Lomond Peak Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Lomond Peak Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF806Aug 13, 2026

  Based on interview and record review, the facility did not ensure each resident received and the facility provided food that accommodated the resident allergies. Specifically, for 1 out of 27 sampled residents, a resident was served food that contained an allergen resulting in the resident being administered an epinephrine injection. This non-compliance resulted in a HARM deficiency. Resident identifier: 52.Findings included:Resident 52 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Helicobacter Pylori, atrial fibrillation, chronic kidney disease, neuromuscular dysfunction of bladder, retention of urine, exocrine pancreatic insufficiency, cardiac arrhythmia, hypertensive retinopathy, hypertension, cardiac pacemaker, cardiomyopathy,… […]

• Actual harm, isolatedF689Oct 9, 2025

  Based 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.Findings included: HARM 1. Resident 43 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, mild cognitive impairment, and ataxia. On 10/6/25 at 2:59 PM, an interview was conducted with resident 43. […]

• No harm, potential for more than minimal, widespreadF812Apr 25, 2024

  Based 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. Findings include: 1. On 4/22/24 at 10:38 AM, an initial tour of the kitchen was conducted. The following observations were made: a. On 4/22/24 at 10:41 AM, an observation was made of Dietary Aide (DA) 2. DA 2 was observed to touch dirty dishes and loaded them into a dish machine basket. […]

• No harm, potential for more than minimal, patternF773Aug 13, 2026

  Based on interview and record review, the facility did not obtain laboratory services only when ordered by a physician. Specifically, for 3 out of 27 sampled residents, the facility did not have a physician order for laboratory tests that were obtained. Resident identifiers: 8, 52, and 62.Findings included:1. Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, palpitations, chronic pain, heart failure, cerebral infarction, peripheral vascular disease, type 2 diabetes mellitus, asthma, chronic kidney disease, hyperlipidemia, and hypertension. Resident 8's laboratory results were reviewed. The following test results were identified as not having a physician order:a. […]

• No harm, potential for more than minimal, patternF812Aug 13, 2026

  Based on observation and interview, the facility failed to store and prepare food under sanitary conditions to prevent cross-contamination and ensure proper food rotation. Specifically, food items were not labeled, and food items were not stored appropriately.Findings included:On 8/10/26 at 8:27 AM, an initial observation of the kitchen environment was conducted and revealed the following:a. Walk-In Refrigerator: A box of tomatoes located on the bottom shelf was uncovered and undated. A tote containing a plastic bag of chicken was stored directly above this box of tomatoes. b. Dry Storage: An opened box of flour tortillas and four boxes of [NAME] Round Top Bread lacked a received date on the outside of the packaging. c. […]