Average — CMS composite of the measures below.
The next survey window likely opens around September 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 Lomond Peak Nursing And Rehabilitation, Llc during CMS and state inspections, most recent first.
Two residents with high fall risk had repeated falls without new or updated interventions after subsequent incidents. One resident with encephalopathy, mild cognitive impairment, and ataxia fell multiple times in the bathroom and during transfers, with repeated education and no updated care plan interventions after some falls. Another resident with severe cognitive impairment, dementia, and repeated falls had multiple transfer and bathroom falls, repeated use of the same interventions, and no fall mat at bedside despite the care plan noting one should be placed there.
Expired glucometer control solution was found in the med cart and med storage room, with no unexpired bottles available. An LPN did not know the testing process because night shift handled it, while the ADON said each resident had their own glucometer and night shift nurses tested them weekly. The glucometer manual stated to check the expiration date and not use expired control solution.
Food was not palatable, attractive, or served in an appetizing manner for multiple residents. Several residents reported bland, dry, lukewarm, or otherwise poor-tasting meals, and one resident said the kitchen had trouble getting orders correct. Surveyors also sampled a test tray and found the pasta mushy and flavorless, the chicken dry and hard to chew, the carrots lacking the listed seasoning, and the dessert dry with an artificial flavor. The DM acknowledged resident complaints and said he had altered preparation by overcooking chicken and stopping seasonings after prior feedback.
Infection control deficiencies were identified involving inconsistent EBP implementation, missed hand hygiene during med pass, and improper glucometer disinfection. EBP signage was not posted outside rooms for residents with EBP orders or indicators, an EMR banner remained outdated for a resident no longer on EBP, an LPN failed to sanitize hands before touching shared med cart items after passing meds to a resident, and a resident's glucometer was disinfected with an alcohol prep pad instead of following the meter's manufacturer-approved cleaning and disinfection process.
Food service safety standards were not followed when kitchen and resident refrigerator items were found undated, unlabeled, or improperly stored, and one resident refrigerator had no thermometer. During tray line service, an aide wore a hairnet incorrectly, handled chicken, fish, and pasta with the same gloves after touching multiple surfaces, and used the same knife and area to chop fish and then chicken. The DM stated items should be dated and labeled, gloves should be changed when staff move or touch things, and two residents had fish allergies.
Failure to Provide Written Notice for Roommate Changes: A resident with dementia, anxiety, cognitive communication deficit, and other diagnoses had multiple roommate changes, but the record contained no notifications or nursing progress notes documenting the changes. The RA stated the resident complained about a roommate, was moved, then later requested the original roommate back, but there was no documentation that either resident received written notice or that the room-change form was signed and filed.
Nurse aide competency and training requirements were not met when an NA remained employed and worked beyond 120 days without completing the state-approved CNA program or testing. Interviews with the BOM, CNA Coordinator, and ADM confirmed the NA had been assigned to the course but had not finished it, and the NA continued to work as a CNA despite not being certified.
A resident with dementia, GAD, MDD, PTSD, and a long trauma history reported feeling fearful and emotionally distressed by other residents and said she really needed a therapist. Her PASRR Level II and care plan both called for referral for mental health therapy and medication management as needed, but the record contained no documentation that counseling or therapy was ever offered. Staff gave conflicting accounts about whether therapy was offered or refused, and the DON and Administrator acknowledged the lack of documentation.
Expired medications and vaccines were found in the medication storage room and medication fridge, including multiple bottles of tablets, powders, oral solutions, protein shakes, and influenza and Covid vaccines. The DCS and DON stated night shift nurses were supposed to check expired meds and return them to the pharmacy, and that the pharmacy came to the facility daily except Sunday.
A resident with cerebral infarction, hemiplegia, neurologic neglect, dysphagia, MDD, insomnia, and malnutrition reported a left shoulder subluxation and said an MRI recommended by orthopedics had not been scheduled. Record review showed the ortho provider recommended an MRI of the left shoulder, the MD was notified, and staff later could not locate the appointment on the transport spreadsheet or in the transport director’s folder, despite the ADON stating the referral had been received.
