Lomond Peak Nursing and Rehabilitation

Inspectors wroteBased on observation, interview, and record review it was determined, for 2 out of 26 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, two high fall-risk residents did not have interventions put in place after falls and interventions were repeated. One of these examples was cited as harm. Resident identifiers: 39 and 43.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility did not provide or obtain laboratory services to meet the needs of its residents. If the facility provided its own laboratory services; the services must meet the applicable requirement for laboratories. Specifically, the facility glucometers were not being calibrated according to the manufacturer requirements and the control solution available was expired.

Inspectors wroteBased on observation and interview, the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, for 7 out of 26 sampled residents, residents complained of the quality and taste of the food and a test tray was not palatable. Resident identifiers: 3, 4, 6, 10, 11, 56, and 77. Findings Included: On 10/6/25 at 10:22 AM, an interview was conducted with resident 56. Resident 56 stated the food was bland and did not taste good. On 10/6/25 at 11:50 AM, an interview was conducted with resident 4. Resident 4 stated that the food did not taste good and most of the time she bought her own food to eat. On 10/6/25 at 2:34 PM, an interview was conducted with resident 10. Resident 10 stated that the food was dry and not tasty. On 10/6/25 at 3:07 PM, an interview was conducted with resident 6. Resident 6 stated the food was not edible. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there were undated food items stored in the refrigerator and freezer, hairnets were not worn correctly; resident refrigerators' temperatures were not monitored and food was unlabeled and undated; a dietary aide touched fish, chicken, and pasta with gloved hands after touching multiple surfaces; and chicken and fish were chopped with the same knife during lunch service causing cross-contamination of foods.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 5 out of 26 residents, Enhanced Barrier Precautions (EBP) were not implemented for residents, staff were observed not performing hand hygiene during medication administration, and glucose monitors were not disinfected according to manufacturer instructions. Resident identifiers: 5, 8, 39, 67, and 73.

Inspectors wroteBased on interview and record review, for 1 of 26 sampled residents, the facility did not provide residents the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. Specifically, a resident was not provided written notice when she had roommate changes. Resident identifier: 77.

Inspectors wroteBased on interview and record review, it was determined that the facility did not ensure that any individual working in the facility as a nurse aide for more than 4 months was competent to provide nursing and nursing related services; and completed a training and competency program, or a competency evaluation program approved by the State. Specifically, a Nurse Aide (NA) was employed at the facility and worked as a NA for over 4 months without completion of a training or a competency evaluation program approved by the State.

Inspectors wroteBased on observation, interview and record review, for 1 of 26 sampled residents, the facility did not ensure each resident received necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, a resident with mental health diagnoses was not offered counseling services. Resident identifier: 77.

Inspectors wroteBased on observation and interview, it was determined that the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, under proper temperature controls and cautionary instructions, and the expiration date when applicable. Specifically, there were expired medications stored in the facility's medication storage room available for patient use.

Inspectors wroteBased on interview and record review, for 1 of 26 sampled residents, the facility did not provide or obtain radiology services to meet the needs of the residents. Specifically, a resident did not have a Magnetic Resonance Imaging (MRI) scheduled. Resident identifier: 3.

Inspectors wroteBased on observation, interview, and record review it was determined that, for 1 of 26 sampled residents, the facility failed to provide food that accommodated resident allergies, intolerances, and preferences. Specifically, a resident was provided food that was listed as an allergy. Resident identifier: 50.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dish machine washing temperature did not reach the required temperature, cups were observed to have a white substance inside of them and a staff member was observed to touch dirty surfaces with gloves and then touched clean dishes. Resident identifier: 84.

Inspectors wroteBased on observation and interview it was determined, for 4 of 29 sampled residents, the facility did not provide a safe, clean, comfortable and homelike environment, which included housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, resident rooms were observed to have fly strips that were covered in flies that had been hung for an unknown amount of time. Resident identifiers: 8, 24, 34 and 47. Findings Include: On 4/22/24 at 11:23 AM, an observation was made in the 100 and 200 hall. Fly strips with dead flies were found in room [ROOM NUMBER] and room [ROOM NUMBER]. On 4/22/24 at 12:27 PM, an observation was made of room [ROOM NUMBER] with a fly strip present. Multiple dead flies were observed stuck to the paper. [...]

Inspectors wroteBased on observation, interview and record review it was determined the facility did not provide sufficient support personnel to safely and effectively carry out the function of the food and nutrition services. Specifically, meals were served later than the posted meal time, there were contradicting meal times provided to surveyors verses posted in the dining room and residents complained of late meals. Resident identifiers: 17, 30, and 68.

Inspectors wroteBased on interview and record review, it was determined that for 4 out of 28 sampled residents, that the facility did not ensure that residents were free from abuse. Specifically, one resident was headbutted by another resident and two other resident experienced physical altercations on two different occasions and the facility did not identify it as abuse. Resident identifiers: 4, 5, 34, and 268.

Inspectors wroteBased on observation and interview it was determined, for 9 of 28 sampled resident, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of the food quality and a test tray was not palatable. Resident identifiers: 4, 8, 18, 27, 35, 39, 41, 52 and 62.

Inspectors wroteBased on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, areas in the kitchen were unclean and staff used purell hand sanitizer on a thermometer.

Inspectors wroteBased on interview and record review, it was determined that the facility did not inform residents, resident families and representatives of a confirmed COVID-19 infection in a timely manner. Specifically, the facility did not send a notification to resident families and representatives by 5:00 p.m. the next calendar day following the occurrence of a confirmed COVID-19 infection.

Inspectors wroteBased on interview and record review it was determined that the facility did not provide 1 of 28 sampled residents with supportive treatment and services to maintain or improve his or her ability to carry out the activities of daily living which included bathing or showering. Specifically, a resident was not showered according to his shower schedule and had gone 10 days without a shower. Resident identifiers: 35.

Inspectors wroteBased on observation, interview and record review it was determined, for 2 of 28 sampled residents, that the facility did not have adequate supervision to prevent accidents. Specifically, a resident was missing from the facility for over 5 hours without staff noticing. This will be cited at past non-compliance. In addition, another resident's mouth was hit by the hoyer lift during a transfer, resulting in a broken tooth. Resident identifiers: 31 and 67.

Inspectors wroteBased on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not obtain routine dental services to meet the needs of the resident. Specifically, one resident who received a chipped tooth in the facility was not scheduled for routine dental care. Resident identifier: 31.