Inspection·December 6, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on review of clinical records, Resident Council meeting minutes, and grievance records, as well as staff interviews, it was determined that the facility failed to make ongoing efforts to resolve grievances for the residents. The deficiency is being cited as past non-compliance. Findings include: The facility's policy regarding grievances, dated October 28, 2024, indicated that the facility would support each resident's right to voice grievances; to ensure that after receiving a complaint/grievance, the facility would take any immediate actions needed to prevent further potential violations of any resident rights; and would make prompt efforts to resolve grievances. The Grievance Official would take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form, and would keep the resident appropriately apprised of the progress towards resolution of the grievances. Resident Council meeting minutes, dated September 11, October 16, and November 5, 2024, revealed that the residents reported staff were slow with answering call bells. Interview with the Director of Nursing on December 6, 2024, at 11:11 a.m. confirmed that there was no documented evidence that prompt efforts were made to resolve the resident's grievances following the Resident Council meetings on September 11 and October 16, 2024. Interview with the Clinical Coordinator on December 6, 2024, at 12:13 a.m. 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, and should have been. Following the identification that resident grievances were not resolved, the facility's corrective actions included: Nursing staff were provided education regarding the policy and procedures for responding to and resolving grievances, and answering call bells in a timely manner. Audits were completed to ensure that prompt efforts were made to resolve grievances and call bells were answered in a timely manner. Grievances and concerns would be added to the clinical worksheet and stay there until completely resolved. The Social Service Director would update and review daily in stand up and stand down meetings. The findings would be reviewed with the quality assurance performance improvement committee. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 395860 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395860 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loyalhanna Care Center 535 McFarland Road Latrobe, PA 15650 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)