Failure to honor a resident's lactose intolerance on meal trays. A resident with DM2, IBS, and lactose intolerance repeatedly received dairy products, including ranch dressing and cheese shavings on a salad, despite a meal ticket stating no milk or milk products at all. The resident reported that staff were aware of the issue, but he was told ranch was the only dressing available and substitutes were not always in stock; the DON stated staff were expected to check trays before delivery and substitutes were expected to be available.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The dish machine temperatures were consistently below the required range, and staff were observed handling clean dishes after touching dirty surfaces without changing gloves or performing hand hygiene. A resident reported dirty cups with a white film, which was attributed to hard water buildup.
The facility failed to provide a safe, clean, and comfortable environment for four residents, as evidenced by neglected fly strips covered in dead flies in multiple rooms. Housekeeping staff did not handle the fly strips, and the Maintenance Director confirmed that some rooms with fly strips were not logged properly. Despite monthly pest control measures, the facility did not maintain a sanitary environment.
The facility failed to provide sufficient support personnel for food and nutrition services, resulting in meals being served later than posted times and inconsistencies between provided and posted meal times. Residents complained about the late meals, and observations confirmed delays in meal delivery across various hallways and the main dining room.
Repeated Falls With Unchanged Interventions and Inadequate Supervision
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and that residents received adequate supervision and assistance devices to prevent accidents. Two residents with repeated falls were identified, and for both residents the record showed that fall-related interventions were repeated without new or updated interventions being implemented after subsequent falls. One of the residents was cited with harm related to the deficiency. Resident 43 was admitted with diagnoses including encephalopathy, mild cognitive impairment, and ataxia, and was documented as needing supervision or touching assistance with transfers, toileting, and bed mobility. His care plan identified him as at risk for falls related to impaired gait and balance, Parkinson disease, impaired cognition, ataxia, chronic pain, osteoarthritis, degenerative disk disease, neurogenic claudication, medications that increase fall risk, impaired vision, impaired hearing, and recurring falls. The record documented multiple falls in bathrooms, showers, and while transferring to and from a wheelchair or walker. Several interventions were repeated, including educating him to ask for staff assistance, use his wheelchair for nocturnal restroom visits, keep shoes out of the walkway, and use his walker when ambulating. For two falls on 6/15/25 and 7/3/25, the record stated there was no updated intervention added to the care plan. Survey interviews also showed staff described him as unsteady, having balance problems, and needing help with transfers and bathroom use. Resident 39 was admitted and readmitted with diagnoses including unspecified dementia, insomnia, generalized muscle weakness, and repeated falls. Her BIMS score was 4, indicating severe cognitive impairment, and her care plan identified her as at risk for falls related to dementia, CHF, unsteady gait and balance, history of falls, medications, respiratory failure, chronic hypoxia, shortness of breath, oxygen use, incontinence, recurring falls, and pain. The record documented repeated falls in the bathroom, common areas, and room while attempting to transfer, stand, or move from a wheelchair or chair. Interventions were repeated multiple times, including offering her a recliner, reinforcing call light/alarm use, and educating staff about her call light system. The record also noted that a fall mat was to be placed next to her bed, but on observation she did not have a fall mat at bedside. Interviews with staff confirmed she was a fall risk, required significant transfer assistance, and relied on alarms and staff response for supervision.
Expired Glucometer Control Solution and Inconsistent Testing Process
Penalty
Summary
Timely, quality laboratory services/tests were not provided to meet resident needs because the facility’s glucometers were not being calibrated according to manufacturer requirements and the available control solution was expired. During observation of the 200 hall medication cart and medication storage room, bottles of glucometer control solution were found in both locations with an expiration date of [DATE], and there were no unexpired bottles available. An LPN stated she did not know the process for testing the glucometers because the night shift tested them. The ADON stated each resident had their own glucometer and that night shift nurses tested the glucometers weekly, and also stated staff were trained according to manufacturer requirements. The facility Administrator provided the glucometer manual, which stated to always check the expiration date and not use expired control solutions.
