Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

ASPIRE TRANSITIONAL CARE

FLAGSTAFF, AZ · 50 certified beds · Last Life Safety survey August 21, 2025

CMS Certification Number 035296 · first certified October 2018

Ownership

Operated by THE GOODMAN GROUP · Non profit - Corporation

  • Ownership changed August 1, 2020 (change of ownership)from WELBROOK SENIOR LIVING FLAGSTAFF LLC
36
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
4
Tags cited more than once
Across separate surveys
12
Inspection & testing records
Of the citations on file

Position within AZ

36 citations — more than 99% of the 140 certified nursing homes in AZ. Compared within AZ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 0 citations; the earlier surveys in the window averaged 18. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens October 2026 — about 1 month from now. This facility’s last Life Safety survey was August 2025. Facilities in AZ are typically surveyed 14–22 months after the last one (median 18), measured over 143 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

18 of the 36 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 36 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in AZ, and nationally. Surveyors differ markedly between states, so the AZ figure is the meaningful one.

This facility36AZ median8National median11
Citations on file over three years, compared
MeasureCitations
This facility36
Median facility in AZ8
Median facility nationally11

Survey history

Citations at each Life Safety survey
122023-08242024-0802025-08
Citations at each Life Safety survey
Survey dateCitations
August 18, 202312
August 22, 202424
August 21, 20250

Most-cited tags

Most-cited tags at this facility
K-09182K-03532E-00152E-00392E-00231E-00041E-00061K-02111
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0918Have generator or other power source capable of supplying service within 10 seconds.22024-08-22
K-0353Inspect, test, and maintain automatic sprinkler systems.22024-08-22
E-0015Address subsistence needs for staff and patients.22024-08-22
E-0039Conduct testing and exercise requirements.22024-08-22
E-0023Establish policies and procedures for medical documentation.12024-08-22
E-0004Develop and maintain an Emergency Preparedness Program (EP).12024-08-22
E-0006Conduct risk assessment and an All-Hazards approach.12024-08-22
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.12024-08-22

What the citations cover

Citations by CMS category
  • Emergency Preparedness Deficiencies 18
  • Smoke Deficiencies 8
  • Gas, Vacuum, and Electrical Systems Deficiencies 5
  • Egress Deficiencies 3
  • Other 2
Citations by CMS category
CategoryCitations
Emergency Preparedness Deficiencies18
Smoke Deficiencies8
Gas, Vacuum, and Electrical Systems Deficiencies5
Egress Deficiencies3
Miscellaneous Deficiencies2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

August 22, 2024 — 24 citations

Citations issued on August 22, 2024
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (October 16, 2024)
E-0006Conduct risk assessment and an All-Hazards approach.Deficient, Provider has date of correction (October 16, 2024)
E-0007Address patient/client population and determine types of services needed.Deficient, Provider has date of correction (October 16, 2024)
E-0009Include a process for Emergency Preparedness collaboration.Deficient, Provider has date of correction (October 16, 2024)
E-0013Develop Emergency Preparedness policies and procedures.Deficient, Provider has date of correction (October 16, 2024)
E-0015Address subsistence needs for staff and patients.Deficient, Provider has date of correction (October 16, 2024)
E-0018Establish procedures for tracking staff and patients during an emergency.Deficient, Provider has date of correction (October 16, 2024)
E-0023Establish policies and procedures for medical documentation.Deficient, Provider has date of correction (October 16, 2024)
E-0029Develop a communication plan.Deficient, Provider has date of correction (October 16, 2024)
E-0032Provide primary/alternate means for communication.Deficient, Provider has date of correction (October 16, 2024)
E-0033Establish methods for sharing information.Deficient, Provider has date of correction (October 16, 2024)
E-0034Provide a means of sharing information on occupancy/needs.Deficient, Provider has date of correction (October 16, 2024)
E-0035Provide family notifications of emergency plan.Deficient, Provider has date of correction (October 16, 2024)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (October 16, 2024)
E-0041Implement emergency and standby power systems.Deficient, Provider has date of correction (October 16, 2024)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (October 16, 2024)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (October 16, 2024)
K-0341Install a fire alarm system that can be heard throughout the facility.Deficient, Provider has date of correction (October 16, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (October 16, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 16, 2024)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (October 16, 2024)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (October 16, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (October 16, 2024)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (October 16, 2024)

August 18, 2023 — 12 citations

Citations issued on August 18, 2023
TagWhat the surveyor checksStatus
E-0015Address subsistence needs for staff and patients.Deficient, Provider has date of correction (October 3, 2023)
E-0020Establish policies and procedures including evacuation.Deficient, Provider has date of correction (October 3, 2023)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (October 3, 2023)
K-0222Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.Deficient, Provider has date of correction (October 3, 2023)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (October 3, 2023)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (October 3, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 3, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (October 3, 2023)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (October 3, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (October 3, 2023)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (October 3, 2023)
K-0927Have proper fire barriers, ventilation and signs for the transfilling of oxygen.Deficient, Provider has date of correction (October 3, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.