Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Lochearn Nursing Home, Llc during CMS and state inspections, most recent first.
A resident was observed in the Activities room being fed by a GNA who was standing beside the resident, even though a chair was available at the table. The GNA stated there was no feeder program and that the resident was only sometimes assisted with eating. During interview, the DON stated staff should always be seated while feeding a resident.
A resident’s MDS was inaccurate because it documented one insulin injection in the last 7 days or since admission, even though the MAR, current orders, and staff interviews showed the resident did not receive insulin and instead received Januvia for type 2 diabetes. The ADON and DON both confirmed the discrepancy, and there were no discontinued insulin orders in the resident’s record.
A resident’s care plan was not appropriately revised and continued to identify the resident as an elopement risk with wanderguard interventions, even though a wandering risk assessment showed low risk. During observation, the resident was not wearing a wanderguard, and the DON confirmed the care plan was incorrect and that the resident was not a wander risk.
Improper Refrigerator Temperature Control for Medications, Biologicals, and Resident Food. Two refrigerators in the 3rd floor med and resident food storage area were found with temperature issues during survey observation. One refrigerator held resident food items and was documented at 45 degrees, while another held medications and biologicals and was documented at 20 degrees C. Both refrigerators had posted temperature forms stating they should be kept between 38 and 42 degrees, and staff confirmed the findings.
A facility failed to follow infection control practices for oxygen equipment when two residents were found with oxygen tubing and humidifier equipment in use without dates or labels. Staff confirmed the equipment was not dated as required, and the DON stated that all tubing was expected to be labeled. One resident was receiving 2 L O2 via nasal cannula, and the other had oxygen equipment attached to a concentrator.
Missing Annual GNA Clinical Training Documentation: The facility failed to document and verify that 5 GNAs had the required 12 hours of annual clinical training/in-services in their HR and education records. The ADON stated that hands-on training was provided annually and that HealthStream online education was available, but completion was not mandated, staff were resistant to completing it, and no additional proof of compliance was provided for the GNAs reviewed.
Resident rooms in multiple areas did not meet the required square footage per resident. Surveyors found several rooms measuring 150 or 155 square feet, and the facility provided a CMS waiver letter for some of the rooms; however, the report also noted an incorrect room number in the prior approval letter. During resident observations and interviews, no residents voiced concern about room size.
Facility staff did not inform a resident's family after the resident sustained a fall with injury and was transferred to the hospital, despite the resident having given permission for such notifications. Leadership interviews confirmed that staff did not routinely notify families for residents considered responsible for themselves, even in cases of significant injury.
A resident with POTS who required daily IV fluids was discharged without home health services in place after the facility's referral to a home health agency was declined due to insurance issues, and the facility did not secure an alternative arrangement.
A resident with quadriplegia and a spinal cord injury was assessed as fully dependent for self-care activities during an MDS assessment, but the care plan continued to list these activities as independent. Observation and interviews confirmed the resident required staff assistance for all self-care, and the DON acknowledged the care plan was inaccurate and did not reflect the resident's needs.
Staff failed to thoroughly assess and manage pain for a resident who sustained a fracture after a fall. Although a physician was notified and Tylenol was ordered, there was no documentation in the MAR of pain medication being administered, nor were there follow-up pain assessments. The resident continued to report severe pain until transfer to the hospital, where effective pain relief was provided.
Staff failed to maintain accurate and complete medical records for a resident with diabetes, including missing documentation of insulin administration after a high blood sugar reading, lack of a nurse's note following a low blood sugar result, and omission of a blood sugar value on another occasion. These lapses were confirmed by the DON.
The facility failed to obtain consent and provide education to five residents before administering the influenza vaccine, and did not offer an additional pneumococcal vaccine to two eligible residents, as per CDC guidelines. This lack of documentation and adherence to facility policies resulted in deficiencies in the vaccination process.
The facility failed to document discharge summaries for two residents after their discharge. Medical record reviews revealed the absence of these summaries, which was confirmed by the DON upon reviewing the progress notes.
The facility failed to maintain accurate medical records for two residents. One resident's records lacked documentation of a psychiatry consult and nursing assessment following an abuse allegation, and there was a gap in physician notes. Another resident's record contained a progress note dated before their admission, with no explanation provided by the DON.
The facility failed to provide adequate room size for residents, with 77 multi-resident rooms not meeting the required 80 square feet per resident. Despite a waiver request to CMS in 2019, the issue persisted, as confirmed by the Regional Director of Operations. No residents expressed concerns about room size during interviews.