Food Not Palatable or Appealing
Penalty
Summary
Food and drink were not provided in a palatable, attractive, and safe appetizing manner for multiple sampled residents. Seven of 26 sampled residents, including residents 3, 4, 6, 10, 11, 56, and 77, reported dissatisfaction with the quality and taste of the food. Resident 56 stated the food was bland and did not taste good. Resident 4 said the food did not taste good and that she most of the time bought her own food to eat. Resident 10 described the food as dry and not tasty, resident 6 said the food was not edible, resident 11 said the food was lukewarm and not good and that he had to buy his own snacks, resident 3 said the food was only good when they got it right and that the kitchen had trouble getting orders correct, and resident 77 stated the food was absolutely terrible. A test tray sampled by surveyors included garlic roasted chicken, penne alfredo, parsley carrots, and bananas foster cake. The pasta was described as mushy, overcooked, and having no flavor. The chicken was dry, grisly, and hard to chew. The carrots were diced and did not contain parsley, and the cake had a strong artificial banana flavor and was dry in texture. The Dietary Manager stated he had received resident food complaints and that there was a food committee. He also stated that after complaints about undercooked chicken, he was making sure the chicken was overly cooked, and after being told the food was too spicy, he stopped using seasonings in the food.
Infection Control Deficiencies with EBP, Hand Hygiene, and Glucometer Disinfection
Penalty
Summary
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. Surveyors identified that Enhanced Barrier Precautions (EBP) were not consistently implemented for residents with orders or indicators for EBP, including residents 5, 8, and 73. On 10/6/25, no EBP signage was observed outside resident 5's room or resident 8's room, and the hallway tour showed no transmission-based precaution signage outside resident doorways. Resident 5 had diagnoses including COPD, type 2 diabetes mellitus, and hemiplegia/hemiparesis following cerebral infarction, and EBP had been ordered on 9/19/25 related to wounds. Resident 8 had diagnoses including paraplegia, neuromuscular dysfunction of bladder, and neurogenic bowel, and EBP had been ordered on 6/5/25 related to an indwelling catheter. Resident 73's electronic medical record banner still stated Special Instructions: EBP, but no physician order for EBP could be located in the chart. The DON stated staff were informed of EBP through the chart, a staff messaging app, and signage outside resident rooms, and also stated the facility had previously used colored dots to indicate transmission-based precautions. The DON further stated resident 73 had previously been on EBP and the electronic banner had not been updated after the resident was no longer on EBP. NA 2 stated that nursing management communicated EBP changes through a staff messaging app and that room signage was a new system, while CNA 2 stated signage should have been posted but frequent room changes made it difficult to update the signage. During medication administration, hand hygiene was not performed as expected. LPN 2 administered medications to resident 39, then exited the room to get more water and failed to sanitize hands before touching cups and the water pitcher on the 400 hall medication cart used for residents on that hall. Resident 39 had medications passed in the room with a cup of water, and LPN 2 later acknowledged that hand hygiene should have been performed after passing medications and before touching the cups and water pitcher. In addition, resident 67's personal glucometer was observed being disinfected with an alcohol prep pad after blood glucose testing, while the ADON stated the glucometers were cleaned daily with microclean wipes and cleaned after every use. The manufacturer instructions for the EvenCare G2 meter stated that cleaning and disinfection are important for prevention of infectious disease and listed approved disinfecting wipes for use with the meter.
