Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 The Peaks Health & Rehabilitation 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.
The facility did not maintain or provide access to required records, including grievance logs, self-reports, and Resident Council Meeting Minutes, when requested by surveyors. Leadership interviews revealed uncertainty about record retention requirements, and facility policy specified permanent or long-term retention for these documents. The inability to locate these records resulted in non-compliance with documentation standards.
A resident with multiple diagnoses experienced medication administration errors when an RN failed to dispense the correct dosage of ascorbic acid and omitted atorvastatin due to interruptions. The RN also administered levothyroxine after the resident ate, contrary to orders, and crushed extended-release medications, which should not be crushed. Interviews with the DON and NP confirmed these actions violated facility policy and posed risks to the resident.
A facility failed to maintain a medication error rate below 5%, with a rate of 21.43% observed. Errors included incorrect administration of medications to a resident with multiple diagnoses, such as crushing extended-release tablets and incorrect dosages. An RN was observed making these errors, and interviews revealed a lack of understanding of medication protocols. Facility policies on medication administration were not followed, leading to these deficiencies.
A resident was found with medications at their bedside without a self-administration order, contrary to facility policy. Additionally, expired medications and supplies were discovered in the medication room, which were not disposed of as required by the facility's policy.
A resident with moderate cognitive impairment was not assessed for medication self-administration, yet had Systane eye drops and Fluticasone nasal spray at their bedside without an order. Facility policy requires an interdisciplinary team assessment for self-administration, which was not conducted, leading to a deficiency in care.
The facility failed to implement comprehensive care plans for two residents, one requiring dialysis and another on oxygen therapy. The dialysis care plan lacked specific interventions for pre and post-dialysis care, while the oxygen therapy care plan was absent despite physician orders. Staff interviews confirmed these omissions, which were against facility policy, potentially affecting care continuity.
The facility failed to revise care plans after fall incidents for two residents, leading to potential risks of inadequate care. One resident, identified as a fall risk, experienced falls without updates to their care plan. Another resident had multiple falls over several months, yet their care plan was not revised with new interventions. Staff interviews revealed a lack of adherence to the facility's policy requiring care plan updates after status changes.
A facility failed to ensure proper disposal of a medication when an RN mistakenly dispensed a multiple vitamins capsule, retrieved it with gloved hands, and returned it to the container. The RN admitted the error, and the DON confirmed that the facility's process is to discard such medications to prevent contamination. The facility lacked a specific policy for non-controlled medication disposal.
A resident with moderate cognitive impairment and multiple diagnoses did not receive a pneumococcal vaccine despite expressing a desire for it and having family consent. The facility's Quality Infection Control staff failed to place the order for the vaccine, and the Director of Nursing confirmed the oversight, acknowledging the risk of illness. Facility policy requires offering the vaccine unless contraindicated, but this was not followed.
The facility failed to implement its policies for investigating and reporting abuse allegations involving three residents. A resident with moderate cognitive impairment reported being grabbed and twisted by another resident with a history of aggression, but the incident was not reported to the State Agency or investigated promptly. Another resident was involved in a previous unreported incident with the aggressive resident, highlighting a systemic failure to adhere to abuse reporting policies.
The facility failed to report alleged abuse incidents involving three residents to the proper authorities within the required timeframes. A resident with moderate cognitive impairment reported being grabbed and twisted by another resident, but the incident was not reported to the State Agency. Another resident with Alzheimer's disease exhibited aggressive behaviors towards others, yet these incidents were not reported or investigated promptly. The facility's policy mandates immediate reporting, but staff interviews revealed a lack of adherence, leading to potential continued harm.
The facility failed to investigate allegations of abuse involving two residents, leading to potential continued abuse. A resident with moderate cognitive impairment reported being grabbed and twisted by another resident, but no investigation was conducted. Another resident with Alzheimer's disease exhibited aggressive behavior towards others, but these incidents were not thoroughly investigated. Staff interviews revealed a lack of timely reporting and investigation, contrary to the facility's abuse policy.
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.
