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 November 7, 2024
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
28 citations — more than 95% 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 1 citation; the earlier surveys in the window averaged 13.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (January 2026 to September 2026). Most AZ facilities have been surveyed by December 2026. This facility’s last Life Safety survey was November 2024. 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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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
9 of the 28 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
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 | 28 |
| Median facility in AZ | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 11, 2022 | 9 |
| September 22, 2023 | 18 |
| November 7, 2024 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0020 | Establish policies and procedures including evacuation. | 2 | 2023-09-22 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2023-09-22 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 2 | 2023-09-22 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2023-09-22 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2023-09-22 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2023-09-22 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2023-09-22 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2023-09-22 |
What the citations cover
- Emergency Preparedness Deficiencies 9
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Miscellaneous Deficiencies 6
- Smoke Deficiencies 4
- Other 2
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 9 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Miscellaneous Deficiencies | 6 |
| Smoke Deficiencies | 4 |
| Egress Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
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) |
August 11, 2022 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (October 3, 2022) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (October 3, 2022) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 3, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 3, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (October 3, 2022) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (October 3, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 3, 2022) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (October 3, 2022) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (October 3, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.