Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Peaks Care Center, The during CMS and state inspections, most recent first.
A cook repeatedly handled food, meal tickets, clean plates, and equipment with the same gloves during meal service without proper hand hygiene or glove changes, including after touching the floor and wiping the prep area. Staff also thawed frozen goulash in an unheated steamer, several kitchen staff were observed without proper hair restraints, the microwave had peeling and bubbling paint, and an aide ate lunch at a food prep table in the kitchen.
Air mattress settings were not properly specified or documented for four residents. The physician orders required air mattresses and shift checks for wound healing and prevention, but did not identify the correct settings, and the EMRs did not show assessments or routine monitoring documentation. Staff said settings were checked by touch or based on weight, but the records for the residents did not document the needed settings, and one resident’s mattress was observed at a setting that did not match the resident’s weight.
Missing and incorrect respiratory orders led to deficient care for three residents. A resident using CPAP had no physician order for the machine or its routine cleaning and maintenance, and the CPAP mask was left out in the room. Two other residents had oxygen orders that did not match their actual use or lacked a clear flow rate; staff and the DON acknowledged the orders were incorrect, and observations showed one resident not receiving oxygen continuously as ordered.
Multiple medication carts and storage areas contained opened eye drops, an inhaler, a PPD vial, glucometer test strips, and glucose control solutions that were not labeled with the date opened. Staff on several units stated the items were usable until the printed expiration date, while the DON said there was confusion about which medications required open dates and acknowledged that patient-specific meds and glucometer supplies still needed labeling.
Infection control procedures were not maintained when staff failed to wear EBP PPE during high-contact care for a resident with an indwelling catheter, including a slide-board transfer and catheter irrigation. Staff also did not offer hand hygiene before meals in resident rooms and the dining room, and no wipes or sanitizer were available on meal carts or tables. In addition, a resident’s CPAP mask and oxygen tubing/nasal cannula were repeatedly observed stored in an unsanitary manner rather than in a bag when not in use.
A resident with moderate cognitive impairment had conflicting code status documentation: the MOST form, signed by the resident’s representative and DON, indicated no CPR with selective treatment, while the physician order and care plan listed CPR. A care conference note stated a new MOST form was completed, but it did not document a change in code status, and staff interviews confirmed the chart contained inconsistent resuscitation information.
The facility failed to properly manage positioning and contracture care for two residents with ROM limitations. One resident with spastic hemiplegia, MS, and lower-extremity contractures had her leg tied to a wheelchair leg rest with a resistance band without a physician order, documented monitoring, or clear care plan guidance, and staff were unsure who was responsible for oversight. Another resident with Swan neck deformities in both hands had hand splints arrive at the facility, but they were left unused while he waited for therapy to apply them, despite therapy notes showing splinting was needed.
A resident receiving hospice care had severe cognitive impairment, used a wheelchair, and required extensive assistance with ADLs. The facility did not maintain a clear communication process or accessible hospice documentation in the EMR. Hospice staff were observed visiting the resident, and the resident had a Broda chair and specialty mattress in use, but the record lacked hospice visit notes, documentation of hospice-provided DME, and evidence that hospice volunteer services were requested.
A resident with a history of falls and requiring substantial assistance for transfers sustained rib fractures and facial bruising after a CNA failed to follow proper transfer techniques, including positioning and use of a gait belt, and allowed the resident to wear slip-on shoes without backs. The CNA assisted from the side rather than in front, contrary to facility policy and training, and the resident's shoe became caught on the wheelchair, leading to a fall.
The facility failed to provide adequate supervision and assistance to prevent falls for two residents, leading to multiple incidents where residents were not properly assessed by an RN, NP, or physician after unwitnessed falls. One resident experienced multiple falls due to a sliding mattress, resulting in pain and hospital visits, while another resident fell reaching for a snack, sustaining a head injury. The facility did not adhere to its policy requiring thorough assessments after such incidents.