Food Storage and Tray Line Cross-Contamination
Penalty
Summary
The facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen tour, a Dietary Aide was observed wearing a hairnet with her bangs uncovered. Undated food items were found in the refrigerator and freezer, including pudding cups, covered juice cups, an opened carton of thickened orange juice, an opened container of lettuce, and an opened bag of tater tots in the freezer. During observation of the resident refrigerators, the 200/300 refrigerator had no thermometer to monitor temperature. Inside were multiple unlabeled or undated items, including pasta, mushy leaking fruit, pudding, burritos in the freezer, an ice cream shake, a frozen chimichanga with a use-by date of 10/4/23, a Subway sandwich, and a chicken sandwich that were hard to the touch. The shelves in the door of the 200/300 refrigerator were also covered in a brown sticky substance. The Dietary Manager stated that items should be dated and labeled if they were in the refrigerator or freezer, and the DON stated that items in the refrigerator should be dated and labeled. During lunch tray line observation, a Dietary Aide repeatedly handled food with gloved hands after touching plates, surfaces, and a dirty countertop. The aide touched chicken, fish, and pasta with the same gloves, used the same knife and area to chop fish and then chicken, and continued handling food without changing gloves until later in the meal service. The Dietary Manager stated that kitchen staff should change gloves every time they moved out of their station or if they touched things, and that he preferred staff not touch food with gloved hands. The Dietary Manager also stated there were two residents in the facility with fish allergies.
Failure to Provide Written Notice for Roommate Changes
Penalty
Summary
The facility did not provide written notice, including the reason for the change, before a resident's room or roommate was changed. Resident 77 was admitted with diagnoses including dementia, generalized anxiety disorder, cognitive communication deficit, hypothyroidism, fibromyalgia, major depressive disorder, and post traumatic stress disorder. During an interview, Resident 77 stated she had different roommates and that her current roommate had recently returned from the hospital, and she said her roommate was not the same since returning. The resident's medical record contained no notifications documenting roommate changes and no nursing progress notes regarding roommate changes. The Resident Advocate stated Resident 77 complained about her roommate and was moved out, then another resident moved in, and later the original roommate was moved back after Resident 77 said she missed her. The Resident Advocate stated she did not have documentation of room moves or notification to the residents. The DON stated the roommate was moved and then moved back, and that staff usually provided a 24-hour notice of room changes unless there was a safety concern. The DCS stated the Resident Advocate should provide both residents a form to notify them of the room change, and that the form should be signed and scanned into the medical record.
Nurse Aide Worked Beyond 120 Days Without Completing Certification
Penalty
Summary
The facility did not ensure that a nurse aide who had worked more than 4 months was competent to provide nursing and nursing related services and had completed a training and competency program, or a competency evaluation program approved by the State. NA 1 was hired on 5/7/25 and was still employed as a nurse aide when the employee file was reviewed on 10/8/25, with the last shift worked on 10/3/25. The record review showed that NA 1 had not completed the nurse aide program or taken the test required for certification. During interviews, the Business Office Manager stated that NA 1 was still employed as a nurse aide, had not taken the test, and had not completed the NA program. The CNA Coordinator stated that NA 1 had been in the certification program but had not completed it, and that she learned at the beginning of September 2025 that NA 1 had not finished the program. The CNA Coordinator also stated that nurse aides should not work after 120 days until they become certified. The Administrator stated that NA 1 had been hired and assigned to the CNA course, had personal problems, did not complete the course, and was working after 120 days.
Failure to Document and Provide Behavioral Health Services
Penalty
Summary
The facility did not ensure that a resident with multiple behavioral health diagnoses received necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Resident 77 was admitted with diagnoses including dementia, generalized anxiety disorder, cognitive communication deficit, hypothyroidism, fibromyalgia, major depressive disorder, and post traumatic stress disorder. During an interview, the resident stated she was distressed by other residents she believed were child molesters, said these concerns brought back feelings related to her past trauma, and reported she feared her roommate at night. She also stated she did not have a therapist and really needed one. The resident’s PASRR Level II documented a long history of trauma, depression, anxiety, prior suicide attempts, and regular suicidal ideations for the past two years, and recommended referral for mental health therapy and medication management as needed, along with ongoing monitoring of suicidal ideations. The care plan identified her as significantly mentally ill and included interventions such as referral for mental health therapy and medication management as needed, psychology consult as needed or recommended, and use of facility resources to meet her needs. A separate trauma-informed care plan also listed arranging services from a licensed mental health provider as indicated. Despite these documented needs and recommendations, there was no documentation in the medical record that Resident 77 was ever offered therapy or counseling services. The RA stated she did not think the resident would want counseling, while the DON stated therapy services were offered but the resident refused, though no documentation was made of when services were offered. The Administrator and Director of Clinical Services stated the resident had been offered therapy shortly after admission and refused, but also acknowledged that offering mental health services should be documented in the resident’s medical record.
