Pennsylvania Department of Health
LOYALHANNA CARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LOYALHANNA CARE CENTER
Inspection Results For:

There are 217 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


LOYALHANNA CARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated complaint survey completed on August 26, 2026, it was determined that Loyalhanna Care Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food under sanitary conditions.

Findings include:

The facility's policy for food safety requirements dated January 1, 2026, revealed that food will be stored, prepared, distributed and served in accordance with professional standards for food service safety, which included keeping foods covered or in tight containers.

Observations in the kitchen on August 26, 2026, at 9:54 a.m. revealed that the scoop for the powdered sugar was in the plastic powder sugar container, and the lid to the Thick-it (a powdery additive used to thicken liquids for residents with swallowing difficulties) storage container was not secured to the container.

Interview with the Dietary Manager on August 26, 2026, at that time, confirmed that the scoop should not have been stored in the plastic powder sugar container, and the lid to the Thick-it container should have been firmly secured.

Interview with the Nursing Home Administrator on August 26, 2026, at 14:50 p.m. confirmed that the powder sugar and Thick-it were not properly stored in the kitchen, and they should have been.

28 Pa. Code 211.6(f) Dietary Services.

Plan of Correction - To be completed: 09/15/2026

F812 - Food Procurement/Store/Prepare/Serve - Sanitary
Regulation: 42 CFR §483.60(i)(1)-(2) | Scope/Severity: E
Survey basis: The survey found a scoop stored inside the powdered-sugar container and a Thick-It storage-container lid that was not firmly secured. The Dietary Manager and Administrator confirmed the storage practices were not appropriate.
1. Corrective action
On 26 August 2026, the scoop was removed from the powdered-sugar container and cleaned/sanitized before reuse, the powdered-sugar container was properly closed, and the Thick-It container lid was secured. The Dietary Manager/designee inspected the remaining food-storage areas and containers for similar concerns. No other concerns identified
2. Identification of others who could be affected
All residents receiving food or beverages prepared or stored by the facility have the potential to be affected by improper food-storage practices. The Dietary Manager/designee will complete an inspection of kitchen food-storage areas, including dry storage, refrigeration/freezer storage, and food-preparation areas, to verify that storage conditions protect food from contamination, dry-storage areas are clean and dry, containers are appropriately closed/secured as applicable, and food-contact utensils/equipment are maintained in a sanitary condition. Identified concerns will be corrected immediately.
3. Systemic changes to prevent recurrence
Dietary staff will be re-educated on the facility Food Safety Requirements policy including prevention of contamination throughout the food-handling process, safe dry-food storage, protection/closure of food containers as applicable, and cleaning/sanitizing food-contact equipment.
The Dietary Manager/designee will add container closure and scoop storage to routine kitchen sanitation inspections.
4. Monitoring
The Dietary Manager/designee will conduct documented food storage and sanitation audits weekly for two weeks and then monthly for two months.
Audits will include dry-storage conditions and container lids/covers. Identified concerns will be corrected immediately. Results will be reviewed by the Administrator/designee and reported to QAPI for further action as indicated.
Date Certain: 09/15/2026

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to accurately transcribe physician's orders for one of 15 residents reviewed (Resident 2).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 29, 2026, indicated that the resident was cognitively intact, required assistance with care needs, received antipsychotic and antianxiety medications( psychotropic medications used to treat mental health disorders by altering brain chemistry), and had diagnoses that included depression, anxiety and bipolar disorder (a mental health condition causing mood swings including emotional highs and lows).

Physician's orders for Resident 2, dated April 29, 2026, included an order for the resident to receive 20 milligrams (mg) of Olanzapine (Zyprexa) (an antipsychotic medication) daily at bedtime for bipolar disorder.

A physician's note for Resident 2, dated August 11, 2026, at 5:17 p.m. included orders for a gradual dose reduction (GDR-the systematic, stepwise lowering of a medication dose over time) of the resident's Zyprexa and to decrease the medication to 15 mg nightly.

A nursing note for Resident 2, dated August 12, 2026, at 12:38 a.m. revealed that the resident was seen by the physician and new orders were obtained to decrease the resident's Zyprexa to 15 mg at bedtime.

Review of Resident 2's Medication Administration Record (MAR), dated August 2026, revealed that as of August 12, 2026, the resident's Zyprexa was discontinued.

Interview with the Director of Nursing on August 25, 2026, at 4:53 p.m. confirmed that Resident 2's Zyprexa was discontinued and not decreased as ordered on August 11, 2026.

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

Plan of Correction - To be completed: 09/15/2026

Facility Reservation Statement
Submission of this Plan of Correction is intended to demonstrate the facility's good-faith corrective response and allegation of compliance. It is not intended as an admission that every factual or legal conclusion in the Statement of Deficiencies is correct. The facility reserves all rights available under applicable law and regulation.

