Inspection Reports for
The Peaks, A Senior Living Community
3150 N Winding Brook Rd, Flagstaff, AZ 86001, United States, AZ, 86001
Back to Facility Profile27 Reports
Inspection Report — Apr 28, 2026
Complaint Investigation
Date: Apr 28, 2026
Visit Reason
On-site complaint investigation of complaint 00167271 at an Assisted Living Center, conducted 28 April 2026.
Complaint Details
No deficiencies were found during the on-site investigation of complaint 00167271 on April 28, 2026.
Findings
No deficiencies were found during the investigation.
Report Facts
Complaints investigated: 1
Inspection Report — Apr 2, 2026
Annual Inspection
Date: Apr 2, 2026
Visit Reason
On-site complaint investigation and annual compliance inspection of complaints 00161843, 00162963, 00163123, 00163274, 00163422, and 00163959 at an Assisted Living Center, conducted 2 April 2026.
Complaint Details
This statement of deficiencies supersedes the SOD sent on April 29, 2026. Deficiencies were found during the on-site compliance inspection and investigation of complaints 00161843, 00162963, 00163123, 00163274, 00163422, and 00163959 conducted on April 2, 2026.
Findings
Four deficiencies were found related to opioid administration documentation, failure to report suspected abuse or neglect, inadequate verification of caregiver skills before assignment, and unsafe storage of poisonous materials. The deficiencies posed risks to resident health and safety.
Deficiencies (4)
R9-10-120 — The manager failed to ensure authorized individuals identified the resident's need for opioids and monitored the resident's response before administration, with no pain level recorded despite medication given for pain.
R9-10-803 — The manager failed to document immediate actions and report suspected abuse or neglect to adult protective services or peace officers as required, leaving the Department unable to assess resident safety.
R9-10-806 — The manager failed to verify and document caregiver skills and knowledge before providing physical health services for four of seven personnel sampled, risking inadequate resident care.
R9-10-820 — The manager failed to ensure poisonous or toxic materials were stored in locked, labeled containers inaccessible to residents, with chemicals found in unlocked cabinets in the memory care kitchenette.
Report Facts
Deficiencies cited: 4
Complaints investigated: 6
Inspection Report — Nov 3, 2025
Complaint Investigation
Date: Nov 3, 2025
Visit Reason
On-site complaint investigation of complaint 00149560 at an Assisted Living Center, conducted 3 November 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaint 00149560 conducted on November 4, 2025.
Findings
No deficiencies were found during the inspection.
Report Facts
Complaints investigated: 1
Inspection Report — Jul 10, 2025
Complaint Investigation
Date: Jul 10, 2025
Visit Reason
The inspection was conducted due to an allegation of abuse reported by Resident #5, including physical and sexual abuse claims, to assess the facility's compliance with mandated reporting requirements.
Complaint Details
Resident #5 alleged physical abuse on December 12, 2024, and sexual abuse reported during hospitalization in July 2025. The facility did not report these allegations to mandated entities within required timeframes. The resident provided inconsistent statements, and the facility's investigation was incomplete.
Findings
The facility failed to timely report an allegation of abuse to mandated entities within 2 hours for Resident #5. The resident made multiple inconsistent abuse allegations, and the facility did not submit required reports to authorities, relying instead on hospital reporting.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents present during inspection: 2
Residents affected by deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Speech Language Pathologist | Speech Language Pathologist | Provided written statement regarding Resident #5's communication and abuse allegations |
| Social Services Director | Social Services Director | Provided written statement and interviews regarding Resident #5's abuse allegations and facility reporting |
| Director of Nursing | Director of Nursing | Interviewed regarding facility reporting procedures and knowledge of abuse allegations |
| Administrator | Administrator | Interviewed regarding facility investigation and reporting of Resident #5's abuse allegations |
Inspection Report — Jul 8, 2025
Complaint Investigation
Date: Jul 8, 2025
Visit Reason
On-site complaint investigation of complaints 00136078 and 00136086 at an Assisted Living Center, conducted 8 July 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaints 00136078 and 00136086 conducted on July 8, 2025.
Findings
No deficiencies were found during the inspection.