Unsafe Food Handling and Kitchen Sanitation Lapses
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. During a continuous observation of the lunch meal, a cook repeatedly handled food, meal tickets, plates, utensils, and equipment with the same pair of single-use gloves while moving between tasks and food areas. The cook handled cooked and raw foods, prepared sandwiches and burgers, opened cans, used the microwave, touched clean plates and meal tickets, and served residents without changing gloves or performing hand hygiene between many of these actions. The cook also picked up a bun that had fallen on the floor, discarded it, and continued preparing food without changing gloves. Another cook removed gloves and donned new gloves without performing hand hygiene, and staff were observed handling food with wet gloves and wiping the food preparation area with a towel from the sanitizer bucket without changing gloves or washing hands. The facility also failed to follow safe thawing practices for frozen food. Frozen American goulash was observed placed in a convection steamer with the door open and the steamer not turned on, while the pan showed visible frost and ice buildup. The dietary manager stated the goulash had been removed from the freezer that morning and given to the cook, and that the cook should have closed the steamer door and started cooking it. Staff interviews reflected differing descriptions of thawing practices, including refrigerator thawing, cold running water, and use of the oven, but the observed method involved leaving the frozen food in an unheated steamer. In addition, staff were observed without proper hair restraints in the kitchen, including staff with exposed hair and a dietary aide who entered the kitchen without a hair net and then went to get one. The microwave in the kitchen had peeling and bubbling paint on the interior wall, and the dietary manager stated she would replace it because she did not want bubbling paint to contaminate food. Staff were also observed eating lunch at a food preparation table in the kitchen, even though the dietary manager and registered dietitian stated employees were expected to eat in a designated area away from food preparation.
Air mattress settings not specified or documented for four residents
Penalty
Summary
The facility failed to ensure that air mattresses for four residents were managed according to professional standards of quality. Surveyors found that the residents’ physician orders directed staff to apply an air mattress and check settings every shift for wound healing and prevention, but the orders did not specify the exact mattress settings to be used. Review of the residents’ electronic medical records also did not reveal assessments or documentation identifying what the air mattress settings should be for each resident, and there was no documentation showing the mattresses were being monitored and maintained on a routine basis. Resident #5 had diagnoses including CHF, peripheral vascular disease, and chronic respiratory failure with hypoxia, and was cognitively intact. The resident’s Meridian Medical air mattress was observed with the power and static switches illuminated, the normal pressure indicator lit, and the firmness dial set to the second blue block. The physician order required an air mattress and shift checks, but did not identify the proper setting, and the record did not show any assessment or documentation of the correct setting or routine maintenance. Resident #9 had dementia, type 2 diabetes mellitus, emphysema, stage 4 CKD, and a sacral pressure ulcer, and was cognitively intact. The resident’s Meridian Medical air mattress was observed with the power and static switches illuminated, the normal pressure indicator lit, and the firmness dial set to the middle. The care plan and physician order both called for an air mattress and checking settings, but neither identified the correct setting, and the EMR and hospice notes did not show an assessment or routine monitoring documentation. Resident #47 had hypertensive heart disease, atherosclerotic heart disease, senile degeneration of the brain, restlessness, and agitation, and was severely cognitively impaired. The resident’s Meridian Medical air mattress was observed with the power and static switches illuminated, the normal pressure indicator lit, and the firmness dial set to the fifth blue block. The physician order required an air mattress and shift checks, but did not specify the setting, and the record did not show an assessment or documentation of the correct setting or routine maintenance. Resident #61 had dementia, spinal stenosis, peripheral vascular disease, and pressure-induced deep tissue damage of the right heel, and was severely cognitively impaired. The resident’s Genesis III air mattress was observed with the firmness dial near the 225 lb setting, while the resident weighed 180 lbs. The power indicator and lower pressure indicator were on, and the normal pressure indicator was off. The physician order required an air mattress and monitoring, but did not specify the setting, and the EMR did not show an assessment or documentation of the correct setting or routine maintenance.
