Deficiencies (last 5 years)
Deficiencies (over 5 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 29, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with nursing home regulations, focusing on resident safety and care practices.
Findings
The facility failed to ensure adequate supervision and proper transfer techniques for residents, resulting in a resident sustaining rib fractures from a fall during an improper transfer. Staff did not consistently follow facility policies on resident transfers, including appropriate use of gait belts and footwear.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents, resulting in a resident sustaining rib fractures during an improper transfer.
Report Facts
Residents reviewed for accident hazards: 6
Resident involved in fall: 1
Date of fall incident: Jul 11, 2025
Date survey completed: Oct 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in improper transfer leading to resident fall and injury |
| LPN #1 | Licensed Practical Nurse | Completed incident report and assessed resident after fall |
| RN #1 | Registered Nurse | Assessed resident after fall and conducted neurological assessments |
| NHA | Nursing Home Administrator | Interviewed regarding staff training and reprimand of CNA #1 |
| DON | Director of Nursing | Interviewed regarding transfer policies and resident care |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 29, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall incident involving Resident #4, focusing on the facility's failure to ensure adequate supervision and proper transfer techniques to prevent accidents.
Complaint Details
The complaint investigation was substantiated, finding that the facility failed to follow proper transfer protocols, leading to Resident #4's fall and subsequent rib fractures. CNA #1 was verbally reprimanded but not re-educated on transfer techniques.
Findings
The facility failed to ensure staff followed appropriate transfer techniques during a resident transfer, resulting in Resident #4 sustaining rib fractures after a fall. The investigation revealed inadequate staff training and supervision, improper use of gait belts, and failure to ensure appropriate footwear, contributing to the accident.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Report Facts
Residents reviewed for accident hazards: 6
Residents affected: 1
Date of fall incident: Jul 11, 2025
Date of hospital transfer: Jul 12, 2025
Heart rate: 90
Oxygen flow rate: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Involved in improper transfer leading to Resident #4's fall |
| LPN #1 | Licensed Practical Nurse | Completed incident report and assessed Resident #4 post-fall |
| RN #1 | Registered Nurse | Assessed Resident #4 after fall and during hospital transfer |
| DON | Director of Nursing | Interviewed regarding transfer protocols and fall incident |
| NHA | Nursing Home Administrator | Interviewed regarding staff training and reprimand of CNA #1 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 20, 2024
Visit Reason
The inspection was conducted due to complaints regarding inadequate supervision and failure to assess residents after unwitnessed falls at Peaks Care Center.
Complaint Details
The complaint investigation found that for residents #3 and #9, the facility did not have RN, NP, or physician assessments prior to moving residents off the floor after unwitnessed falls on multiple dates. The residents sustained injuries including bruising, lacerations, and pain. The facility's fall prevention policies were reviewed and staff interviews confirmed the lack of required assessments.
Findings
The facility failed to provide adequate supervision and assistance to prevent falls and did not have a registered nurse, nurse practitioner, or physician assess residents after unwitnessed falls before moving them off the floor. Multiple falls involving two residents were documented with insufficient post-fall assessments.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision and assistance to prevent falls and did not have a licensed nurse or physician assess residents after unwitnessed falls before moving them off the floor.
Report Facts
Fall risk score: 7
Fall risk score: 11
Fall risk score: 9
Fall risk score: 16
Pain rating: 3
Pain rating: 2
Pain rating: 3
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 20, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide adequate supervision and assistance to prevent falls, and failure to assess, implement, and monitor interventions consistent with resident needs for residents with a history of falls.
Complaint Details
The investigation was complaint-related, focusing on falls involving residents #3 and #9. The complaint was substantiated as the facility failed to perform required assessments by licensed nurses or physicians before moving residents off the floor after falls.
Findings
The facility failed to have a registered nurse, nurse practitioner, or physician assess residents after unwitnessed falls prior to moving them off the floor. Multiple falls were documented involving residents #3 and #9, with inadequate post-fall assessments and interventions. The facility's fall prevention policies and interventions were reviewed, and staff interviews confirmed the lack of required assessments after falls.
Deficiencies (1)
Failure to have a registered nurse, nurse practitioner, or physician assess residents after unwitnessed falls prior to removal from the floor.
Report Facts
Fall risk score: 7
Fall risk score: 11
Fall risk score: 9
Fall risk score: 16
Fall risk score: 11
Pain rating: 3
Pain rating: 2
Pain rating: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Interviewed about fall assessment procedures and facility practices |
| LPN #3 | Licensed Practical Nurse | Interviewed about fall assessment procedures and facility practices |
| LPN #1 | Licensed Practical Nurse | Interviewed about fall assessment procedures and facility practices |
| NHA | Nursing Home Administrator | Interviewed regarding fall incidents and facility policies |
| DON | Director of Nursing | Interviewed regarding fall incidents and facility policies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 29, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure quality of care and proper communication related to medication orders for Resident #45.
