01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-11-07 | 11 | 2024-11-07 | 1 |
| Cycle 2 | 2023-09-22 | 3 | 2023-09-22 | 18 |
| Cycle 3 | 2022-08-11 | 14 | 2022-08-11 | 9 |
CMS CCN 0352572026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
The Peaks Health & Rehabilitation
3150 North Winding Brook Road · Flagstaff, AZ 86001 · Coconino County
Certified beds58CMS provider file
Recent citation rows56current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
56 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 7 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-07-10 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-09-05 · complaint2025-01-29 · HEALTHF0842Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-03-28 · complaint2024-11-07 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-11-07 · HEALTHF0607Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2024-12-13 · complaint2024-11-07 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-12-13 · complaint2024-11-07 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2024-12-13 · complaint2024-11-07 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-11-07 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-11-07 · HEALTHF0658Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-11-07 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-11-07 · HEALTHF0759Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-11-07 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure 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.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-11-07 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-11-07 · FIREK0341Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Correction field: Deficient, Provider has date of correction · 2024-11-182023-09-22 · FIREE0004Severity E · pattern; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2023-10-162023-09-22 · FIREE0006Severity E · pattern; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2023-10-162023-09-22 · FIREE0007Severity E · pattern; potential for more than minimal harm
Emergency Preparedness Deficiencies
Address patient/client population and determine types of services needed.
Correction field: Deficient, Provider has date of correction · 2023-10-162023-09-22 · FIREE0020Severity E · pattern; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures including evacuation.
Correction field: Deficient, Provider has date of correction · 2023-10-162023-09-22 · FIREE0030Severity E · pattern; potential for more than minimal harm
Emergency Preparedness Deficiencies
List the names and contact information of those in the facility.
Correction field: Deficient, Provider has date of correction · 2023-10-162023-09-22 · FIREE0035Severity E · pattern; potential for more than minimal harm
Emergency Preparedness Deficiencies
Provide family notifications of emergency plan.
Correction field: Deficient, Provider has date of correction · 2023-10-162023-09-22 · FIREE0039Severity E · pattern; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2023-10-162023-09-22 · HEALTHF0947Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Correction field: Deficient, Provider has date of correction · 2023-11-15 · complaint2023-09-22 · FIREK0211Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2023-10-162023-09-22 · FIREK0342Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Correction field: Deficient, Provider has date of correction · 2023-10-1603 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- NORTHERN ARIZONA HEALTHCARE CORPORATIONOrganization · 5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 12/24/1997
- NORTHERN ARIZONA SENIOR LIVING COMMUNITY, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 02/15/2017
- THE GOODMAN FAMILY OPERATING FOUNDATIONOrganization · 5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 01/01/2024
- EBEID, SADEKIndividual · CONTRACTED MANAGING EMPLOYEENOT APPLICABLE · since 09/16/2020
- FARR, CAMERONIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 04/01/2024
- BAVASI, CHRISTOPHERIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/18/2015
- DAVISON, LISAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/13/2020
- LANSBURG, JACOBIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/27/2020
- SALMEN, THOMASIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- WILSON, MARKIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- BAVASI, CHRISTOPHERIndividual · CORPORATE OFFICERNOT APPLICABLE · since 11/18/2015
- KNACKE, CLINTONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 10/12/2022
- NORTHERN ARIZONA HEALTHCARE CORPORATIONOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/24/1997
- NORTHERN ARIZONA SENIOR LIVING COMMUNITY, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/15/2017
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.52per resident day
RN hours1.06per resident day
Weekend nurse hours4.01per resident day
Staff turnover58.6%CMS reported field
06 / LOCAL RECORDS
Open the Flagstaff ledger →