Missing and Incorrect Respiratory Orders
Penalty
Summary
The facility failed to ensure respiratory care was provided consistent with professional standards for three residents receiving oxygen-related services. Survey findings showed missing or incorrect physician orders for a resident using CPAP, and incorrect or incomplete oxygen orders for two residents who were receiving or expected to receive oxygen therapy. The report states that oxygen is considered a medication and requires a prescription and continuous monitoring by the nurse, and that oxygen therapy is to be administered under physician orders except in emergencies. For one resident with obstructive sleep apnea, staff observed a CPAP machine and mask in the room, but the mask was repeatedly left on the bedside table and not stored in a bag. The resident said he wore CPAP at night and that staff did not clean it, though they brought water for it. Record review showed no physician order for the CPAP machine or instructions for routine cleaning and maintenance in the resident’s chart, and the care plan did not include CPAP use or equipment maintenance. A hospital note indicated the resident was to continue CPAP use at night per home settings. For a second resident with chronic respiratory failure with hypoxia, the chart contained an oxygen order that said oxygen via nasal cannula, titrate to 90% continuously, but it did not specify a flow rate. The resident stated she always wore oxygen and that it should be set at 2 LPM, and observations showed the concentrator set at 2 LPM. Staff stated the order did not indicate a continuous LPM flow rate and the DON said the order was incorrect because the facility did not use titration orders. For a third resident with CHF and chronic respiratory failure with hypoxia, the chart showed an order for oxygen via nasal cannula at 2 to 3 LPM continuously, but observations found the resident without oxygen in place and not receiving oxygen continuously. Staff and the DON stated the resident used oxygen off and on and that the order should have reflected as-needed use, while the resident’s representative said the order was as needed because the resident’s oxygen saturation had been low when staff checked it.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored according to accepted professional principles. During observations, multiple medication carts and medication storage areas contained opened eye drops, inhalers, PPD vials, glucometer test strips, and glucose control solutions that were not labeled with the date opened, and some test strips and control solutions were found without proper expiration tracking. The facility also had opened glucose control solutions with open dates that were visible, but staff stated the solutions were still considered usable until the bottle expiration date rather than based on the opened date. On the Sunlight Hall medication cart, an opened bottle of Xalatan eye drops for one resident and an opened Trelegy inhaler for another resident were observed without open dates. Two opened bottles of blood glucose test strips were also present without open dates. In the Sunlight Hall medication storage room, two opened glucose monitoring control solutions had open dates, but an opened Tuberculin PPD vial had no open date. Staff told surveyors the inhaler and test strips were good until the expiration date, and the LPN stated she had been told it was no longer necessary to write open dates on medications. Additional observations found the same issue on other units: one opened container of glucose test strips on Frontier unit medication cart B lacked an open date, two opened containers on Frontier unit medication cart A lacked open dates, and three opened containers on the Red Cloud unit medication cart were not labeled with the date opened. At the Frontier nurses’ station, one opened glucose control solution lacked an open date, and at the shared nurses’ station for Red Cloud and Castle Peak units, two more opened containers of glucose test strips were not labeled. The DON stated there had been a misunderstanding among nursing staff about which medications required open dates, and acknowledged that patient-specific medications and glucometer supplies still needed to be labeled.
Infection Control Failures with PPE, Hand Hygiene, and Respiratory Equipment Storage
Penalty
Summary
The facility failed to maintain infection control procedures intended to provide a safe and sanitary environment and prevent the development and transmission of disease. One deficiency involved Resident #59, who had an indwelling urinary catheter and was identified as being on enhanced barrier precautions (EBP). A sign posted on the resident’s door indicated EBP. During a hands-on slide board transfer from wheelchair to bed, a CNA donned gloves but did not put on a gown, even after reaching for PPE and after the resident stated gowns were not needed. During catheter care later that day, an RN donned gloves, disconnected the catheter bag from the tubing, and irrigated the catheter without wearing a gown. The RN stated she should have worn a gown for the procedure but had forgotten because she did not usually work with the resident. The facility also failed to ensure residents were offered hand hygiene before meals. During observations on the Castle Peak unit, meal trays were delivered to resident rooms from a cart that did not have hand sanitizer or hand wipes, and staff did not offer hand hygiene before residents ate. On the Red Cloud unit, a CNA delivered meal trays to multiple resident rooms from a two-shelf cart that also had no hand wipes, and hand hygiene was not offered before the meals were served. In the main dining room, no hand wipes or hand sanitizer were observed on the tables, and residents were served lunch without being offered hand hygiene, including Resident #59 and several residents seated at a table for feeding assistance. Residents interviewed stated staff did not offer hand hygiene when meal trays were delivered and that they received nothing to clean their hands other than the paper napkin wrapped around the silverware. The facility further failed to store oxygen cannulas and CPAP masks in a sanitary manner. Resident #57’s CPAP mask was repeatedly observed lying on the bedside table next to the machine and on top of a lamp base rather than in a storage bag. In another room, an oxygen concentrator was observed with oxygen tubing and a nasal cannula attached, with the tubing and cannula lying coiled on the floor or underneath the handle of the concentrator and no storage bag present when the equipment was not in use. Resident #57 stated staff had not provided a way to store the CPAP mask when it was not being used. An oxygen representative stated the company provides bags for CPAP masks and oxygen tubing and nasal cannulas, and the DON stated these items were to be stored in a plastic bag when not in use.