Complaint Details
The complaint investigation focused on Resident #45, who did not receive medications ordered by a cardiac specialist for nearly two months, resulting in multiple paracentesis procedures. The facility staff acknowledged communication failures and lack of collaboration between providers. The facility implemented a Quality Assurance Orders Action Plan to improve collaboration and communication.
Findings
The facility failed to notify Resident #45's cardiac specialist when the facility chose not to implement the specialist's recommended physician's orders and failed to inform the resident about medications ordered by the specialist that were not implemented. Additionally, the facility failed to ensure proper labeling and timely removal of expired and discontinued medications in medication carts and storage rooms.
Deficiencies (2)
Failure to notify cardiac specialist and resident about non-implementation of specialist's medication orders for Resident #45.
Failure to ensure medications were labeled with the date opened and removal of expired and discontinued medications in medication carts and storage rooms.
Report Facts
Residents reviewed: 26
Residents affected: 1
Paracentesis procedures: 3
Medication delay: 2
Medication doses: 12.5
Medication doses: 25
Medication doses: 25
Medication doses: 12.5
Medication order period: 14
Medication carts: 5
Medication storage rooms: 3
Expired vaccine vials: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Signed off on specialist orders but did not enter them into EMR or notify resident |
| DON | Director of Nursing | Interviewed multiple times regarding communication failures and facility policies |
| NP | Nurse Practitioner | Decided not to start specialist-ordered medications due to low blood pressure concerns |
| PA | Physician Assistant | Interviewed about medication orders and documentation practices |
| PH | Physician | Facility physician who discussed communication and order signing processes |
| HVP | Heart and Vascular Physician | Specialist whose medication orders were not implemented timely and not communicated with |
| LPN #5 | Licensed Practical Nurse | Discussed order implementation and documentation practices |
| LPN #2 | Licensed Practical Nurse | Discussed order signing and documentation practices |
| LPN #3 | Licensed Practical Nurse | Observed medication cart and discussed labeling and expiration issues |
| RN #2 | Registered Nurse | Observed medication storage room and noted expired vaccines |
| NHA | Nursing Home Administrator | Interviewed about expectations for resident notification and provider communication |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 29, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to ensure quality of care and communication related to medication orders for Resident #45.
Complaint Details
The complaint investigation focused on Resident #45's medication orders from a cardiac specialist that were not implemented timely or communicated properly. The complaint was substantiated with findings of delayed medication administration and poor communication.
Findings
The facility failed to notify Resident #45's cardiac specialist when the facility chose not to implement the specialist's recommended physician's orders and failed to inform the resident about medications ordered but not implemented. Additionally, the facility failed to ensure proper labeling and timely removal of expired and discontinued medications in medication carts and storage rooms.
Deficiencies (2)
F 0684: The facility failed to notify the cardiac specialist and resident when medications ordered by the specialist were not implemented, resulting in delayed treatment for Resident #45.
F 0761: The facility failed to label medications with the date opened and did not timely remove expired and discontinued medications from medication carts and storage rooms.
Report Facts
Residents reviewed: 26
Residents affected: 1
Paracentesis procedures: 3
Medication delay: 2
Medication carts: 5
Medication storage rooms: 3
Expired vaccine vials: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Signed off on specialist orders but did not enter them into EMR or notify resident |
| DON | Director of Nursing | Interviewed multiple times regarding communication failures and facility policies |
| NP | Nurse Practitioner | Decided not to start medications due to low blood pressure and did not communicate with specialist |
| PA | Physician Assistant | Interviewed about medication orders and documentation practices |
| PH | Physician | Facility physician who discussed communication and order signing policies |
| LPN #3 | Licensed Practical Nurse | Observed medication cart with unlabeled inhalers and expired insulin |
| RN #2 | Registered Nurse | Observed expired vaccines in medication storage room |
| LPN #5 | Licensed Practical Nurse | Discussed documentation of non-implemented orders |
| LPN #2 | Licensed Practical Nurse | Discussed order changes and documentation practices |
| Heart and Vascular Physician (HVP) | Specialist Physician | Interviewed regarding delayed and non-implemented medication orders |
| NHA | Nursing Home Administrator | Interviewed about expectations for resident notification and provider communication |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 19, 2023
Visit Reason
The inspection was conducted as an annual survey of Peaks Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Jul 19, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Peaks Care Center, a nursing home, related to a regulatory survey completed on 07/19/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Dec 10, 2019
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements and evaluate the facility's adherence to standards related to resident care, safety, and food service.
