SeniorHomeViolations
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75/100

THE PEAKS HEALTH & REHABILITATION Inspection Report, Violations & Safety Grade (FLAGSTAFF, Arizona)

3150 NORTH WINDING BROOK ROAD, FLAGSTAFF, Arizona 86001

Phone: 9287747106

CMS Overall:3/5

Overview & Bed Count

Certified Beds
58
Avg Residents/Day
40.3
Ownership
Non profit - Other
Provider Type
Medicare and Medicaid
County
Coconino
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall3/5
Health3/5
Staffing4/5
Quality4/5

Nurse Staffing Check

MetricThis FacilityArizona AvgDifference
RN Hours per Resident per Day0.970.74+0.23
Total Nurse Hours per Resident per Day4.604.08+0.52
CMS Staffing Rating4/53/5-
Nursing Staff Turnover50.8%44.8%-

Health Citation History

17 health citations on record

DateCategoryDescriptionSeverity
2026-02-12Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2026-02-12Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2026-02-12Pharmacy Service DeficienciesEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.D – Moderate Harm Potential
2025-07-10Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D – Moderate Harm Potential
2025-01-29Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.E – Moderate Harm Potential
2024-11-07Resident Assessment and Care Planning DeficienciesEnsure services provided by the nursing facility meet professional standards of quality.E – Moderate Harm Potential
2024-11-07Pharmacy Service DeficienciesEnsure medication error rates are not 5 percent or greater.E – Moderate Harm Potential
2024-11-07Pharmacy Service DeficienciesEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.E – Moderate Harm Potential
2024-11-07Resident Rights DeficienciesAllow residents to self-administer drugs if determined clinically appropriate.D – Moderate Harm Potential
2024-11-07Freedom from Abuse, Neglect, and Exploitation DeficienciesDevelop and implement policies and procedures to prevent abuse, neglect, and theft.D – Moderate Harm Potential
2024-11-07Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D – Moderate Harm Potential
2024-11-07Freedom from Abuse, Neglect, and Exploitation DeficienciesRespond appropriately to all alleged violations.D – Moderate Harm Potential
2024-11-07Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential
2024-11-07Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2024-11-07Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D – Moderate Harm Potential
2024-11-07Infection Control DeficienciesDevelop and implement policies and procedures for flu and pneumonia vaccinations.D – Moderate Harm Potential
2023-09-22Nursing and Physician Services DeficienciesEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.E – Moderate Harm Potential

Fire Safety Citation History

21 fire safety citations on record

DateCategoryDescriptionSeverity
2026-02-12Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.E – Moderate Harm Potential
2026-02-12Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.E – Moderate Harm Potential
2024-11-07Smoke DeficienciesInstall a fire alarm system that can be heard throughout the facility.E – Moderate Harm Potential
2023-09-22Emergency Preparedness DeficienciesDevelop and maintain an Emergency Preparedness Program (EP).E – Moderate Harm Potential
2023-09-22Emergency Preparedness DeficienciesConduct risk assessment and an All-Hazards approach.E – Moderate Harm Potential
2023-09-22Emergency Preparedness DeficienciesAddress patient/client population and determine types of services needed.E – Moderate Harm Potential
2023-09-22Emergency Preparedness DeficienciesEstablish policies and procedures including evacuation.E – Moderate Harm Potential
2023-09-22Emergency Preparedness DeficienciesList the names and contact information of those in the facility.E – Moderate Harm Potential
2023-09-22Emergency Preparedness DeficienciesProvide family notifications of emergency plan.E – Moderate Harm Potential
2023-09-22Emergency Preparedness DeficienciesConduct testing and exercise requirements.E – Moderate Harm Potential
2023-09-22Miscellaneous DeficienciesProvide a written emergency evacuation plan.E – Moderate Harm Potential
2023-09-22Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.E – Moderate Harm Potential
2023-09-22Miscellaneous DeficienciesTo conduct inspection, testing and maintenance of fire doors by qualified individuals.E – Moderate Harm Potential
2023-09-22Gas, Vacuum, and Electrical Systems DeficienciesHave proper fire barriers, ventilation and signs for the transfilling of oxygen.E – Moderate Harm Potential
2023-09-22Egress DeficienciesKeep aisles, corridors, and exits free of obstruction in case of emergency.D – Moderate Harm Potential
2023-09-22Smoke DeficienciesHave a complete alarm system manually initiated and initiated by fire sprinkler system connection.D – Moderate Harm Potential
2023-09-22Smoke DeficienciesInstall corridor and hallway doors that block smoke.D – Moderate Harm Potential
2023-09-22Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.D – Moderate Harm Potential
2023-09-22Gas, Vacuum, and Electrical Systems DeficienciesEnsure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.D – Moderate Harm Potential
2023-09-22Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.D – Moderate Harm Potential
2023-09-22Gas, Vacuum, and Electrical Systems DeficienciesEnsure that testing and maintenance of electrical equipment is performed.D – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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