Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Aspire Transitional Care during CMS and state inspections, most recent first.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Improper Hand Hygiene During Wound Care: An RN failed to follow proper hand hygiene and glove-changing practices during a wound dressing change for a resident with a right lower extremity wound and significant medical comorbidities, including bacteremia, ESRD, and DM2. The RN did not sanitize hands before donning gloves, did not change gloves or sanitize hands after removing the soiled dressing before cleaning the wound, and again donned new gloves without hand hygiene. The DON confirmed the expected wound care technique required hand hygiene and glove changes between steps, and the facility wound care policy outlined the same procedure.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility failed to ensure that an LPN and a CNA maintained current CPR certification, as required by facility policy. Despite expired certifications, both staff members continued to work shifts. Interviews with the Business Office Assistant and the DON confirmed the lack of current certification and acknowledged the risk of patient suffering due to non-compliance.
Three residents with diabetes in an LTC facility were found with unsupervised access to blood glucometers and lancets in their rooms, contrary to facility policies. Despite the facility's protocol to prevent cross-contamination, staff interviews revealed that these items were stored in resident rooms for convenience, posing a risk of unsupervised use. The Director of Nursing acknowledged the potential hazards, which contradicted the facility's accident prevention and exposure control policies.
The facility failed to provide appropriate dialysis care for three residents, leading to potential complications. A resident had blood pressure taken from a restricted arm, another did not receive necessary pre-dialysis communication or meals, and a third had no medical information communicated to the dialysis center, risking exposure to infections. The facility lacked proper communication protocols and agreements with dialysis centers.
The facility failed to secure medication and treatment carts, as observed in Hall A where both were found unlocked and unattended. RNs confirmed the carts should be locked, with one RN unaware of the keys needed. The facility's policy requires all drugs to be stored in locked compartments, but this was not followed, risking unauthorized access.
The facility failed to store food under sanitary conditions, with observations revealing unlabeled and expired food items in the kitchen and nourishment refrigerators. Moldy lemons and improperly labeled bread were also found. Staff interviews confirmed lapses in adhering to food storage policies, posing a risk of foodborne illness.
The facility failed to maintain accurate clinical records for two residents, leading to discrepancies in care. One resident required a fluid restriction due to SIADH, but there were no orders or documentation to enforce it, causing staff confusion. Additionally, interventions like air mattresses and wheelchair cushions were documented but not provided. Another resident lacked documentation for an air mattress, which was only provided after a nurse's intervention. These deficiencies highlight issues in maintaining accurate and complete medical records.
A resident was discharged to a hospital without proper documentation or notification to the receiving facility. The discharge followed an alleged theft and discovery of contraband in the resident's room. The facility failed to complete the necessary acute transfer form or provide a discharge summary, as required by policy. Staff interviews revealed discrepancies in the discharge process, with the DON acknowledging the lack of documentation and the ED disputing the need for it due to the resident's arrest.
A facility failed to develop a baseline care plan for a resident within 48 hours of admission, omitting critical information about the resident's weightbearing status and knee orthotic requirements. Despite these instructions being documented in therapy notes, they were not included in the care plan, as confirmed by staff interviews. This oversight contravened the facility's policies on baseline care plans and clinical documentation.
The facility failed to transcribe necessary weightbearing and orthotic orders for a resident with a tibia fracture, risking further injury. Additionally, a resident with Alzheimer's fell due to oxygen tubing entanglement, and an untrained housekeeper assisted her, contrary to facility policy. These deficiencies highlight lapses in order transcription and fall management protocols.