F658 – Services Provided Meet Professional Standards
The facility failed to ensure physician orders were transcribed accurately and verified through the redlining process, resulting in a medication order being discontinued in error rather than decreased in dose, in accordance with professional standards of quality under F658.
1. Corrective Action for Resident Affected by the Deficient Practice
The physician order was reviewed immediately upon identification of the transcription error. The resident was assessed for any adverse effects related to the missed/discontinued medication, and findings were documented in the clinical record. The attending physician and pharmacy were notified as applicable, and the medication was to remain discontinued as there were no adverse reactions noted. The responsible, licensed nurse was counseled and re-educated regarding accurate transcription of physician orders.
2. Identification of Other Residents With Potential to Be Affected
All residents with new, changed, or discontinued physician orders since the survey exit date have the potential to be affected by this deficient practice. The Director of Nursing/designee will review physician orders entered during this period to verify that orders were accurately transcribed and appropriately redlined. Any identified discrepancies will be corrected immediately, with physician and pharmacy notification as indicated, and resident assessment completed and documented.
3. Measures and Systemic Changes to Prevent Recurrence
Licensed nursing staff will receive education on the facility process for transcribing physician orders, including verification of medication dose changes, avoidance of unintended discontinuation of medications, and completion of the redlining process. Education will include review of the expectation that new, changed, and discontinued orders are compared against the physician's order and medication administration record to confirm accuracy prior to implementation.
4. Monitoring to Ensure Continued Compliance
The Director of Nursing/designee will audit physician orders for accuracy of transcription and completion of redlining weekly for two weeks, then monthly for two additional months. Audits will include a review of newly entered orders, medication dose changes, discontinued orders, and comparison to the medication administration record. Any discrepancies identified during audits will be corrected immediately, and involved staff will receive one-on-one re-education. Audit findings will be reported to the Quality Assurance and Performance Improvement Committee for review and recommendations until substantial compliance is sustained.
Date Certain: 09/15/2026

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident received proper care for an indwelling urinary catheter for one of 15 residents reviewed (Resident 7).

Findings include:

The facility's policy regarding urinary catheters (a tube inserted and held in the bladder to drain urine), dated January 1, 2026, indicated that the purpose of the policy was to ensure safe handling of the urinary catheter in order to reduce the risk of urinary tract infections, and ensure the drainage bag is located below the level of the bladder to discourage backflow of urine.

A Quarterly Minimum Data Set (MDS) assessment dated July 30, 2026, indicated that the resident was cognitively intact was understood and able to understand, had an indwelling urinary catheter and had diagnoses that included urinary retention (inability to fully empty the bladder) related to an enlarged prostate gland.

Observations on August 26, 2026, at 12:18 p.m. revealed that Resident 7 was in his room sitting in his wheelchair eating his lunch, his catheter drainage bag was attached to the chair by his waist, which made the catheter drainage bag above the level of his bladder.

Interview with Nurse Aide 1 on August 26, 2026, at 12:22 p.m. confirmed that Resident 7's catheter drainage bag should not have been attached to his chair at his waist level and that the tubing and bag should have been below the level of his bladder to prevent a backflow of urine.

Interview with the Nursing Home Administrator on August 26, 2026, at 2:22 p.m. confirmed that Resident 7's catheter drainage bag should have been below the level of his bladder, and it was not.

28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Plan of Correction - To be completed: 09/15/2026

F690 – Bowel/Bladder Incontinence, Catheter, and UTI
The facility failed to ensure appropriate catheter care and services were provided when an indwelling urinary catheter was observed not secured and positioned below the level of the bladder, creating the potential for catheter-related complications, including tissue injury, infection risk, or impaired urinary drainage.
1. Corrective Action for Resident Affected by the Deficient Practice
The identified resident was assessed immediately upon notification of the concern. The indwelling urinary catheter was repositioned and secured appropriately below the level of the bladder to promote unobstructed urinary drainage and reduce the risk of catheter-related complications. The resident was assessed, and findings were documented in the clinical record, and the physician was notified as indicated.
2. Identification of Other Residents With Potential to Be Affected
All residents with indwelling urinary catheters have the potential to be affected by this deficient practice. The Director of Nursing/designee will complete a review of all residents with indwelling catheters to ensure catheters are secured appropriately, and drainage bags are maintained below the level of the bladder and off the floor. Any concerns identified will be corrected immediately, and residents will be assessed as needed.
3. Measures and Systemic Changes to Prevent Recurrence
Licensed nursing staff and nursing assistants will receive education regarding indwelling urinary catheter care, including maintaining the drainage bag below the level of the bladder, securing catheter tubing to prevent pulling or traction, keeping the drainage bag off the floor, observing for unobstructed urine flow, and reporting concerns related to discomfort, decreased output, leakage, signs or symptoms of urinary tract infection, or catheter-related skin or tissue concerns. Education will include immediate correction and nurse notification when catheter tubing or drainage bag positioning is not maintained appropriately.
4. Monitoring to Ensure Continued Compliance
The Director of Nursing/designee will audit residents with indwelling urinary catheters weekly for two weeks, then monthly for two additional months, to ensure catheter tubing is secured appropriately, drainage bags are maintained below the level of the bladder and off the floor, and urine flow is unobstructed. Any identified concerns will be corrected immediately, and involved staff will receive one-on-one re-education. Audit findings will be reported to the Quality Assurance and Performance Improvement Committee for review and recommendations until substantial compliance is sustained.
Date Certain: 09/15/2026

