Peaks Care Center, The
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
she was removed from the floor on 7/11/25. He said she was not yelling out in pain and there was no bleeding. He said the resident had a large hematoma on her head. He said he also performed an overall assessment on the resident. He said the resident did not report any pain in the bony areas. He said he did not recall if the resident had any pain in the rib cage area. He said neurological assessments were started and he was unable to recall the resident's transfer status.CNA #2 was on 10/29/25 at 11:35 a.m. CNA #2 said she had worked with Resident #4. She said the resident was a one-person gait belt transfer. She said
the resident was also a stand-to-pivot for transfers. She said to transfer the resident when seated on the bed, she would place the wheelchair in front of the resident. CNA #2 said she would be standing in front of
the resident, place her hands on the gait belt and pivot the resident into the wheelchair. She said 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 #2 said this methodology of transferring the resident was the safest and easiest way to transfer Resident #4. She said the resident was usually strong and she had not had any issues with transfers with her.CNA #3 was interviewed on 10/29/25 at 11:45 a.m. CNA #3 said she had worked with Resident #4. She said the resident was a one-person gait belt strand to pivot transfer. She said if the resident was seated on the bed, she would either place the wheelchair in front of the resident or at an angle with the front of the wheelchair closest to the bed. She said if she were in front of the resident, she would place both hands on the gait belt and pivot the resident into the wheelchair. She said if she were in front of the resident, she would be able to protect the resident from a fall easier. She said there were times
she placed the wheelchair at an angle and positioned herself between the bed and the wheelchair. She said she would place her hand on the gait belt on the resident's back and assist with the transfer. She said
she would not know how she would protect the resident from falling forward using this method for transfers.The DON was interviewed again on 10/29/25 at 12:42 p.m. The DON agreed the staff were taught how to transfer a resident with a gait belt by the Transferring a Resident training slides. The DON said the slides demonstrated that staff were to be straight on (in front of) with the resident, hold onto the gait belt and then pivot the resident to the wheelchair. The DON said Resident #4 was a one-person gait belt stand-to-pivot for transfers. The DON said the weekly skin assessment dated [DATE REDACTED] revealed the resident had no skin issues (bruising) and this was incorrect. She said the resident had bruises on the left side of her eye orbit, forehead and cheek. She said the resident fell forward onto the floor during the transfer with CNA #1 on 7/11/25. The DON agreed with the 7/12/25 hospital CT scan results. The DON said the facility wanted all residents to be transferred safely and staff were to transfer residents with gait belts according to
the Transfer a Resident in-service slides (see above). The DON said during the morning meetings, falls were discussed and part of the risk management portion for falls included any environmental contributing factors. The DON said LPN #1's progress note nor the incident report for Resident #4's fall mentioned any environmental issues as contributing factors to the fall.The NHA was interviewed on 10/29/25 at 1:38 p.m.
The NHA said the provided Transfer a Resident in-service slides were reviewed for the all staff meetings on 7/31/24 and 7/15/25. He said CNA #1 was hired on 6/19/25 and had completed/demonstrated competency
in resident transfers. The NHA said facility staff should transfer residents according to the in-services unless therapy made different recommendations. The NHA said CNA #1 was given a verbal reprimand related to making sure the resident wore appropriate footwear before the transfer on 7/11/25.
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If continuation sheet
PEAKS CARE CENTER, THE in LONGMONT, CO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LONGMONT, CO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PEAKS CARE CENTER, THE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.