Peaks Care Center, The

In the surveyor’s words

From the most serious findings on record at Peaks Care Center, The, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 29, 2025

  Based on observations, record review and interviews, the facility failed to ensure residents had adequate supervision and assistive devices to prevent accidents for one (#4) of six residents reviewed for accident hazards out of six sample residents. Specifically, the facility failed to ensure staff followed the appropriate transfer techniques when transferring residents, which resulted in Resident #4 sustaining rib fractures following a fall that occurred during an improper transfer with CNA #1.Resident #4, who had a history of falling, was admitted on [DATE] and readmitted on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Apr 9, 2026

  Based on observations, record review and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to:-Ensure dietary staff washed their hands and changed single-use glove use appropriately during meal service;-Ensure meat was thawed according to safe food handling practices;-Ensure staff wore hair nets during food preparation; -Ensure the microwave was maintained in good repair and safe condition; and,-Ensure staff maintained sanitary conditions in the kitchen when eating at a food preparation table. Findings include:I. Hand hygieneA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, were retrieved on 4/16/26. […]

• No harm, potential for more than minimal, patternF658Apr 9, 2026

  Based on observations, record review and interviews, the facility failed to ensure four (#5, #9, #47 and #61) of four residents out of 39 sample residents were provided services that met professional standards of quality. Specifically, the facility failed to: -Ensure staff obtained a physician's order specifying personalized settings for air mattresses for Resident #5, Resident #9, Resident #47 and Resident #61; and, -Ensure staff maintained air mattresses according to the manufacturer's recommendations for Resident #5, Resident #9, Resident #47 and Resident #61.Findings include: I. […]

• No harm, potential for more than minimal, patternF695Apr 9, 2026

  Based on observations, record review and interviews, the facility failed to ensure staff provided respiratory care consistent with professional standards of practice for three (#57, #52 and #5) of five residents reviewed for oxygen services out of 39 sample residents. Specifically, the facility failed to:-Ensure there was a physician's order in place for Resident #57's continuous positive airway pressure (CPAP) machine and routine maintenance of the CPAP; and,-Ensure there were appropriate oxygen orders in place for Resident #52 and Resident #5.Findings include: I. Professional reference According to Nursing Skills, Open Resources for Nursing (Open RN); Ernstmeyer K, [NAME] E, editors. […]

• No harm, potential for more than minimal, patternF761Apr 9, 2026

  Based on observations and interviews, the facility failed to provide proper storage for medications for four of five medication carts and one of three medication storage rooms. Specifically, the facility failed to:-Ensure eye drops, inhalers and Tuberculin Purified Protein Derivative (PPD) vials were labeled with the date they were opened;-Ensure glucometer test strips and glucose control solutions were labeled with the date they were opened; and,-Ensure glucometer test strips and glucose control solutions were discarded when expired.Findings include:I. […]