Loyalhanna Care Center

In the surveyor’s words

From the most serious findings on record at Loyalhanna Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Dec 28, 2021

  Based on review of established guidelines for cardiopulmonary resuscitation (CPR), the facility's policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Guidelines from the American Heart Association (AHA), dated 2020, revealed that the AHA urged all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place; if there were obvious clinical signs of irreversible death present, including rigor mortis (stiffness of the limbs and body that develops 2 to 4 hours after death and may take up to 12 hours to fully develop), dependent lividity (reddish-blue discoloration of the skin… […]

• Actual harm, isolatedF600Aug 20, 2025

  Based on review of policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of five residents reviewed (Residents 2), resulting in a fall with a fractured hip. This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding fall prevention, dated September 1, 2024, indicated that each resident will be assessed for their fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. […]

• Actual harm, isolatedF689Aug 20, 2025

  Based on review of facility policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls for one of five residents reviewed (Resident 2) resulting in a fall with a hip fracture. This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding fall prevention, dated September 1, 2024, indicated that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. […]

• Actual harm, isolatedF805Aug 20, 2025

  Based on review of facility policy, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with the proper food consistency as ordered by the physician for one of five residents reviewed (Resident 1), who choked, requiring a hospital admission for hypoxia and aspiration. Findings include: A facility policy for therapeutic diet orders dated January 13, 2025, indicated that dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. […]

• Actual harm, isolatedF689Jul 3, 2023

  Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that assistance devices to prevent accidents or injury were in place as care planned for one of three residents reviewed (Resident 2) who was at risk for falls, resulting in a fall with multiple fractures. Findings include: A significant Change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 5, 2023, revealed that the resident was cognitively impaired, required extensive assistance from staff for activities of daily care needs including transfers, and had diagnoses that included dementia and osteoporosis (a condition which causes the bones to become weak and… […]