The facility failed to maintain Enhanced-Based Precautions for two residents, risking infection spread. One resident with a history of ESBL E. coli was assisted by staff not wearing gowns, despite EBP requirements. Another resident with C. difficile had no precaution sign outside their room, contrary to facility policy. Staff interviews revealed inconsistencies in understanding and implementing transmission-based precautions.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Improper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during wound care for a resident with diagnoses including infection and inflammatory reaction due to an internal fixation device of the right tibia, bacteremia, end-stage renal disease, and Type 2 diabetes mellitus. The resident had a wound to the right lower extremity, and a provider order directed staff to clean the wound with normal saline, cover it with xeroform, wrap with rolled gauze, and cover with an ACE wrap every day. Another order directed staff to wear PPE for enhanced barrier precautions for direct care, including wound care. During an observed dressing change, an RN donned a gown and gloves before entering the room but was not observed to sanitize his hands before putting on gloves. After removing the soiled dressing, he did not doff gloves, sanitize his hands, or don new gloves before cleaning the wound with gauze moistened with normal saline. He then discarded the soiled dressing and gauze, doffed his gloves, donned new gloves without sanitizing his hands, and completed the dressing change. The RN acknowledged he did not follow proper hand hygiene procedures, and the DON stated the expected technique included sanitizing hands and changing gloves between steps of the dressing change. The facility policy for wound care also required handwashing, glove changes, and hand sanitizing at specific points during the procedure.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Expired CPR Certifications Among Staff
Penalty
Summary
The facility failed to ensure that two staff members, a Licensed Practical Nurse (LPN) and a Certified Nurse Assistant (CNA), maintained current Cardio Pulmonary Resuscitation (CPR) certification. The personnel file review revealed that the LPN's CPR certification had expired, and there was no evidence of renewal. Similarly, the CNA's CPR certification had also expired, with no documentation of current certification. Despite the expiration of their certifications, both staff members continued to work shifts at the facility. Interviews with the Business Office Assistant and the Director of Nursing (DON) confirmed the lack of current CPR certification for the LPN and CNA. The Business Office Assistant, responsible for monitoring CPR certifications, acknowledged that the staff should not be working without valid certification. The DON expressed an expectation for staff to complete CPR certification upon hire and recognized the risk of patient suffering due to non-compliance. The facility's policy mandates that CPR-certified staff be available at all times and maintain current certification, which was not adhered to in this case.
Unsupervised Access to Sharps in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents, leading to potential harm due to unsupervised access to sharps. Resident #281, who has type two diabetes mellitus and moderate cognitive impairment, was found with a blood glucometer and an opened container of lancets in their room. The resident reported using the lancets without supervision, and staff were unaware of this usage. The resident was not informed about the proper use of the equipment, nor was any assessment conducted after the resident admitted to using the lancets. Similarly, Resident #26, with intact cognition and type two diabetes mellitus, was observed with a blood glucometer and lancets in their room. Resident #482, also with intact cognition and type two diabetes mellitus, had similar equipment in their room. Both residents were capable of performing many activities of daily living independently, but the presence of sharps in their rooms posed a risk of unsupervised use. Interviews with staff revealed that blood glucometers and lancets were routinely stored in resident rooms for convenience, despite the facility's policy classifying lancets as sharps that should be disposed of immediately after use. The Director of Nursing acknowledged the risk of residents having access to sharps without supervision, which contradicted the facility's policies on accident prevention and exposure control. The facility's policies emphasized maintaining a hazard-free environment and ensuring adequate supervision to prevent accidents, which was not adhered to in these cases.
Deficient Dialysis Care and Communication
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for three residents, leading to potential complications. For Resident #15, the facility did not adhere to physician orders that specified no blood pressure measurements or blood draws should be taken from the left arm due to the presence of a shunt/fistula. Despite this, there were three recorded instances where blood pressure was taken from the left arm, which was confirmed by the staff as not meeting the facility's expectations. Interviews with staff revealed a lack of adherence to protocols, even though the resident wore a limb alert bracelet as a reminder. Resident #10's care was compromised by the facility's failure to coordinate effectively with the dialysis center. The facility did not consistently send the required pre-dialysis communication forms to the dialysis center, as evidenced by eight instances where the forms were not sent. Additionally, the resident reported not receiving meals or snacks to take to dialysis, which was contrary to the Director of Nursing's expectations. The lack of communication and provision of meals resulted in the resident missing dinner after returning late from dialysis. For Resident #234, the facility did not communicate essential medical information to the dialysis center, including the resident's need for contact precautions due to a C. Difficile infection. The dialysis center confirmed that they did not receive any medical information or dialysis communication forms from the facility before the resident's treatments. This lack of communication posed a risk to other patients and staff at the dialysis center. The Director of Nursing acknowledged the absence of dialysis contracts or agreements and relied solely on the facility's dialysis policy, which was insufficient to ensure proper communication and care coordination.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that medications and controlled substances were kept locked, as observed during a survey. On two separate occasions, a medication cart and a treatment cart were found unlocked and unattended in Hall A. The first incident involved a medication cart left unlocked outside a room, confirmed by a Registered Nurse (RN) who acknowledged the risk of unauthorized access to medications. The second incident involved a treatment cart left unlocked in the 140's hall, with another RN admitting to being unaware of the keys required to lock the cart. Interviews with staff, including the Minimum Data Set Coordinator RN and the Director of Nursing, revealed that the responsibility for securing medication and treatment carts lies with the nursing staff. The facility's policy mandates that all drugs and biologicals be stored in locked compartments, accessible only to authorized personnel. However, the observations and staff interviews indicate a failure to adhere to this policy, potentially allowing residents, staff, and visitors access to medications.