Findings
The facility was found deficient in multiple areas including failure to post survey results accessibly, failure to inform a resident about bed hold policy upon hospital transfer, inadequate skin assessments for a resident's bruise, failure to address significant weight loss in a resident, poor food quality and preparation, unsafe food storage and handling practices, and inadequate infection control practices related to wound care supplies.
Deficiencies (7)
Failed to post survey results in a place readily accessible to residents and family members, and failed to include results from the preceding three years.
Failed to notify resident or representative in writing about bed hold policy upon hospital transfer for one resident.
Failed to accurately and thoroughly complete skin assessments to monitor a bruise on a resident's left forearm.
Failed to ensure a resident received adequate nutrition resulting in significant weight loss and failed to assess, evaluate, and document the weight loss or notify the physician.
Failed to provide food that was palatable, attractive, and appetizing; food was undercooked, overcooked, bland, runny, dry, and tough for multiple residents.
Failed to store, prepare, distribute, and serve food in accordance with professional standards including disposal of expired foods, improper labeling and covering of foods, improper storage temperatures, unclean kitchen and equipment, potential contamination, improper thawing practices, and inaccurate food temperature logs.
Failed to properly sanitize/disinfect scissors and other equipment used for multiple residents before and after wound care, risking cross contamination.
Report Facts
Residents reviewed: 33
Weight loss percentage: 9
Weight loss percentage: 13
Number of residents affected: 9
Temperature: 45
Temperature: 42
Wound measurements: 4
Wound measurements: 5.7
Wound measurements: 2.9
Wound undermining measurement: 2.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed performing wound VAC change and improper sanitization of wound care supplies |
| DON | Director of Nursing | Interviewed regarding infection control and wound care supply sanitization practices |
| CDM | Certified Dietary Manager | Interviewed regarding food service deficiencies and kitchen sanitation |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding nutritional care and weight monitoring |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding nutritional care and weight monitoring |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding nutritional care and weight monitoring |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding nutritional supplements provided to resident |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Dec 10, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home operations, including resident care, food service, infection control, and administrative policies.
Findings
The facility was found deficient in multiple areas including failure to post survey results accessibly, failure to notify a resident of bed hold policy upon hospital transfer, inadequate skin assessments for a resident's bruise, failure to maintain adequate nutrition for a resident with significant weight loss, poor food quality and preparation, unsafe food storage and handling practices, and inadequate infection prevention practices related to wound care supplies.
Deficiencies (7)
F 0577: The facility failed to post survey results in a place readily accessible to residents and families, and failed to include results from the preceding three years.
F 0625: The facility failed to notify Resident #73 in writing of the bed hold policy when transferred to the hospital.
F 0684: The facility failed to accurately and thoroughly complete skin assessments to monitor a bruise on Resident #36's left forearm.
F 0692: The facility failed to ensure Resident #63 received adequate nutrition, resulting in significant weight loss and failure to obtain weekly weights as ordered.
F 0804: The facility failed to provide palatable, attractive, and properly cooked food for nine residents, including undercooked eggs and tough, overcooked meat.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including expired foods, unlabeled and uncovered foods, improper temperatures, and poor cleanliness.
F 0880: The facility failed to properly sanitize and disinfect wound care equipment, including scissors, flashlight, and marker, used for multiple residents, risking cross contamination.
Report Facts
Weight loss percentage: 9
Weight loss percentage: 13
Resident sample size: 33
Resident count in interviews: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in infection control deficiency related to wound care equipment sanitation. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including skin assessments and infection control. |
| CDM | Certified Dietary Manager | Interviewed regarding food service deficiencies and food safety practices. |
| NHA | Nursing Home Administrator | Interviewed regarding survey results posting and bed hold policy notification. |
Inspection Report
Deficiencies: 12
Date: Dec 13, 2018
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, medication management, infection control, and other aspects of facility operations.
Findings
The facility was found to have multiple deficiencies including failure to disperse resident personal funds timely after discharge, failure to report alleged abuse, failure to ensure physician orders for oxygen and catheter care, medication administration errors, inadequate assistance with activities of daily living, improper positioning and pressure sore prevention, environmental safety hazards, inadequate dialysis communication, failure to ensure timely physician visits, incomplete psychotropic medication assessments, improper medication storage, and infection control lapses related to sanitation and labeling of personal hygiene items.
Deficiencies (12)
Failure to ensure money from personal funds accounts was dispersed within 30 days after discharge for four discharged residents.
Failure to timely report suspected abuse and neglect to proper authorities for one resident.
Failure to ensure physician orders for oxygen therapy for multiple residents and catheter care orders for one resident.
