Peaks Care Center: Accident Hazard Harm - CO
The resident at Peaks Care Center sustained fractures to her left fifth, sixth, and seventh ribs, along with a large hematoma on her head, according to a CT scan performed the following day at the hospital. Federal inspectors found the facility had trained staff on proper transfer techniques but the nursing assistant violated those procedures.
CNA #1 told investigators she positioned herself between the bed and wheelchair during the transfer, placing her hand on the resident's gait belt from behind. When asked how she would protect the resident from falling forward using this method, she said she would not know how.
The facility's own training materials specified that staff should position themselves directly in front of residents during stand-to-pivot transfers, holding the gait belt with both hands to guide them safely into wheelchairs.
Two other nursing assistants who worked with the same resident confirmed the proper technique. CNA #2 said she always stood in front of the resident with hands on the gait belt, explaining that "if the resident happened to fall forward, in this position, she would be able to safely guide the resident to the wheelchair or the floor."
CNA #3 described the same positioning, noting that when staff stood in front of residents, "she would be able to protect the resident from a fall easier." She acknowledged that when positioned at an angle between the bed and wheelchair, "she would not know how she would protect the resident from falling forward."
The resident required a one-person gait belt transfer and was typically strong during transfers, according to staff interviews. She had no documented skin issues or bruising on her weekly assessment prior to the incident.
After the fall, the resident developed visible bruises on the left side of her eye orbit, forehead and cheek. The licensed practical nurse who responded said the resident was not crying out in pain and had no bleeding, but noted the large head hematoma during his assessment.
Neurological assessments were initiated following the incident, though the LPN could not recall the resident's transfer status or whether she reported rib cage pain during his evaluation.
The facility's Director of Nursing acknowledged that the weekly skin assessment dated after the fall incorrectly documented that the resident had no skin issues, when she actually had multiple facial bruises. The assessment failed to capture the extent of injuries from the transfer incident.
Investigators found gaps in the facility's incident documentation. Neither the progress note nor the incident report mentioned any environmental factors that might have contributed to the fall, despite facility policy requiring discussion of such factors during morning meetings as part of fall risk management.
The nursing home administrator confirmed that CNA #1 had completed and demonstrated competency in resident transfers when hired three weeks before the incident. He said the facility had reviewed proper transfer techniques during all-staff meetings in July 2024 and July 2025, using the same training slides that specified front positioning.
Staff were expected to follow the standardized transfer procedures unless physical therapy made different recommendations for specific residents. No such alternative instructions existed for this resident's care plan.
The administrator said CNA #1 received a verbal reprimand related to ensuring residents wear appropriate footwear before transfers, but inspection records did not indicate whether additional corrective action addressed the improper positioning that caused the fall.
The incident occurred during CNA #1's fourth week of employment at the facility. Despite completing transfer competency training, she used a positioning method that her colleagues recognized as unsafe and that contradicted the facility's own training materials.
Federal inspectors determined the improper transfer technique caused actual harm to the resident, who required hospitalization for evaluation of her rib fractures and head trauma.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Peaks Care Center, The from 2025-10-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PEAKS CARE CENTER, THE in LONGMONT, CO was cited for violations during a health inspection on October 29, 2025.
Federal inspectors found the facility had trained staff on proper transfer techniques but the nursing assistant violated those procedures.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.