Deficient Food Storage Practices
Penalty
Summary
The facility failed to ensure that food was stored under sanitary conditions, as observed during a survey. During an initial kitchen tour, the Dining Services Director attempted to discard several food items, including macaroni and cheese, cheese sauce, turkey gravy, and bread stuffing, which were either unlabeled or past their discard dates. Additionally, a bowl of unlabeled cooked potatoes was found on the fridge shelf. Further observations revealed expired milk cartons, sushi, and yogurts in the nourishment refrigerator. Moldy lemons were also found in the walk-in fridge, along with a bag of lemons containing a mushy, slimy, and sour-odored lemon. Opened packages of bread and hot dog buns were found without labels or discard dates. Interviews with staff and residents highlighted the facility's failure to adhere to its food storage policy, which requires all foods to be dated when opened and expired foods to be removed. The Dining Services Director admitted to being unsure about the preparation date of some items and acknowledged the risk of foodborne illness due to improper labeling and storage. A resident reported receiving moldy grapes, and staff confirmed that expired foods were sometimes forgotten. The Executive Director confirmed the facility's expectations for food freshness and acknowledged the potential risks of outdated foods, including illness and contamination.
Deficiency in Accurate Clinical Documentation
Penalty
Summary
The facility failed to ensure that clinical records accurately reflected care and services provided to two residents, specifically regarding fluid restriction, care interventions, and the use of an air mattress. For Resident #281, there was a lack of documentation and orders for a fluid restriction despite medical notes indicating the need for such a restriction due to the resident's condition of syndrome of inappropriate antidiuretic hormone secretion (SIADH). The resident's care plan did not include a fluid restriction, and there were no physician's orders to enforce it, leading to confusion among staff about the resident's care requirements. Additionally, Resident #281's care plan lacked documentation for the use of an air mattress or wheelchair cushions, despite system notes indicating these interventions were in place. Observations revealed that the resident did not have an air mattress or wheelchair cushion, and the room was not located near the nurse's station as documented. This discrepancy between documented interventions and actual care provided highlights a failure in maintaining accurate and complete clinical records. For Resident #19, the facility also failed to document the use of an air mattress in the care plan, despite system notes indicating its presence. A nurse identified the absence of an air mattress and took action to provide one due to concerns about pressure-related injuries. The lack of accurate documentation and orders for necessary interventions for both residents demonstrates a deficiency in the facility's ability to maintain accurate and complete medical records, potentially impacting the quality of care provided.
Improper Discharge Documentation and Notification
Penalty
Summary
The facility failed to ensure proper documentation and notification during the transfer and discharge of a resident to a short-term general hospital. The resident, who had no cognitive impairment, was discharged without evidence of provider orders, progress notes, or a care plan related to the discharge. Additionally, there was no documentation of notification to the receiving facility, and a request for a discharge summary from the hospital was not responded to by the facility. The incident involved a resident who was initially admitted with a fracture and later discharged to a hospital following an alleged theft incident. A police report indicated that the resident allegedly stole a phone and was found with contraband, including meth, syringes, and weapons. The Executive Director expressed a desire for the resident to be removed from the premises, leading to the resident's transfer to the hospital. However, the facility did not complete the necessary acute transfer form or provide a discharge summary, as required by their policy. Interviews with facility staff, including the Director of Nursing and the Executive Director, revealed discrepancies in the discharge process. The Director of Nursing acknowledged that the acute care form was not completed and that the discharge was not properly documented. The Executive Director, however, disagreed with the assessment, stating that the resident's arrest and police custody negated the need for standard discharge documentation. The facility's policy mandates that even in emergency transfers, a transfer form should be completed and sent with the resident, which was not adhered to in this case.