Staff Fed Resident While Standing
Penalty
Summary
The facility failed to treat a resident with dignity and respect when GNA #16 was observed standing while feeding Resident #52 at a table in the Activities room, despite an available chair in the room. Resident #52 was sitting in a wheelchair at the table with a breakfast tray in front of them, and GNA #16 was standing to the left of the resident with a fork in hand and assisting with feeding. Three other residents in wheelchairs, an Activities Assistant, and a vacant chair were also present at the table. When asked about feeder status and training, GNA #16 stated there was no feeder program and that the resident was not designated as a feeder, but was sometimes encouraged to eat and helped. During an interview with the DON, Regional Nurse, and NHA, the surveyor reported the observation, and the DON stated that staff should always be seated while feeding a resident.
Inaccurate MDS Documentation for Insulin Use
Penalty
Summary
The facility failed to ensure the accuracy of Resident #3’s MDS. Resident #3’s January 2026 MAR and current medication orders showed that the resident did not receive insulin and instead received a 50 mg tablet of Januvia each morning for type 2 diabetes. During interview, the ADON confirmed that Resident #3 did not receive insulin and received Januvia. However, the MDS with an ARD/target date of 12/19/25 documented in Section N, N0350 Insulin, that the resident received one insulin injection during the last 7 days or since admission/entry. Review of discontinued medication orders also showed no discontinued insulin orders since the resident was admitted to the facility. The DON was informed of the discrepancy and agreed that the MDS was wrong because Resident #3 did not receive insulin.
Inaccurate Care Plan for Wandering Risk
Penalty
Summary
The facility failed to appropriately revise Resident #5’s care plan. The resident’s care plan problem area, created on 08/04/2022 and revised on 11/14/2025, identified the resident as an elopement risk with interventions to apply a wanderguard and check its placement each shift and function each day. However, a Wandering Risk Scale - V3 assessment completed on 11/17/2025 showed a score of 3, indicating the resident was a low risk for wandering. During observation rounds on 01/08/2026 at 9:15 AM, Resident #5 was observed not wearing a wanderguard. In an interview later that morning, the DON confirmed the care plan was incorrect and stated the resident was not a wander risk and should not be wearing a wanderguard.
Improper Refrigerator Temperature Control for Medications, Biologicals, and Resident Food
Penalty
Summary
The facility failed to properly store medications, biologicals, and resident food items under proper temperature controls in 2 of 4 medication, biologicals, and resident food refrigerators observed during the annual survey. In the 3rd floor medication and resident food storage rooms, refrigerator #1 contained several residents' food items and had a posted January 2026 temperature form stating the refrigerator must be maintained between 38 and 42 degrees. Facility documentation showed that at 5:00 AM on 01/07/2026, staff recorded the refrigerator at 45 degrees Celsius, and at the time of survey observation the refrigerator was 45 degrees Fahrenheit. Refrigerator #2 contained several medications and biologicals for facility residents and also had a posted January 2026 temperature form stating the refrigerator must be maintained between 38 and 42 degrees. Facility documentation showed that at 1:00 AM on 01/07/2026, staff recorded the refrigerator at 20 degrees Celsius. Staff #4 confirmed the refrigerator readings and stated the findings would be reported to the supervisor. During interview, staff #3 was informed of the temperature findings and acknowledged the incorrect temperature parameters on the form.
Undated Oxygen Equipment
Penalty
Summary
The facility failed to implement infection control practices related to oxygen equipment by not ensuring that oxygen humidifier bottles and tubing were dated when in use for two residents. Resident #37 was observed with an oxygen setup in which the humidifier bottle and oxygen tubing attached to the concentrator were in use but not dated, and Staff #4 confirmed they were not dated as required. Resident #135 was observed receiving 2 L O2 via nasal cannula with oxygen tubing that was not labeled, and the DON stated that all tubing was expected to be labeled. Record review for Resident #135 showed a current order for oxygen via nasal cannula at 2 LPM every shift and as needed to maintain POX above 90%.