Medications left at bedside and not administered timely for one resident.
Failure to provide assistance with eating and positioning for residents, leading to risk of aspiration and discomfort.
Failure to position resident properly and apply physician-ordered pressure-relieving heel-lift boots.
Environmental hazards including unsecured sliding glass doors leading to outdoor courtyard, unsafe storage of cleaning chemicals and sharps, and unsafe storage of razors in shower rooms.
Failure to provide ongoing communication and coordination between nursing home and dialysis center for one resident receiving dialysis.
Failure to ensure resident was seen by physician every 30 days for the first 90 days after admission.
Failure to complete necessary provider assessment every 14 days for continued use of as-needed psychotropic medication.
Failure to remove expired and undated medications and properly date opened multi-dose vials on medication carts.
Failure to ensure infection control practices including labeling of personal hygiene items, adherence to disinfectant dwell times, and proper shower room sanitation.
Report Facts
Discharged residents with undistributed personal funds: 4
Residents reviewed for abuse: 39
Residents reviewed for oxygen and catheter care: 39
Residents reviewed for medication administration: 39
Residents reviewed for activities of daily living: 39
Residents reviewed for environmental safety: 2
Residents reviewed for dialysis care: 1
Residents reviewed for physician visits: 39
Residents reviewed for psychotropic medication use: 5
Expired medication found: 1
Undated opened insulin vials: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication administration and insulin dating |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding resident physician visits and psychotropic medication |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding oxygen therapy orders |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding medication cart observations and resident care |
| CNA #3 | Certified Nurse Aide | Interviewed regarding shower cleaning procedures |
| CNA #5 | Certified Nurse Aide | Interviewed regarding environmental safety and shower cleaning |
| CNA #7 | Certified Nurse Aide | Interviewed regarding resident repositioning and pressure sore prevention |
| CNA #8 | Certified Nurse Aide | Interviewed regarding shower cleaning and towel labeling |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication management, physician visits, and environmental safety |
| SDC | Staff Development Coordinator / Infection Control Nurse | Interviewed regarding infection control practices and environmental hazards |
| Pharmacist | Interviewed regarding medication dating and expiration |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Dec 13, 2018
Visit Reason
Annual inspection of Peaks Care Center to assess compliance with regulatory requirements including resident care, safety, medication management, infection control, and facility environment.
Findings
The facility had multiple deficiencies including failure to disperse resident funds timely after discharge, failure to report alleged abuse, lack of physician orders for oxygen use, medication administration issues, inadequate assistance with activities of daily living, improper positioning and use of pressure-relieving devices, environmental hazards, poor communication with dialysis center, failure to ensure timely physician visits, incomplete psychotropic medication assessments, improper medication storage, and inadequate infection control practices.
Deficiencies (11)
F 0569: Facility failed to ensure money from personal funds accounts was dispersed within 30 days after discharge for four discharged residents.
F 0609: Facility failed to timely report alleged violations of potential abuse to the state survey agency for one resident.
F 0658: Facility failed to ensure professional standards of quality for catheter care, oxygen orders, and medication administration for multiple residents.
F 0676: Facility failed to ensure residents did not lose ability to perform activities of daily living without medical reason, including failure to assist with eating and positioning.
F 0684: Facility failed to position resident properly and provide physician-ordered heel-lift boots to relieve pressure.
F 0689: Facility failed to provide an environment free from accident hazards including unsecured sliding glass doors and unsafe storage of cleaning and personal items.
F 0698: Facility failed to provide safe, appropriate dialysis care with ongoing communication and coordination between nursing home and dialysis center.
F 0712: Facility failed to ensure resident was seen by physician every 30 days for first 90 days after admission.
F 0758: Facility failed to complete necessary provider assessment every 14 days for continued use of as-needed psychotropic medication.
F 0761: Facility failed to ensure all medications and biologicals were stored and labeled properly, including removal of expired and undated medications from medication carts.
F 0880: Facility failed to ensure infection control practices to prevent cross-contamination, including lack of labeling personal hygiene items, improper disinfection dwell times, and lack of standard shower room cleaning procedures.
Report Facts
Residents reviewed: 39
Discharged residents with undistributed funds: 4
Residents affected by abuse reporting failure: 1
Residents affected by oxygen order issues: 3
Residents affected by medication administration issues: 1
Residents affected by ADL assistance issues: 2
Residents affected by positioning and pressure relief issues: 1
Residents affected by environmental hazards: 2
Residents affected by dialysis communication issues: 1
Residents affected by physician visit delays: 1
Residents affected by psychotropic medication assessment delays: 1
Medication carts with expired or undated medications: 2
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