Lochearn Nursing Home, LLC

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to treat residents with dignity and respect as evidenced by staff standing over residents while assisting them to eat. This was evident for 1 (resident #52) out of 1 resident observed for dignity during the annual survey.

Inspectors wroteBased on resident record reviews and staff interviews, it was determined that the facility failed to ensure the accuracy of the resident's Minimum Data Set (MDS). This was evident for 1 resident (Resident #3) out of 10 residents reviewed during the recertification survey. On 01/06/2026 at 1:06 PM, the surveyor reviewed Resident # 3's medical records. The resident record review revealed that, according to Resident # 3's January 2026 Medication Administration Record and current medication orders, Resident #3 did not receive insulin. It was documented in Resident #3's January 2026 Medication Administration Record and current medication orders that Resident #3 received a 50 mg tablet of Januvia, an oral anti-diabetic medication, each morning for type 2 diabetes. On 01/06/2026 at 1:32 PM, the surveyor asked the Assistant Director of Nursing staff #18 if Resident #3 received insulin. [...]

Inspectors wroteBased on review of resident medical records, observation and interviews, it was determined that the facility failed to perform appropriate revisions to resident care plan. This was evident for 1 resident (Resident #5) out of 10 residents reviewed during the survey.

Inspectors wroteBased on observations, interviews and review of facility documentation, the facility failed to properly store medications, biologicals and resident food items under proper temperature controls. This was evident for 2 out of the 4 medication, biologicals and resident food refrigerators observed during the annual survey.

Inspectors wroteBased on observation, record reviews and interviews, it was determined that the facility failed to implement infection control practices to ensure oxygen equipment was dated when put into use. This deficient practice was evident for 2 (resident #37 and #135) of 3 residents reviewed for oxygen equipment during the annual survey.

Inspectors wroteBased on administrative records reviews and interviews it was determined that the facility failed to document and ensure that geriatric nursing assistants' (GNAs) human resources and clinical education records reflected the required 12 hours of annual clinical training/in-services as required. This was evident to be true for 5 out of 5 (GNA # 15, #16, #17, #21, #22 ) geriatric nursing aide clinical education and human resources records reviewed during the survey.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide resident's rooms that measured at least 80 square feet per resident in 77 of 77 multi-resident rooms. Rooms 100, 102, 103, 104, 105, 107, 108, 109, and 110, measured 150 square feet. 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. This failure had the potential for residents not to have reasonable privacy or adequate space.

Inspectors wroteBased on complaint, record review, and interview, it was determined that the facility staff failed to inform a resident's representative of a fall with injury and subsequent transfer to the hospital. This was evident for 1 (#7) of 12 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on review of a complaint, medical record review and interviews, it was determined the facility staff failed to ensure home health services were set up for a resident at discharge (Resident #19). This was evident for 1 of 3 residents reviewed for discharge during a complaint survey.

Inspectors wroteBased on observation, medical record review, and interviews, it was determined that facility staff failed to thoroughly evaluate and revise a resident's plan of care after each MDS (Minimum Data Set) assessment to reflect accurate and current interventions (Resident #17). This was evident for 1 of 19 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, medical record review, and interviews, it was determined the facility staff failed to thoroughly assess a resident for pain after a fall with fracture. This was evident for 1 (#7) of 12 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #16). This was evident for 1 of 19 residents reviewed during a complaint survey.

Inspectors wroteBased on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure five of five residents (Resident (R) 40, R158, R73, R7, and R96) reviewed for influenza vaccines had consents signed, including the risks and benefits explained to the resident and/or representative prior to the administration of the vaccine. The facility further failed to offer an additional pneumococcal vaccine to two of five residents (R73 and R96) reviewed for pneumococcal vaccines out of a total sample of 39 residents. The failure of not offering/providing the additional pneumococcal vaccine increased the risk for residents to contract pneumonia. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to provide resident's rooms that measured at least 80 square feet per resident in 77 of 77 multi-resident rooms. Rooms 100, 102, 104, 105, 107, 108, 109, and 110, measured 150 square feet. Rooms 300, 325, 326, 327, 331, 332, 333, 334, 335, 336, 337, 338, 341, 342, 346, 400, 411, 412, 421, 423, 424, 425, 426, 427, 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. This failure had the potential for residents to not have reasonable privacy or adequate space.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to place a discharge summary on resident's medical record after discharge. This was evident for 2 (#919 and #923) of 89 residents reviewed during the survey.