Failure to Maintain and Provide Required Documentation
Penalty
Summary
The facility failed to maintain and provide access to required documentation, including self-reports and investigations, grievance logs, and Resident Council Meeting Minutes for a specified month. When these documents were requested by surveyors, the Executive Director reported that they were unable to locate them. Interviews with the Interim DON and Executive Director revealed a lack of clarity regarding the required retention period for such records and acknowledged the importance of maintaining these documents for tracking resident issues and supporting the facility's actions. Facility policy indicated that grievance reports should be retained permanently in electronic form, committee minutes for a specified number of years, and all correspondence with the Department of Health permanently. Despite this, the facility was unable to produce the requested records, indicating non-compliance with their own record retention policy and regulatory requirements. No specific residents or medical conditions were mentioned in relation to the missing documentation.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that care and services met professional standards of practice regarding medication administration for a resident diagnosed with type 2 diabetes, essential hypertension, hyperlipidemia, and Alzheimer's disease. During a medication administration observation, a Registered Nurse (RN) dispensed only one ascorbic acid tablet instead of the prescribed two tablets and initially omitted atorvastatin calcium from the medication cup. The RN was interrupted multiple times during the medication preparation process, which contributed to these errors. Additionally, the RN administered levothyroxine after the resident had eaten breakfast, contrary to the physician's order to administer it on an empty stomach. The RN also crushed and administered extended-release medications, including Bupropion, Oxybutynin, and Metoprolol Succinate, by mixing them in chocolate pudding. This practice was against the drug specifications, which stated that these medications should not be chewed, cut, or crushed, as it could lead to the resident receiving the entire dose immediately rather than over an extended period. The RN was unsure about the implications of crushing extended-release medications, indicating a lack of understanding of medication administration protocols. Interviews with the Director of Nursing (DON) and a Nurse Practitioner (NP) confirmed that the facility's medication administration policy was not followed. The DON emphasized the importance of adhering to physician orders and manufacturer recommendations, while the NP highlighted the risks associated with crushing extended-release medications, such as potential overdose. The facility's policy also specified that crushing long-acting medications is only permissible with a specific physician's order, which was not present in this case.
Medication Administration Errors and High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 21.43% during a medication administration observation. This deficiency was identified through the observation of six medication administration errors out of 28 opportunities. The errors involved a resident with multiple diagnoses, including type 2 diabetes, essential hypertension, hyperlipidemia, and Alzheimer's disease. The errors included the incorrect administration of medications, such as crushing extended-release tablets that should not be crushed and failing to administer the correct dosage of prescribed medications. During the medication administration observation, a Registered Nurse (RN) was seen administering only one Ascorbic Acid tablet instead of the prescribed two, and crushing extended-release medications like Bupropion, Metoprolol Succinate, and Oxybutynin, which were then given to the resident in chocolate pudding. Additionally, the RN initially failed to dispense Atorvastatin into the medication cup due to an interruption and did not verify whether the resident had eaten breakfast before administering Levothyroxine, which should be given on an empty stomach. Interviews with the RN and the Director of Nursing (DON) revealed a lack of understanding and adherence to medication administration protocols. The RN was unsure about the rules regarding crushing extended-release medications, and the DON confirmed that such medications should not be crushed due to the risk of immediate release of the full dose. The facility's policies on medication administration and error monitoring were not followed, leading to the observed deficiencies.
Medication Storage and Expired Supplies Deficiency
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for a resident and did not discard expired medications and supplies. A resident was observed with Fluticasone Propionate Suspension nasal spray and Systane eye drops on their bedside table over several days. The resident expressed a preference for keeping these medications nearby to avoid asking nurses for them. However, there was no physician order allowing the resident to self-administer these medications, and the Director of Nursing confirmed that facility policy prohibits leaving medications at the bedside without such an order. Additionally, during a medication room observation, expired medications and supplies were found, including insulin pens, COVID-19 vaccines, and various medical kits and test strips. The RN acknowledged the presence of expired items and indicated they would be disposed of immediately. The facility's policy requires expired drugs and supplies to be discarded with proper record-keeping before their expiration date, but this was not adhered to, leading to the deficiency.
