The Peaks Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at The Peaks Health & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF760Aug 11, 2022

  Based on facility documents and closed clinical record review, staff interviews, and review of policies, the facility failed to ensure one resident (#81) was free from a significant medication error. The deficient practice could result in adverse medication side effects for a resident. Findings include: Resident #81 was admitted to the facility on [DATE] and discharged from the facility on December 3, 2021. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan revealed an undated problem: Black Box Warnings for Antipsychotics: [MEDICATION(S)]; Adverse cardiovascular effects, risk for infections, falls, blood glucose and lipid elevations, abnormal involuntary movement, [CONDITION(S)] adverse events like stroke, sedation. […]

• No harm, potential for more than minimal, patternF812Feb 12, 2026

  Based on observations, staff interviews and policy review, the facility failed to ensure expired food items in the kitchen were discarded, food items were dated and stored correctly. The deficient practice could result in possible food-borne illnesses and unwanted pests. Findings include: An initial kitchen observation was conducted on February 10, 2026 at 11:11 a.m. with the Dining Services Director (Staff #15). At this time an observation of the main kitchen refrigerator was conducted with Staff #15, the following was observed;Twenty small bowls with corn salad on a baking sheet uncovered with no dates or labelsLarge clear container with cantaloupe and honeydew open and exposed to airClear containers with peeled mandarins in liquid (x2) open and exposed to airRoughly, half of a chocolate… […]

• No harm, potential for more than minimal, patternF842Jan 29, 2025

  Based on staff interview, review of facility documentation, and policy, the facility failed to ensure that facility documents regarding grievances, reportables and resident council meeting minutes were available. The deficient practice could result in documentation regarding residents' issues and concerns pertaining to life and safety not being readily available. Findings include: The copy of the December 2023 self-reports and investigations, December 2023 grievance logs, and December 2023 Resident Council Meeting Minutes was requested from the facility on January 29, 2025 at 8:24 a.m. An email from the Executive Director (ED/staff #96) was received on January 29, 2025 at 10:13 a.m. […]

• No harm, potential for more than minimal, patternF658Nov 7, 2024

  Based on observations, staff interviews, and review of facility policy, the facility failed to ensure that care and services met professional standards of practice regarding medication administration for one of six sampled residents (#3). The deficient practice could result in residents not receiving the appropriate medication and for additional errors in medication administration. Findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes without complications, essential hypertension, hyperlipidemia, and Alzheimer's disease. […]

• No harm, potential for more than minimal, patternF759Nov 7, 2024

  Based on observations, staff interviews, record review, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for one resident (#3). The medication error rate was 21.43%. Six medication administration errors were identified out of 28 opportunities during medication administration observation. The deficient practice could result in further medication errors. Findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes without complications, essential hypertension, hyperlipidemia, and Alzheimer's disease. […]