Inspectors wroteBased on review of the medical record and interview with staff it was determined the facility staff failed to maintain complete and accurately documented medical records. This was evident for 2 (#924 and #914) of 89 residents reviewed during the survey.

Inspectors wroteBased on observation and staff interview it was determined that 1.) Facility staff failed to maintain a safe environment. This was observed during the initial tour of the fifth floor during an annual recertification survey; and 2.) Facility staff failed to put a system in place to provide housekeeping and maintenance services necessary to maintain a sanitary, order and comfortable interior and wheelchairs for residents. This was found to be true for 3 of 6 resident floors during the environmental observations of the facility.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for a resident. This was evident for 1 of 57 residents )Resident #69) selected for medical record review during the annual survey process.

Inspectors wroteBased on interview and observation, it was determined the nursing staff failed to provide a resident with the most dignified existence. This was evident for 1 of 1 resident (Resident #86) reviewed during the annual survey for dignity.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to: 1.) initiate a resident specific care plan with interventions for Resident #69 and 2.) failed to initiate a comprehensive care plan for Resident #174 to address dental needs. This was evident for 1 of 3 resident selected for review of hemodialysis and 1 of 4 residents selected for review of dental concerns during the survey process and 2 of 57 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to review and revise the care plan for Resident #124 to reflect accurate and current interventions. This was evident for 1 of 57 residents reviewed for care plans during the survey process.

Inspectors wroteBased on observation, medical record review and interview, it was determined the facility staff failed to provide services that would allow residents the ability to achieve the greatest independence with performing Activities of Daily Living (ADL) to a resident. This was evident for 1 of 57 residents (Resident #90) selected for review during the survey process.

Inspectors wroteBased on medical record review, observation and interview, it was determined, the facility staff failed to promote an environment free from potential accidents for Resident #69. This was evident for 1 of 2 residents selected for review of accidents and 1 of 57 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review and interview it was determined that 1.) Facility staff failed to thoroughly assess the need for pain medication for Resident (#33). This was evident for 1 of 4 resident selected for pain assessment and 1 of 57 residents selected for review during the annual survey; and 2.) Failed to document the administration of pain medicine and monitor its effectiveness. This was true for 1 out of the 57 residents (Resident #107) reviewed during the annual recertification survey.

Inspectors wroteBased on observation, staff interviews and review of facility daily Controlled Drugs-Count per shift records, it was determined that the facility failed to accurately complete the record each shift. This was evident for 2 of 8 medication storage carts reviewed.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to document the heart rate and blood pressure for Resident #24 when the physician ordered parameters. This was evident for 1 of 6 residents selected for unnecessary medication review and 1 of 57 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to follow the physician order for the administration of as needed psychotropic medications for Resident #107. This was evident for 1 of 57 residents selected for review during the survey process.

Inspectors wroteBased on observation, it was determined the facility staff failed to 1.) Properly store medications. This was observed once during an annual recertification survey; and 2.) Failed to ensure that medications were disposed of in a proper manner. This was evident for 1 of 3 facility staff observed during medication pass review.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure hand rails were secured firmly to the wall. This was found to be true on 1 of 6 floors (6th floor) observed during the survey. This deficient practice has the potential to affect all residents, staff, and visitors on the unit.

Inspectors wroteBased upon surveyor observation it was determined that resident rooms did not measure at least 80 square feet per resident in multi-resident bedrooms.