Report Facts
Complaints investigated: 2
Inspection Report — Jun 10, 2025
Complaint Investigation
Date: Jun 10, 2025
Visit Reason
On-site complaint investigation of complaints 00105359, 00105496, 00126039, 00132742, 00127189, 00127352, 00132760, and 00132762 at an Assisted Living Center, conducted 9 and 10 June 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaints 00105359, 00105496, 00126039, 00132742, 00127189, 00127352, 00132760, and 00132762, conducted on June 9, 2025, and June 10, 2025.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 8
Inspection Report — May 29, 2025
Complaint Investigation
Date: May 29, 2025
Visit Reason
On-site complaint investigation of complaints 00129762 and 00131960 at an Assisted Living Center, conducted 29 May 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaints 00129762 and 00131960 conducted on May 29, 2025.
Findings
No deficiencies were found during the investigation.
Report Facts
Complaints investigated: 2
Inspection Report — May 2, 2025
Complaint Investigation
Date: May 2, 2025
Visit Reason
On-site complaint investigation of complaint 00127719 at an Assisted Living Center, conducted 2 May 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaint 00127719 conducted on May 2, 2025.
Findings
No deficiencies were found during this inspection.
Report Facts
Complaints investigated: 1
Inspection Report — Mar 17, 2025
Complaint Investigation
Date: Mar 17, 2025
Visit Reason
On-site complaint investigation of complaint 00122834 at an Assisted Living Center, conducted 17 March 2025.
Complaint Details
No deficiencies were found during the on-site investigation of complaint 00122834 conducted on March 17, 2025.
Findings
No deficiencies were found during the inspection.
Report Facts
Complaints investigated: 1
Inspection Report — Feb 21, 2025
Complaint Investigation
Date: Feb 21, 2025
Visit Reason
On-site complaint investigation at an Assisted Living Center, conducted 21 February 2025.
Complaint Details
On February 21, 2024, an off-site review of the plan of correction was conducted. The plan of correction was accepted for all citations.
Findings
One deficiency was found related to assistance in the self-administration of medication. The plan of correction was accepted for all citations.
Deficiencies (1)
Assistance in the self-administration of medication provided to a resident was not demonstrated to be in compliance with an order; no evidence text was provided.
Report Facts
Deficiencies cited: 1
Inspection Report — Jan 29, 2025
Date: Jan 29, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with record retention policies, specifically regarding the availability of grievance logs, reportables, and resident council meeting minutes for December 2023.
Findings
The facility failed to ensure that documentation regarding grievances, reportables, and resident council meeting minutes were available as required. Staff interviews confirmed the missing documents and lack of knowledge about retention requirements, which could impact the facility's ability to support claims and track resident care.
Deficiencies (1)
Failed to ensure facility documents regarding grievances, reportables, and resident council meeting minutes were available.
Report Facts
Date of missing documentation: 202312
Retention period for Committee Minutes: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Provided information about missing documentation and expectations for record retention | |
| Interim Director of Nursing | Interviewed regarding knowledge of documentation retention and impact of missing records |
Inspection Report — Jan 16, 2025
Complaint Investigation
Date: Jan 16, 2025
Visit Reason
On-site complaint investigation of complaints AZ00220752, AZ00220256, and AZ00221414 at an Assisted Living Center, conducted 16 January 2025.
Complaint Details
No deficiencies were found during the investigation of complaints AZ00220752, AZ00220256, and AZ00221414, conducted on January 16, 2025.
Findings
No deficiencies were found during the investigation.
Report Facts
Complaints investigated: 3
Inspection Report — Dec 12, 2024
Complaint Investigation
Date: Dec 12, 2024
Visit Reason
On-site complaint investigation of complaints AZ00220208, AZ00220176, and AZ00220210 at an Assisted Living Center, conducted 12 December 2024.
Complaint Details
The following deficiency was found during the investigation of complaints AZ00220208, AZ00220176, and AZ00220210 conducted on December 12, 2024.
Findings
The inspection found one deficiency related to medication administration where a resident received medication beyond the prescribed discontinuation date.