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on review of nursing schedules, staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to provide one NA per 11 residents on the evening shift for 4 of 21 days, and failed to provide one NA per 15 residents on the night shift for 2 of 21 days reviewed for July 15 2026, through July 21, 2026, and for August 12, 2026, through August 25, 2026.

Findings include:

Review of facility census data revealed:

On August 17, 2026, the facility census was 84, during the evening shift, which required 7.64 NA's during the evening shift. Review of the nursing time schedules revealed 6.88 NA's provided care on the evening shift.

On August 18, 2026, the facility census was 84, during the evening shift, which required 7.64 NA's during the evening shift. Review of the nursing time schedules revealed 7.13 NA's provided care on the evening shift.

On August 19, 2026, the facility census was 84, during the evening shift, which required 7.64 NA's during the evening shift. Review of the nursing time schedules revealed 7.06 NA's provided care on the evening shift.

On August 21, 2026, the facility census was 84, during the evening shift, which required 7.64 NA's during the evening shift. Review of the nursing time schedules revealed 6.84 NA's provided care on the evening shift.

On July 16, 2026, the facility census was 90, during the night shift, which required 6.00 NA's during the night shift. Review of the nursing time schedules revealed 5.53 NA's provided care on the night shift.

On August 21, 2026, the facility census was 84, during the night shift, which required 5.60 NA's during the night shift. Review of the nursing time schedules revealed 4.89 NA's provided care on the night shift.

However, there were no additional excess higher-level staff available to compensate for these deficiencies.

Interview with the Nursing Home Administrator on August 26, 2026, at 6:10 p.m. confirmed that the facility did not meet the required NA-to-resident staffing ratios for the days listed above.

Plan of Correction - To be completed: 09/15/2026

5520 – Nurse Aide Staffing Ratios
The facility failed to ensure required nurse-aide staffing ratios were maintained and/or documented, creating the potential for resident care needs not to be met in a timely manner.
1. Corrective Action for Residents Affected by the Deficient Practice
Upon identification of the concern, staffing assignments and nurse aide coverage for the cited date(s) and shift(s) were reviewed by the Nursing Home Administrator and Director of Nursing/designee. Resident care needs were reviewed to determine whether any resident experienced unmet care needs related to nurse aide staffing. No unmeant needs were identified.
2. Identification of Other Residents With Potential to Be Affected
All residents residing in the facility have the potential to be affected by insufficient or undocumented nurse aide staffing ratios. The Nursing Home Administrator/designee will review nurse aide staffing schedules, assignment sheets, call-off records, agency staffing records, and payroll/timekeeping documentation for the cited period and current schedule to verify nurse aide coverage meets required ratios. Any identified staffing gaps will be addressed immediately through reassignment of available staff, use of additional staff, agency staff, or other approved staffing resources to ensure resident care needs are met.
3. Measures and Systemic Changes to Prevent Recurrence
The Nursing Home Administrator/designee will educate the Director of Nursing, scheduler, charge nurses, and other staff responsible for staffing oversight on required nurse aide staffing ratios, completion and retention of staffing documentation, timely review of call-offs, and the process for initiating contingency staffing when ratios are at risk of not being met. The facility staffing process will include daily review of projected census, scheduled nurse aide coverage, call-offs, and replacement coverage before and during each shift. Staffing documentation will be maintained to support compliance with required ratios.
4. Monitoring to Ensure Continued Compliance
The Scheduling Coordinator/designee will audit nurse aide staffing ratios and supporting documentation daily for two weeks, then weekly for two additional months, to verify required nurse aide ratios are met and documented. Audits will include review of daily census, staffing schedules, assignment sheets, call-off records, replacement coverage, and timekeeping documentation. Any identified concerns will be corrected immediately, and responsible staff will receive one-on-one re-education. Audit findings will be reported to the Quality Assurance and Performance Improvement Committee for review and recommendations until substantial compliance is sustained.
Date Certain: 09/15/2026

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