Expired medications and vaccines found in storage
Penalty
Summary
Drugs and biologicals in the facility were not stored and labeled in accordance with accepted professional principles because multiple expired items were found in the medication storage room and medication refrigerators and were available for resident use. On 10/8/25 at 2:05 PM, surveyors observed one bottle of Naproxen tablets expired 9/25, two bottles of Vitamin C tablets expired 8/25, one bottle of Calcium tablets expired 7/24, Multi-Symptom Day Cold/Flu medicine expired 9/24 on the box with the medication inside showing an expiration date of 9/22, Anti-Anxiety Relief bottles expired 10/2/23, 6/2/24, and 7/24/24, Fiber Therapy expired 12/22/24, one bottle of Fiber Powder expired 3/25, two boxes of Fiber Lax caplets expired 9/25, a box containing twenty-three bottles of protein shake supplements expired 3/1/25, Ammonium Lactate expired 7/25, Arginine powder/Arginaid expired 8/6/25, and two bottles of Magnesium Citrate oral solution expired 9/13/25. Expired biologicals were also present in the medication fridge, including three boxes of influenza vaccines expired 6/29/25 and Covid vaccines expired 3/29/25. On 10/9/2025 at 10:57 AM, the DCS and DON stated that night shift nurses were supposed to go through expired medications and return them to the pharmacy, and they stated the pharmacy came to the facility daily except Sunday.
MRI Not Scheduled After Orthopedic Recommendation
Penalty
Summary
The facility did not provide or obtain radiology services to meet the needs of a resident when an MRI of the left shoulder was recommended but not scheduled. Resident 3 was admitted and later readmitted with diagnoses including cerebral infarction, hemiplegia and hemiparesis, neurologic neglect, dysphagia, major depressive disorder, insomnia, and mild-protein calorie malnutrition. During an interview, the resident stated she had a subluxation of the left shoulder, had gone to a doctor’s appointment about 3 weeks earlier, and still had not had the MRI scheduled. Record review showed that after an orthopedic appointment, the provider noted atrophy of the left shoulder with intact rotator cuff tendons and recommended an MRI of the left shoulder, along with more intensive post-stroke care in a neuro rehab facility. The medical director was notified. Interviews with staff later showed the MRI referral had been received by the ADON, but the Administrator and DON could not locate the MRI appointment on the transport spreadsheet, and there were no documents for the resident’s MRI in the transport director’s folder.
Failure to Honor Lactose Intolerance on Meal Trays
Penalty
Summary
The facility failed to provide food that accommodated a resident's lactose intolerance and food preferences. Resident 50 was admitted with diagnoses including type 2 diabetes, irritable bowel syndrome, and lactose intolerance, and his meal ticket stated, "LACTOSE INTOLERANT, NO MILK OR PRODUCTS AT ALL." During interview, the resident stated that dairy products were frequently placed on his meal trays despite repeated discussions with CNA staff and kitchen staff about his intolerance. He reported that he had to constantly watch for dairy because consuming it caused diarrhea. The resident stated that ranch dressing was often served with his salad and that when he asked for a substitute, he was told ranch was the only dressing available. During observation, his lunch tray included ranch dressing, which he gave to his roommate, and he planned to eat the side salad dry because no substitute was available. When he uncovered the salad, he found cheese shavings mixed into it. CNA 2 stated that food allergies were listed on the meal ticket and that substitutes were available, though the substitute for ranch dressing was not always in stock. The Dietary Manager stated that a lactose intolerant resident would not be served ranch dressing or cheese, and the DON stated that staff were expected to check meal trays before delivery and that substitutes were expected to be available in the kitchen.