Deficiencies (1)
The manager failed to ensure that assistance in the self-administration of medication provided to a resident was in compliance with a physician's order. The medication Eliquis was administered until December 10, 2024, despite being ordered discontinued on December 7, 2024.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 26, 2024
Annual Inspection
Date: Nov 26, 2024
Visit Reason
On-site complaint investigation of complaints AZ00219330 and AZ00219373 combined with an annual compliance inspection at an Assisted Living Center, conducted 26 November 2024.
Complaint Details
No deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00219330 and AZ00219373 conducted on November 26, 2024.
Findings
No deficiencies were found during this inspection and complaint investigation.
Inspection Report — Nov 18, 2024
Complaint Investigation
Date: Nov 18, 2024
Visit Reason
On-site complaint investigation of complaints AZ00185327, AZ00216185, AZ00218387, and AZ00218805 at an Assisted Living Center, conducted 18 November 2024.
Complaint Details
The following deficiencies were found during the investigation of complaints AZ00185327, AZ00216185, AZ00218387, and AZ00218805 conducted on November 18, 2024.
Findings
The inspection found three deficiencies related to incomplete and unsigned service plans for a sample resident. The facility failed to include the level of service, ensure timely reviews, and obtain required signatures on service plans.
Deficiencies (3)
The manager failed to ensure that a sample resident record contained a service plan that included the level of service the resident was expected to receive. The record for R3 had a service plan dated November 4, 2023 missing this information.
The manager failed to ensure that a sample resident record contained documentation of a written service plan reviewed and updated at least once every six months for a resident receiving personal care services. The record for R3 showed reviews on November 4, 2023 and August 28, 2024, which did not meet the six-month requirement.
The manager failed to ensure that a sample service plan, when updated, was signed and dated by the resident or representative, the manager, and the nurse or medical practitioner who reviewed the plan. The service plan dated August 28, 2024 for R3 lacked these signatures.
Report Facts
Deficiencies cited: 3
Inspection Report — Nov 7, 2024
Complaint Investigation
Date: Nov 7, 2024
Visit Reason
The inspection was conducted due to allegations of abuse involving three residents (#13, #19, and #29) at The Peaks Health & Rehabilitation. The investigation focused on failure to timely report and investigate abuse allegations and prevent further harm.
Complaint Details
The complaint involved allegations of resident-to-resident abuse between residents #13, #19, and #29. The facility failed to report incidents timely to the State Agency and did not conduct investigations as required. The allegations were substantiated with evidence of abuse and failure to follow mandatory reporting and investigation procedures.
Findings
The facility failed to implement policies and procedures to prevent abuse, neglect, and timely reporting of abuse allegations. Multiple incidents involving resident-to-resident abuse were not reported to management or the State Agency within required timeframes, and investigations were not completed. The facility also failed to protect residents from further abuse during investigations.
Deficiencies (3)
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft.
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failure to respond appropriately to all alleged violations, including thorough investigation and prevention of further abuse.
Report Facts
Residents Affected: 3
BIMS score: 11
Inspection Report — Nov 7, 2024
Routine
Date: Nov 7, 2024
Visit Reason
Routine inspection conducted to assess compliance with regulatory requirements including medication administration, abuse reporting, care planning, medication storage, and vaccination protocols.
Findings
The facility failed to ensure proper medication self-administration assessment, timely abuse reporting and investigation, comprehensive care planning including dialysis and oxygen use, proper medication administration practices, disposal of medications, medication error rates below 5%, proper medication storage, and administration of pneumococcal vaccine. Several residents experienced medication errors, incomplete care plans, and unreported abuse incidents.
Deficiencies (12)
Failed to assess resident #5 for medication self-administration and left medications at bedside without order.
Failed to implement policies and procedures to prevent abuse, neglect, and theft including timely reporting and investigation of abuse allegations for residents #13, #19, and #29.
Failed to timely report suspected abuse and report investigation results to proper authorities for residents #13, #19, and #29.
Failed to respond appropriately to all alleged violations by not thoroughly investigating abuse allegations and preventing further abuse for residents #19 and #29.
Failed to develop and implement a complete care plan with dialysis care interventions for resident #22 and oxygen use for resident #29.
Failed to revise care plans after each fall for residents #18 and #22 to include new interventions and evaluate effectiveness.