Missing Annual GNA Clinical Training Documentation
Penalty
Summary
The facility failed to document and ensure that geriatric nursing assistants' human resources and clinical education records reflected the required 12 hours of annual clinical training and in-services. This was identified during review of the records for 5 of 5 GNAs reviewed, including GNA #15, #16, #17, #21, and #22, after the surveyor requested employee records from the DON and reviewed the available human resources and clinical education files. During interview, the ADON stated that annual hands-on clinical training is provided to clinical staff in October each year and that HealthStream online training is available, but completion of the online clinical education was not mandated at the time. The ADON also brought additional HealthStream documents that included topics such as behavioral health, dementia training, and managing residents with traumatic stress disorder, but stated that staff were resistant to completing the online educational requirements and there were no disciplinary consequences. The ADON was unable to provide additional proof that the five GNAs had received the required 12 hours of annual clinical training before the exit conference.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to provide resident rooms that measured at least 80 square feet per resident in 77 of 77 multi-resident rooms. During observation, interview, and document review, surveyors found that rooms 100, 102, 103, 104, 105, 107, 108, 109, and 110 measured 150 square feet, and rooms 300, 325, 326, 327, 331, 332, 333, 334, 335, 336, 337, 338, 341, 342, 346, 400, 411, 412, 421, 423, 424, 425, 426, 431, 432, 433, 435, 436, 437, 438, 441, 442, 444, 446, 447, 500, 511, 512, 523, 524, 525, 527, 531, 532, 535, 536, 544, 545, 547, 600, 611, 612, 621, 622, 623, 624, 625, 626, 627, 631, 632, 633, 634, 635, 636, 637, 641, and 642 measured 155 square feet. The report stated that this failure had the potential for residents not to have reasonable privacy or adequate space. On 1/5/2026, the NHA provided a CMS letter dated 10/11/2024 showing the facility had requested a waiver for rooms that did not meet the 80-square-foot-per-resident requirement in multi-resident bedrooms, and the waiver was granted for the listed rooms. During initial pool resident observations and interviews, none of the residents in these rooms voiced concern about the size of their rooms. The report also noted that the prior CMS approval letter listed a room number that did not exist and should have listed a different room number that measured 155 square feet. During an interview on 1/8/2026 with the DON, NHA, and Regional Nurse, the surveyor informed the facility that a waiver request would need to be submitted for the above rooms.
Failure to Notify Family of Resident's Fall and Hospital Transfer
Penalty
Summary
Facility staff failed to notify a resident's representative following a fall with injury and subsequent hospital transfer. The incident involved a resident who, during care, rolled out of bed while staff attempted to place a Hoyer pad, resulting in a right knee distal fracture. Documentation in the medical record confirmed that the physician was notified, an x-ray was ordered, and the resident was transferred to the emergency room for evaluation. However, there was no documentation that the resident's family was informed of the fall, injury, or hospital transfer. Interviews with facility leadership revealed that staff practice was not to notify family members if the resident was cognitively intact and designated as their own responsible party, unless the resident specifically requested family notification. The resident confirmed that the facility had permission to notify their daughter about any issues, but this was not done. Both the ADON and DON stated that communication with family was not standard for residents responsible for themselves, even in cases of significant injury and pain.
Failure to Arrange Home Health Services at Discharge
Penalty
Summary
Facility staff failed to ensure that a resident was set up with home health services upon discharge. The resident, who had a history of Postural Orthostatic Tachycardia Syndrome (POTS) and required daily IV fluid boluses, was admitted to the facility after a hospitalization and continued to receive daily IV fluids during their stay. Prior to discharge, the resident expressed a preference for a specific home health agency, but that agency did not accept the resident's insurance. The facility then referred the resident to an alternative agency, which was documented in the resident's post-discharge plan of care. However, the alternative home health agency also did not accept the resident's insurance and notified the facility of this on the day of discharge. Despite this notification, the resident was discharged without home health services in place. This failure was confirmed through interviews and review of the medical record, as well as direct communication with the home health agency involved.
Failure to Update Care Plan After MDS Assessment
Penalty
Summary
Facility staff failed to thoroughly evaluate and revise a resident's care plan following each Minimum Data Set (MDS) assessment to ensure it accurately reflected the resident's current needs and interventions. Specifically, a resident with a spinal cord injury and quadriplegia was assessed as fully dependent for self-care activities such as eating, oral hygiene, toileting, bathing, dressing, and personal hygiene during a quarterly MDS assessment. Despite this, the resident's care plan continued to list these activities as independent, which did not align with the resident's actual condition or the assessment findings. Observation and interviews confirmed that the resident required staff assistance for all self-care activities, including turning, bathing, and nail care. The discrepancy between the care plan and the resident's actual needs was acknowledged by the Director of Nursing, who confirmed that the care plan was inaccurate and did not reflect the resident's dependent status. This failure to update and revise the care plan after the MDS assessment resulted in a care plan that did not provide accurate guidance for staff regarding the resident's required level of care.
Failure to Assess and Manage Pain After Resident Fall With Fracture
Penalty
Summary
Facility staff failed to thoroughly assess and manage pain for a resident following a fall that resulted in a fracture. After the resident was rolled out of bed during care, documentation showed that the physician was notified and an order for an x-ray and Tylenol for pain was obtained. Nursing notes indicated that Tylenol was administered and that the resident was to be monitored for effective pain management. However, the Medication Administration Record (MAR) did not show any documentation of Tylenol being given, and there were no follow-up pain assessments recorded after the initial administration. Pain levels were documented as 8 out of 10 before and after the incident, but there were no pain assessments between the early afternoon and the time the resident was transferred to the emergency room, where stronger pain medication was administered. Interviews with staff confirmed the lack of documentation regarding pain medication administration and pain assessments. The Assistant Director of Nursing (ADON) was unable to confirm that pain assessments were conducted or that the resident was medicated for pain from the time of the fall until hospital transfer. The resident reported receiving Tylenol but stated it did not relieve the pain and that significant pain persisted until after hospital treatment. The deficiency centers on the facility's failure to provide safe and appropriate pain management, including thorough assessment and documentation, for a resident who required such services after sustaining a fracture.