Failure to Assess Resident for Medication Self-Administration
Penalty
Summary
The facility failed to ensure that a resident was assessed for medication self-administration, which is a requirement for allowing residents to self-administer drugs if clinically appropriate. The resident, who was admitted with chronic respiratory failure, allergic otitis media, and anemia, had a BIMS score indicating moderate cognitive impairment. Despite this, there was no evidence in the care plan or clinical record that an assessment for self-administration of medication was conducted. The resident had active orders for Systane eye drops and Fluticasone nasal spray, but no order for self-administration was found. During an observation, these medications were found on the resident's bedside table, and the resident expressed a preference for keeping them nearby to avoid asking nurses for assistance. Interviews with staff, including a registered nurse and the Director of Nursing, confirmed that there was no order for self-administration and that the facility's policy prohibits medications at the bedside without such an order. The facility's policy requires an interdisciplinary team assessment to determine if a resident can safely self-administer medications, which was not done in this case.
Deficiencies in Care Planning for Dialysis and Oxygen Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident requiring dialysis care. The resident, who was readmitted with diagnoses including end-stage renal disease, had physician orders for pre and post-dialysis care, including site assessments and vital sign monitoring. However, the care plan did not include these specific interventions, and there was no evidence of post-dialysis access site monitoring in the clinical records. Interviews with staff, including the Quality Infection Control and the Director of Nursing, confirmed the absence of dialysis-related interventions in the care plan, which was against the facility's policy. Another deficiency was identified concerning a resident who required oxygen therapy. Despite having a physician order for oxygen therapy, there was no care plan developed to address the use of oxygen. Observations revealed that the resident was not consistently using the oxygen as prescribed, and the portable oxygen tank was sometimes not operational. Interviews with staff, including a CNA and the MDS coordinator, indicated that oxygen use should have been included in the care plan, but it was not. The Director of Nursing acknowledged that the care plan for oxygen use was not in place prior to the survey. The facility's policies on care planning and revisions upon status change were not followed, leading to these deficiencies. The lack of specific care plan interventions for dialysis and oxygen use could result in staff not being aware of necessary care actions, potentially affecting the continuity of care. The Director of Nursing and other staff members recognized the importance of having patient-centered care plans to ensure appropriate care for residents.
Failure to Revise Care Plans After Falls
Penalty
Summary
The facility failed to revise care plans after fall incidents for two residents, which could result in residents not receiving appropriate care. Resident #22, who was readmitted with multiple diagnoses including urinary tract infection and end-stage renal disease, was identified as a fall risk due to poor vision. Despite having fall incidents on October 9 and November 4, 2024, the care plan was not updated with new interventions. Interviews with staff revealed that although preventive measures were in place, no new interventions were deemed necessary, and the care plan was not revised accordingly. Resident #18, admitted with a history of falls and other medical conditions, experienced multiple falls from June to September 2024. The care plan initially included interventions such as education on safety precautions and therapy evaluations. However, after several falls, including incidents on June 16, June 23, and subsequent dates, there was no evidence that the care plan was evaluated for effectiveness or revised with new interventions to prevent further falls. Staff interviews indicated that new interventions should have been added to the care plan after each fall, but this was not done. The facility's policy required care plans to be modified with new or modified interventions upon a resident's status change. However, the care plans for both residents were not updated after their falls, contrary to the facility's policy. Interviews with the Director of Nursing and other staff highlighted a lack of adherence to the policy, resulting in a failure to provide continuity of care and potentially increasing the risk of recurrent falls and injuries for the residents.