Failed to ensure medication administration met professional standards including crushing extended release medications and administering levothyroxine after meals for resident #3.
Failed to properly dispose of medications by returning dispensed medication to container, risking contamination.
Medication error rate was 21.43% due to multiple medication administration errors for resident #3.
Failed to ensure drugs and biologicals were labeled and stored properly; expired medications and supplies were found in medication room.
Failed to ensure medications were not left at bedside for resident #5 and failed to discard expired medications and supplies.
Failed to ensure resident #342 received pneumococcal vaccine despite consent and documented request.
Report Facts
Medication error rate: 21.43
Sample size: 13
Medication administration observations: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #33 | Registered Nurse | Named in medication self-administration finding for resident #5 |
| Staff #123 | Director of Nursing | Named in multiple findings including medication self-administration, abuse reporting, care planning, medication administration |
| Staff #8 | Registered Nurse | Named in medication administration errors for resident #3 |
| Staff #6 | Registered Nurse | Named in medication room observation and expired medication findings |
| Staff #60 | Nurse Practitioner | Named in medication administration and extended release medication interview |
| Staff #149 | Former Administrator | Named in abuse reporting findings |
| Staff #111 | Licensed Practical Nurse | Named in abuse incident observation and reporting |
| Staff #122 | Certified Nursing Assistant | Named in abuse incident observation |
| Staff #61 | MDS Coordinator | Named in care plan development and oxygen use findings |
Inspection Report — Aug 28, 2024
Complaint Investigation
Date: Aug 28, 2024
Visit Reason
On-site complaint investigation of complaints AZ00215197 and AZ00215073 at an Assisted Living Center, conducted 28 August 2024.
Complaint Details
An on-site investigation of complaint AZ00215197 and AZ00215073 was conducted on August 28, 2024 and no deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jun 11, 2024
Complaint Investigation
Date: Jun 11, 2024
Visit Reason
On-site complaint investigation of complaint AZ00210955 at an Assisted Living Center, conducted 11 June 2024.
Complaint Details
The following deficiency was found during the investigation of complaint AZ00210955 conducted on June 11, 2024.
Findings
The inspection found one deficiency related to service plans not being reviewed and updated at least once every three months for residents receiving directed care services.
Deficiencies (1)
The manager failed to ensure that two sampled resident service plans were reviewed and updated at least once every three months as required. Records for residents R1 and R2 showed last updates on January 18, 2024, and February 19, 2024, respectively, and the manager acknowledged the documentation did not reflect timely updates.
Report Facts
Deficiencies cited: 1
Inspection Report — Apr 29, 2024
Complaint Investigation
Date: Apr 29, 2024
Visit Reason
On-site complaint investigation of complaints AZ00208210 and AZ00209181 at an Assisted Living Center, conducted 29 April 2024.
Complaint Details
The following deficiency was found during the investigation of complaints AZ00208210 and AZ00209181 conducted on April 29, 2024.
Findings
The inspection found one deficiency involving failure to treat a resident with dignity, respect, and consideration. The facility terminated the employee responsible following an internal investigation.
Deficiencies (1)
A manager failed to ensure that a resident was treated with dignity, respect, and consideration. An employee was observed yelling at a resident and using frequent profanity, resulting in termination to prevent emotional abuse.
Report Facts
Deficiencies cited: 1
Inspection Report — Jan 30, 2024
Enforcement
Date: Jan 30, 2024
Visit Reason
Civil monetary penalty, action 00111796 (invoice INV-258460), assessed 30 January 2024.
Findings
A $1,750.00 penalty was assessed and paid in full on 26 March 2024.
Report Facts
Penalty amount: 1750
Amount paid: 1750
Amount remaining: 0
Inspection Report — Jan 2, 2024
Annual Inspection
Date: Jan 2, 2024
Visit Reason
On-site complaint investigation of complaint AZ00203700 combined with a compliance (annual) inspection at an Assisted Living Center, conducted 2 January 2024.
Complaint Details
The following deficiencies were found during the compliance inspection and investigation of complaint AZ00203700 conducted on January 2, 2024.