Incomplete Medical Record Documentation for Diabetic Resident
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for a resident with diabetes, as evidenced by several documentation lapses. The resident was admitted with a diagnosis including diabetes, and during a review of the medical record, it was found that on one occasion, staff documented a blood sugar reading of 401 but did not record the insulin administered. On another occasion, a blood sugar reading of 17 was documented without an accompanying nurse's note, and on a separate date, the blood sugar was not documented at all. These deficiencies were confirmed by the Director of Nursing during an interview, indicating that required documentation related to blood sugar monitoring and insulin administration was incomplete or missing for this resident.
Deficiencies in Vaccination Consent and Administration
Penalty
Summary
The facility failed to ensure that consents were signed and education was provided to five residents before administering the influenza vaccine. This deficiency was identified through interviews, record reviews, and policy reviews. The residents involved were not given the opportunity to make informed decisions regarding the influenza vaccine, as there was no documentation of consent or education in their electronic medical records (EMR). The Assistant Director of Nursing confirmed the lack of consent and education for these residents. Additionally, the facility did not offer an additional pneumococcal vaccine to two residents who were eligible according to CDC guidelines. These residents had previously received the PPSV23 vaccine but were not offered the recommended PCV15 or PCV20 vaccine at least one year later. The absence of documentation in the EMR indicated that these residents were not informed or offered the additional pneumococcal vaccine, increasing their risk of contracting pneumonia. The facility's policies on influenza and pneumococcal vaccinations were not followed, as evidenced by the lack of documentation and adherence to CDC recommendations. The policies required that residents be informed and consent obtained before vaccination, and that pneumococcal vaccination status be assessed and updated according to CDC guidelines. The failure to comply with these policies resulted in deficiencies in the vaccination process for the residents involved.
Failure to Document Discharge Summaries
Penalty
Summary
The facility failed to place a discharge summary on the medical records of two residents after their discharge. For one resident, a review of the medical record revealed no evidence of a discharge summary following their discharge from the facility. During an interview, the Director of Nursing (DON) confirmed the absence of the discharge summary after reviewing the progress notes. Similarly, for another resident, the medical record review showed no discharge summary after their discharge. The DON also confirmed this deficiency upon reviewing the progress notes.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility staff failed to maintain complete and accurately documented medical records for two residents during the survey. For one resident, an incident involving an allegation of abuse was investigated, and the facility's final report indicated that a nursing assessment was conducted and a psychiatry consult was planned. However, the surveyor was unable to find documentation of the psychiatry consult or the nursing assessment in the resident's medical record. Additionally, there was a significant gap in the physician's progress notes, with no documentation addressing the resident's allegation of abuse. For another resident, a progress note from a provider was dated before the resident's admission to the facility, which raised concerns about the accuracy of the medical records. The Director of Nursing was unable to provide an explanation for the discrepancy in the date of the provider's note. These findings indicate a failure to maintain accurate and complete medical records in accordance with accepted professional standards.
Deficiency in Resident Room Size Compliance
Penalty
Summary
The facility failed to provide resident rooms that met the required minimum square footage per resident, as mandated by regulations. Specifically, 77 out of 77 multi-resident rooms did not meet the requirement of at least 80 square feet per resident. The rooms in question measured between 150 and 155 square feet, which is insufficient for two residents. This deficiency was identified through observation, interviews, and document reviews conducted by surveyors. The facility had previously requested a waiver from the Centers for Medicare & Medicaid Services (CMS) in 2019 for these room sizes, indicating awareness of the issue. During the survey, the Regional Director of Operations confirmed the room measurements and acknowledged that the facility had 77 semi-private rooms certified for two residents each. Despite the deficiency, none of the residents interviewed expressed concerns about the size of their rooms. The Regional Director also provided a revised list of rooms, correcting previous documentation errors regarding which rooms were included in the waiver request. This indicates that the facility was aware of the room size issue but had not taken sufficient action to rectify it.
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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.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Resorts Of Augsburg | 0.9 mi | ★★★★★ | 40 | 0 |
| Autumn Lake Healthcare At Arlington West | 1.4 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Bridgepark | 1.6 mi | ★★★★★ | 2 | 0 |
| King David Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 22 | 0 |
| Autumn Lake Healthcare At Pikesville | 2.3 mi | ★★★★★ | 0 | 0 |
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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.