Peaks Care Center, The
PEAKS CARE CENTER, THE in LONGMONT, CO — inspection on October 29, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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] 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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