Code Status Documentation Did Not Match MOST Form
Penalty
Summary
The facility failed to document Resident #16’s resuscitation choices accurately in the medical record. Resident #16, who had diagnoses including a left femur neck fracture and asthma and had moderate cognitive impairment with a BIMS score of 9, had a MOST form signed by the resident’s representative and the DON that indicated no CPR with selective treatment, including IV antibiotics and fluids, and also indicated no intubation and no intensive care. However, the computerized physician order for code status stated that the resident was to receive CPR, creating a mismatch between the MOST form and the physician’s order. Record review also showed that a care conference note documented that a new MOST form was completed, but it did not state that the resident’s code status preferences were changed. The care plan continued to list the resident as CPR, while the MOST form had been updated to indicate no CPR. Staff interviews showed that nursing staff and leadership expected the MOST form, physician orders, and EMR to match, and staff stated they would follow the most recent MOST form if conflicting information was present.
Failure to Manage Positioning Devices and Timely Splinting for Residents with ROM Limitations
Penalty
Summary
The facility failed to provide adequate positioning and contracture management for two residents with limited range of motion and mobility. One resident had spastic hemiplegia affecting the left side, multiple sclerosis, gait and mobility impairment, spinal stenosis, and flexion deformities of both ankles and toes. She used a wheelchair, was dependent on staff for showers and transfers, and had range of motion impairments in one upper extremity and both lower extremities. Staff observed her left leg repeatedly tied to her wheelchair leg rest with a bright orange exercise resistance band, which she said was used to keep her leg from getting caught between the leg rests because her leg extended past the footrest and she could not position it safely on her own. Record review showed no physician’s order for the resistance band, no order to monitor it for skin breakdown or circulatory issues, and no documentation identifying the medical condition being treated, who could apply it, how it was to be used, or what monitoring and supervision were required. The resident’s care plans referenced a Velcro strap and therapy involvement, but did not document the resident’s use of the resistance band instead of the Velcro strap. Staff interviews showed CNAs routinely tied the band on her leg, one CNA assumed therapy had approved it, and an RN did not know the leg was tied to the wheelchair. The director of rehabilitation stated the band was acceptable only if the resident could remove it herself and if it was not too tight or left on too long, while the DON stated nursing staff were expected to assess assistive devices at least twice daily and acknowledged there were no current orders or care plans for the resistance band. The second resident had Swan neck deformities in both hands, was cognitively intact, and needed substantial assistance with ADLs. He reported pain in his hands and said he had been working with therapy for weeks to obtain hand splints to help correct the deformity. Although the splints arrived at the facility, observations showed they were left in a basin across the room and the resident had not yet worn them. He stated that someone from therapy needed to apply them and that he had not seen anyone from therapy yet. The contracture care plan identified Swan neck contractures and the assistive devices care plan noted that OT would assist with splints, but the rehabilitation plan did not address the deformities in one note, and the resident did not receive the hand splints in a timely manner despite therapy documentation that splinting was needed for his limited hand and finger function.
