Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
THE PEAKS HEALTH & REHABILITATION
FLAGSTAFF, AZ · 58 certified beds · Last Life Safety survey February 12, 2026
CMS Certification Number 035257 · first certified May 2000
Also on this campus
The same campus holds a state-licensed assisted living facility, with its own state record on the Assisted Living Index: The Peaks, a Senior Living Community (3150 North Winding Brook Road). Matched by the telephone number the two records share. The records are separate and are never added together.
Ownership
Operated by THE GOODMAN GROUP · Non profit - Other
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within AZ
21 citations — more than 91% 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
The latest survey found 2 citations; the earlier surveys on file averaged 9.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens April 2027 — about 6 months from now. This facility’s last Life Safety survey was February 2026. Facilities in AZ are typically surveyed 14–23 months after the last one (median 18), measured over 157 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 about three years in Virginia. How the window is measured
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Emergency preparedness
7 of the 21 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)
1 physical-environment citation 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 21 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in AZ, and nationally. Surveyors differ markedly between states, so the AZ figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 21 |
| Median facility in AZ | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 22, 2023 | 18 |
| November 7, 2024 | 1 |
| February 12, 2026 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2023-09-22 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2023-09-22 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2024-11-07 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2023-09-22 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2023-09-22 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2023-09-22 |
| E-0020 | Establish policies and procedures including evacuation. | 1 | 2023-09-22 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2026-02-12 |
What the citations cover
- Emergency Preparedness Deficiencies 7
- Smoke Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Miscellaneous Deficiencies 3
- Other 2
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 7 |
| Smoke Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 3 |
| Services Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 12, 2026 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 15, 2026) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (May 15, 2026) |
November 7, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (November 18, 2024) |
September 22, 2023 — 18 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (October 16, 2023) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (October 16, 2023) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (October 16, 2023) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (October 16, 2023) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (October 16, 2023) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (October 16, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (October 16, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 16, 2023) |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has date of correction (October 16, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 16, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (October 16, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (October 16, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 16, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (October 16, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (October 16, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 16, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (October 16, 2023) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (October 16, 2023) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.