Improper Medication Disposal Observed
Penalty
Summary
The facility failed to ensure proper disposal of a medication during a medication administration observation. A Registered Nurse (RN) dispensed a multiple vitamins capsule into a medication cup with other medications and then realized it was the incorrect medication. The RN used gloved hands to retrieve the capsule and returned it to the multiple vitamins container, which is against professional standards of practice. This action was observed during a survey conducted on November 6, 2024. Interviews with the RN and the Director of Nursing (DON) revealed that the RN acknowledged the mistake and stated that he usually disposes of such medications in the drug buster. The DON confirmed that the facility's process for disposing of non-controlled medications is to discard them and not return them to the container, as this could contaminate other vitamins in the container. The facility lacked a specific policy for the disposition of non-controlled medications, although they provided documentation that medications are typically placed in the Drug Buster per standards of practice.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident received a pneumococcal vaccine, despite the resident's expressed desire and family consent for the vaccination. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, a fracture of the neck of the right femur, and muscle weakness, had a moderate cognitive impairment as indicated by a BIMS score of 11. A progress note indicated the resident's wish to receive the pneumococcal vaccine during their stay, and a signed consent form from the resident's sister confirmed this intention. However, there was no evidence of a physician order for the vaccine in the medical record, and subsequent progress notes showed no administration or ordering of the vaccine. Interviews with facility staff revealed that the Quality Infection Control staff acknowledged the resident's consent for the vaccine but admitted to not placing the order in the resident's record. The Director of Nursing confirmed that the resident's vaccination was missed and acknowledged the potential risk of residents becoming ill with pneumonia due to this oversight. The facility's policy stated that residents should be offered pneumococcal immunizations unless medically contraindicated or previously immunized, but this was not adhered to in this case.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its policies regarding the investigation and timely reporting of abuse allegations for three residents. Resident #13, who has moderate cognitive impairment, reported an incident where another resident, #29, grabbed and twisted her wrist, causing pain. Despite this allegation, there was no evidence that the incident was reported to the State Agency or that an investigation was conducted promptly. The incident was only documented days later, and the resident's power of attorney was informed belatedly. Resident #29, who has Alzheimer's disease and a history of aggressive behavior, was involved in multiple incidents of physical aggression, including the one with Resident #13. Previous incidents included hitting and attempting to scratch another resident, #19, on September 5, 2024. However, this incident was not reported to management or the State Agency, and no investigation was conducted. The facility's documentation and interviews revealed a lack of immediate reporting and investigation, which are required by the facility's policies. Resident #19, who also has moderate cognitive impairment, was involved in the September 5 incident with Resident #29. Despite documentation of the incident in Resident #29's records, there was no evidence of any adjustments to Resident #19's care plan or any investigation into the incident. Interviews with staff, including the Director of Nursing and the former administrator, confirmed that the incidents were not reported or investigated as required, highlighting a systemic failure to adhere to the facility's abuse reporting policies.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report alleged violations of abuse to the proper authorities within the prescribed timeframes for three residents. Resident #13, who has moderate cognitive impairment, reported an incident where another resident, #29, grabbed and twisted her wrist. Despite the documentation of this incident, there was no evidence that it was reported to the State Agency. The incident was only brought to management's attention days later, delaying any investigation or protective measures. Resident #29, who has Alzheimer's disease and is rarely understood, was involved in multiple aggressive incidents, including hitting and attempting to scratch Resident #19. Despite these documented behaviors, there was no evidence that these incidents were reported to management or the State Agency. The lack of timely reporting and investigation allowed for the potential continuation of aggressive behaviors without intervention. The facility's policy requires immediate reporting of abuse allegations to the administrator and the State Agency within two hours. However, interviews with staff revealed that these procedures were not followed. The Director of Nursing and the former administrator were unaware of the incidents until much later, indicating a breakdown in communication and adherence to the facility's abuse policy. This failure to report and investigate in a timely manner could lead to continued harm to residents.
Failure to Investigate and Prevent Further Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse involving two residents were thoroughly investigated and that further abuse was prevented during the investigation. Resident #13, who has moderate cognitive impairment, reported an incident where another resident, #29, grabbed and twisted her wrist, causing pain. Despite this report, there was no evidence that the facility conducted an investigation into the incident. Additionally, the facility did not inform the resident's power of attorney until two days after the incident. Resident #29, who has Alzheimer's disease and is rarely understood, was involved in multiple aggressive incidents, including an attempt to hit and scratch another resident, #19, on a previous occasion. Despite documentation of these aggressive behaviors, there was no evidence that the facility thoroughly investigated these incidents. The facility's documentation revealed that the incident involving Resident #29 and Resident #13 was not reported or investigated until several days later, and the incident involving Resident #29 and Resident #19 was not reported or investigated at all. Interviews with staff, including the Director of Nursing and the former administrator, revealed that the incidents were not reported to management in a timely manner, and no investigations were initiated as required by the facility's abuse policy. The facility's policy mandates immediate reporting and investigation of abuse allegations, but these procedures were not followed, allowing for the potential of continued abuse.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 3 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Flagstaff
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire Transitional Care | 2.1 mi | ★★★★★ | 2 | 0 |
| Haven Of Flagstaff | 3.5 mi | ★★★★★ | 1 | 0 |
| Haven Of Sedona | 31.8 mi | ★★★★★ | 20 | 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.