Hospice Communication and Documentation Not Maintained
Penalty
Summary
The facility failed to ensure hospice services met professional standards for one resident receiving hospice care. The facility did not establish a communication process, including how communication would be documented, between the facility and the hospice provider, and hospice agency staff notes were not easily accessible to facility staff or consistently documented in the resident’s record. Resident #47 was admitted with diagnoses including hypertensive heart disease, atherosclerotic heart disease, senile degeneration of the brain, restlessness, and agitation. The MDS showed the resident was severely cognitively impaired with a BIMS score of 5, used a wheelchair, required partial assistance with eating, substantial assistance with personal hygiene, and was dependent for oral hygiene, toileting, and showering. The assessment also indicated the resident was receiving hospice care services. The resident’s representative stated the resident had fallen a couple of times since admission and that hospice had provided a Broda chair to help prevent falls. Observation and record review showed the resident was escorted to the dining room by two hospice staff members, but the EMR did not contain documentation of that hospice visit. The resident’s room was observed to have an air mattress and a lipped mattress, yet the EMR did not document that these DME items were supplied by hospice. The hospice care plan included contacting hospice for any change in condition and coordinating care between hospice and facility staff, and the fall care plan referenced hospice volunteer services and hospice medication review, but the EMR contained no documentation that hospice volunteer services were requested. The record also showed no hospice notes from 3/25/26 to 4/9/26. Staff interviews indicated the DON served as the hospice coordinator and said hospice staff checked in with the floor nurse, who entered a progress note regarding the hospice visit, but the DON stated she did not know the hospice notes were not available in the resident’s EMR.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to ensure that staff followed appropriate transfer techniques and provided adequate supervision and assistive devices to prevent accidents, resulting in a resident sustaining rib fractures after a fall during an improper transfer. The resident, who had a history of falls and required substantial/maximal assistance for transfers, was being assisted by a CNA from bed to wheelchair. During the transfer, the CNA positioned herself at the side of the resident due to limited space, rather than in front as per facility training and policy. The resident was wearing slip-on shoes with no backs, and as she pivoted, her shoe became lodged on a wheelchair wheel, causing her to lose balance and fall forward to the floor. The CNA was unable to prevent the fall due to her position and the obstruction caused by the wheelchair and room layout. The incident report and staff interviews confirmed that the CNA did not follow the facility's in-service training, which instructed staff to stand in front of the resident, use a gait belt properly, and ensure the resident wore appropriate footwear during transfers. The care plan for the resident required a one-person transfer with a gait belt but did not specify the need for proper footwear. The CNA admitted to using a side-assist technique and acknowledged she should have been in front of the resident. Other CNAs interviewed stated that standing in front of the resident was the safest method and allowed them to better protect the resident from falls. The facility's policies and training materials emphasized the importance of proper positioning and use of gait belts during transfers to minimize fall risk. Following the fall, the resident was assessed and found to have a hematoma and bruising on her face and head. She was later transferred to the hospital, where imaging revealed acute, mildly displaced fractures of the left anterior third rib and a non-displaced fracture of the left anterior fourth rib, in addition to facial bruising. The resident was cognitively intact and had no impairments in range of motion but required significant assistance for transfers due to weakness and other medical conditions. The failure to adhere to established transfer protocols and ensure the use of appropriate footwear directly contributed to the resident's fall and subsequent injuries.
Inadequate Fall Assessment and Supervision
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent falls for two residents, leading to multiple incidents where residents were not properly assessed by a registered nurse (RN), nurse practitioner (NP), or physician after unwitnessed falls. Specifically, the facility did not conduct necessary assessments before moving residents from the floor, which is a critical step in ensuring resident safety and preventing further injury. This deficiency was identified for two residents who were reviewed for falls, out of a sample of seven. Resident #3, a 76-year-old with a history of falls and other medical conditions, experienced multiple falls due to issues with her mattress sliding off the bed. Despite being cognitively intact, she suffered from falls that resulted in pain and required hospital visits. The facility's failure to assess her properly after each fall, as per their policy, was a significant oversight. The resident's care plan included interventions like providing a clutter-free environment and ensuring the call light was within reach, but these measures were insufficient to prevent the falls. Resident #9, an 82-year-old with moderate cognitive impairment, also experienced a fall that was not properly assessed by a qualified healthcare professional before being moved. The resident fell while reaching for a snack, resulting in a head injury. The facility's policy required a thorough assessment by an RN, NP, or physician after such incidents, but this was not adhered to, highlighting a systemic issue in the facility's fall management and response procedures.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Longmont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mcintosh Care And Rehabilitation Center | 1.1 mi | ★★★★★ | 10 | 0 |
| Life Care Center Of Longmont | 1.4 mi | ★★★★★ | 16 | 0 |
| Katherine And Charles Hover Green Houses | 1.6 mi | ★★★★★ | 9 | 0 |
| Accel At Longmont Health And Rehab, Llc | 4 mi | ★★★★★ | 47 | 1 |
| Berthoud Care And Rehabilitation | 8.7 mi | ★★★★★ | 0 | 0 |
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