Food Service Safety Deficiency
Penalty
Summary
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. During an initial tour of the kitchen, it was observed that dietary aides were handling dirty dishes and then touching clean dishes without changing gloves or performing hand hygiene. The dish machine temperatures were consistently below the required range, and the sanitizer solution was at 100 parts per million of chlorine, which is below the standard. Additionally, a meal cart was observed with a dried white substance dripping from the vents, and cups stored in the clean area had a white residue inside them. Resident 84 reported that the cups were dirty with a white film, which he could wipe off with his finger, and he requested to use only Styrofoam cups. During a follow-up kitchen tour, the same issues were observed, including the dish machine temperatures being below the required range and staff handling clean dishes after touching dirty surfaces without changing gloves or performing hand hygiene. The Dietary Manager (DM) acknowledged the issues with the dish machine temperatures and the white residue in the cups, attributing it to hard water buildup. The DM stated that the facility was looking into installing a water softener and that the glasses were soaked in lime-away weekly and then re-washed. The DM was not aware that staff were putting clean dishes away after touching dirty surfaces with soiled gloves.
Failure to Maintain a Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for four residents. Observations revealed that fly strips covered in dead flies were present in multiple resident rooms, including rooms 101 and 200. Housekeeper 1 admitted to not handling the fly strips and expressed frustration about their presence. Interviews with residents indicated that the fly strips had been in place for an extended period, with one resident noting that the strip had been up since last summer. The Maintenance Director confirmed that fly strips were typically put up in the spring or fall and were supposed to be changed monthly, but some rooms with fly strips were not logged properly. The Administrator stated that a pest control company sprayed the facility monthly and that UV lights had been installed to reduce insect presence. However, the log of fly strips was incomplete, missing entries for rooms 101 and 200. The Maintenance Director acknowledged that fly strips were placed in rooms upon resident request and were supposed to be changed more frequently if heavily populated with flies. Despite these measures, the facility did not maintain a sanitary and comfortable environment, as evidenced by the neglected fly strips in resident rooms.
Inconsistent Meal Service Times and Insufficient Support Personnel
Penalty
Summary
The facility did not provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition services. Specifically, meals were served later than the posted meal times, and there were inconsistencies between the meal times provided to surveyors and those posted in the dining room. Residents also complained about the late meals. Observations on multiple days showed that meal carts were delivered to various hallways and the main dining room at times that did not align with the posted schedule. For example, on 4/22/24, the first tray was served at 12:13 PM in the 200 hallway, and the last meal was served in the main dining room at 1:02 PM, which was later than the posted times. Similar delays were observed on 4/24/24, with the first tray served in the 200 hallway at 12:07 PM and the last meal in the dining room at 12:58 PM. Interviews with residents revealed dissatisfaction with the meal service times, with one resident stating that meals were always late and another expressing confusion about when meals would be served due to inconsistent timing. Interviews with staff, including the Administrator and Dietary Manager, indicated that there were recent changes to meal times, and the posted schedule in the dining room was incorrect. The Dietary Manager stated that meals were usually delivered on time, but the observations and resident complaints contradicted this claim. The Administrator confirmed that dietary staff delivered hall trays first, followed by the main dining room, and then residents requiring assistance. The discrepancies between the posted meal times, the times provided to surveyors, and the actual delivery times, along with resident complaints, highlight the deficiency in providing sufficient support personnel for the food and nutrition services.
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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.
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| George E. Wahlen Ogden Veterans Home | 2.1 mi | ★★★★★ | 0 | 0 |
| Harrison Pointe Healthcare And Rehabilitation | 5 mi | ★★★★★ | 5 | 0 |
| Crestwood Rehabilitation And Nursing | 5.3 mi | ★★★★★ | 4 | 0 |
| Stonehenge Of Ogden | 6.3 mi | ★★★★★ | 0 | 0 |
| Mt Ogden Health And Rehabilitation Center | 7.3 mi | ★★★★★ | 0 | 0 |
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