Failure to Develop Baseline Care Plan for Resident's Immediate Needs
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed for a resident within 48 hours of admission, as required by their policy. The resident, who had a history of a left proximal tibia fracture, diabetes mellitus, hypertension, and acute anemia, was admitted with specific precautions for Touchdown Flat Foot Weightbearing on the left lower extremity and the requirement to wear a knee brace unlocked and on at all times. Despite these critical instructions being documented in the physical therapy evaluation and daily encounter notes, they were not included in the resident's care plan. Interviews with facility staff, including a CNA, the Director of Rehab, and the Director of Nursing, revealed that the necessary information regarding the resident's weightbearing status and knee orthotic was not communicated or documented in the care plan. This omission was confirmed by multiple staff members who acknowledged the risk of further injury if such information was not included. The facility's policies on baseline care plans and clinical documentation emphasize the importance of including physician orders and accurate, complete documentation in the medical record, which was not adhered to in this case.
Deficiencies in Transcription of Orders and Fall Management
Penalty
Summary
The facility failed to include necessary weightbearing and orthotic orders for a resident who was admitted with a history of a left proximal tibia fracture, among other diagnoses. The resident was moderately cognitively impaired, as indicated by a BIMS score of 12. Despite the physical therapy evaluation specifying that the resident should remain Touchdown Flat Foot Weightbearing and wear a knee brace at all times, these orders were not transcribed into the electronic medical record. Interviews with the Director of Rehab and the Director of Nursing confirmed the absence of these orders in the medical record, which did not meet the standards of practice and posed a risk of further injury to the resident. Another deficiency was identified in the care and services related to falls for a resident with Alzheimer's Disease and other medical conditions. The resident tripped and fell due to long oxygen tubing becoming trapped around her wheelchair. A housekeeper, who was not trained to assist residents after falls, helped the resident back into her wheelchair. The facility's policy requires trained staff to assist in such situations, and the housekeeper's actions did not align with these expectations. Interviews with the RN and DON revealed that the facility's process for handling falls was not followed, as the housekeeper was not trained for such incidents. The facility's policies on training requirements and post-fall assessments were reviewed, highlighting that only trained staff should assist residents after falls. The job description for the laundry assistant did not include responsibilities related to assisting residents after falls. The failure to adhere to these policies and ensure proper transcription of physician orders led to deficiencies in the care provided to the residents, potentially compromising their safety and well-being.
Failure to Maintain Enhanced-Based Precautions
Penalty
Summary
The facility failed to maintain Enhanced-Based Precautions (EBP) for two residents, leading to a potential risk of infection spread. Resident #430, who had a history of ESBL E. coli infection and was on EBP, was observed being assisted by a CNA who did not wear a gown during a transfer, despite the requirement to wear PPE for wound care. Another CNA also entered the room without a gown while repositioning the resident. This non-compliance with EBP was observed despite the presence of an EBP sign outside the resident's room. Resident #234, diagnosed with C. difficile, was supposed to be on EBP, but there was no precaution sign outside the resident's room. Staff interviews revealed inconsistencies in the understanding and implementation of transmission-based precautions. The facility's policy required contact precautions for C. difficile, but there was no testing to confirm the resident was no longer positive. The Director of Nursing acknowledged that the absence of a precaution sign did not meet the facility's expectations, highlighting a lapse in adherence to infection control protocols.
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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 Flagstaff
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Haven Of Flagstaff | 2 mi | ★★★★★ | 1 | 0 |
| The Peaks Health & Rehabilitation | 2.1 mi | ★★★★★ | 0 | 0 |
| Haven Of Sedona | 30.3 mi | ★★★★★ | 20 | 0 |
| Haven Of Cottonwood | 39.3 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.