongoing antibiotic therapy for the UTI. An interview with the Registered Nurse Assessment Coordinator confirmed that the care plan should have been updated to reflect the resolution of the UTI and the completion of the antibiotic therapy. This oversight was identified during a review of the resident's clinical records and facility policy, as well as staff interviews. The deficiency was noted for failing to update the care plan in accordance with the facility's policy and regulatory requirements.
Failure to Clarify Physician's Order for Hemodialysis Patient
Penalty
Summary
The facility failed to clarify a physician's order for a resident receiving hemodialysis. The resident, who was cognitively intact and required assistance with daily care, had a diagnosis of End-Stage Renal Disease, kidney transplant failure, and cardiomyopathy. The physician's orders initially scheduled the resident to receive Bumetanide on non-dialysis days, but when the dialysis schedule changed, the Bumetanide order was not updated accordingly. This oversight was confirmed by the Director of Nursing during an interview. The facility's policy for hemodialysis, as well as the Pennsylvania Nursing Practice Act, requires that care and services be consistent with professional standards. However, the failure to update the Bumetanide order when the dialysis schedule changed indicates a lapse in following these standards. This deficiency was identified through a review of facility policies, clinical records, and staff interviews, highlighting the need for better communication and adherence to professional standards in managing physician orders for residents undergoing hemodialysis.
Failure to Follow Physician's Orders for Catheter Care
Penalty
Summary
The facility failed to provide suprapubic urinary catheter care as ordered by the physician for a resident. The resident, who was cognitively intact and required extensive assistance with daily care needs, had an indwelling suprapubic catheter and received hospice services. Physician's orders specified a 16 French catheter with a 30 ml balloon, and the care plan was revised to reflect this. However, nursing notes indicated that the catheter was changed using the correct size on specific dates, but an observation revealed that the resident had an 18 French catheter in place instead of the ordered 16 French catheter. The resident confirmed this and showed the surveyor and LPN the box of 18 French catheters on her dresser. Interviews with the LPN and the Nursing Home Administrator confirmed that the catheter size should match the physician's order and care plan. The discrepancy was noted during an observation, and it was confirmed that the resident had an 18 French catheter instead of the ordered 16 French catheter. This failure to follow the physician's orders and care plan constitutes a deficiency in the facility's provision of care.
Failure to Provide Ordered Gastrostomy Tube Care
Penalty
Summary
The facility failed to ensure that gastrostomy tube care was provided as ordered by the physician for one resident. The facility's policy required gastrostomy flushes to be provided as ordered, but a review of the clinical record for a cognitively impaired resident with an anoxic brain injury revealed that the gastrostomy tube was not flushed as ordered on multiple occasions. Specifically, there was no documented evidence of the required flushes on February 18, March 8, and April 5, 2024. The Director of Nursing confirmed the lack of documentation for these dates and times.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide oxygen therapy as ordered for Resident 51. The resident, who was cognitively intact and had diagnoses including cardiomyopathy and non-ST-elevation myocardial infarction, was supposed to receive supplemental oxygen at a flow rate of 2-6 liters via nasal cannula continuously every shift to maintain a pulse oximetry reading greater than 89 percent. However, the Treatment Administration Record for April 2024 revealed multiple instances where the resident did not have his supplemental oxygen on as ordered, including on April 1, 2, 3, 6, and 9 for various shifts. Observations on April 8 and 9 confirmed that the resident was in bed without the supplemental oxygen in place. Interviews with the resident, a Registered Nurse Supervisor, and the Director of Nursing confirmed that the resident did not use the supplemental oxygen continuously as ordered and that the oxygen should have been applied as per the physician's orders. The facility's policy for oxygen administration was not followed, leading to this deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 455 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Latrobe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kadima Rehabilitation & Nursing At Latrobe | 3.4 mi | ★★★★★ | 29 | 0 |
| Twin Lakes Rehabilitation And Healthcare Center | 4.2 mi | ★★★★★ | 29 | 1 |
| Greene Health & Rehab Center | 5.2 mi | ★★★★★ | 44 | 0 |
| Oak Hill Rehabilitation & Healthcare Center | 5.4 mi | ★★★★★ | 1 | 0 |
| Saint Anne Home | 7.3 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Loyalhanna Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.