Findings
This inspection found twelve deficiencies related to missing emergency responder patient information forms, lack of conspicuous posting of inspection reports, incomplete tuberculosis screening documentation for personnel and residents, expired CPR and first aid certifications, incomplete medication storage plans, missing vaccination notification documentation, outdated toxicology reference guides, insufficient disaster and evacuation drills, unsecured oxygen cylinders, and missing annual tuberculosis risk assessments.
Deficiencies (12)
36-420.04.C — The manager failed to ensure that standardized emergency responder patient information forms were completed and maintained for three sample residents, as required.
The manager failed to ensure that the location of the most recent Department inspection report and plan of correction was conspicuously posted, as confirmed by observation and interview. This is a repeat deficiency.
R9-10-113 — The manager failed to ensure that one of four personnel records contained evidence of freedom from infectious tuberculosis prior to providing services, as the TB test was not within 12 months of hire.
The manager failed to ensure that one of four personnel records contained current documentation of first aid and CPR training specific to adults, as certifications had expired. This is a repeat deficiency.
R9-10-808 — The manager failed to ensure that one of three resident records contained evidence of freedom from infectious tuberculosis within seven calendar days after occupancy.
The manager failed to ensure that two sample resident service plans included how medications stored in residents' bedrooms would be stored and controlled. This is a repeat deficiency.
The manager failed to ensure that two sample resident records contained documentation of notification of the availability of influenza and pneumonia vaccinations.
The manager failed to ensure that a current toxicology reference guide was available for use by personnel members. This is a repeat deficiency.
The manager failed to ensure that disaster drills for employees were conducted on each shift at least once every three months and documented. This is a repeat deficiency.
The manager failed to ensure that evacuation drills for employees and residents were conducted at least once every six months, as documentation showed only one drill in the past year.
The manager failed to ensure that oxygen cylinders were secured in an upright position, as two large cylinders were observed unsecured. This is a repeat deficiency.
R9-10-113 — The chief administrative officer failed to ensure annual assessment of the health care institution's risk of exposure to infectious tuberculosis was documented and implemented.
Report Facts
Deficiencies cited: 12
Inspection Report — Sep 22, 2023
Date: Sep 22, 2023
Visit Reason
The inspection was conducted to review compliance with training and orientation requirements for nurse aides, specifically to ensure personnel records included documentation of orientation and in-service education as required by facility policies.
Findings
The facility failed to ensure personnel records for 2 staff members included required documentation of orientation and in-service education related to abuse prevention, dementia care, and other training. This deficiency could result in incompetent care of residents.
Deficiencies (1)
Personnel records for 2 staff (#4 and #101) lacked documentation of orientation and in-service education on abuse/neglect/exploitation, resident rights, dementia care, infection control, and communication training.
Report Facts
Sample size: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Interviewed regarding staff training records for staff #4 and #101 |
| Director of Nursing | Director of Nursing | Interviewed regarding training requirements and staff orientation policies |
Inspection Report — Mar 28, 2023
Enforcement
Date: Mar 28, 2023
Visit Reason
Civil monetary penalty, action 00113589 (invoice INV-259891), assessed 28 March 2023.
Findings
A $1,250.00 penalty was assessed and paid in full on 11 May 2023.
Report Facts
Penalty amount: 1250
Amount paid: 1250
Amount remaining: 0
Inspection Report — Aug 11, 2022
Routine
Date: Aug 11, 2022
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident rights, notification procedures, medication administration, discharge planning, rehabilitative services, infection control, and staffing.
Findings
The facility was found deficient in multiple areas including failure to provide residents with information on advance directives, failure to notify physicians and families of resident falls, failure to provide timely Medicare/Medicaid notices, failure to notify the ombudsman of resident discharges, medication administration errors including a significant overdose, failure to provide adequate ADL care, failure to coordinate hospice services, failure to post daily nurse staffing information, failure to monitor food storage temperatures, and failure to provide timely specialized rehabilitation services.
Deficiencies (14)
Failed to provide one resident with required information concerning advance directives.
Failed to ensure physician was notified of one resident's fall.
Failed to provide required Medicare/Medicaid notices to residents at discharge or payment changes.
Failed to provide written notice of transfer/discharge to residents and ombudsman.
Failed to ensure medication administration met professional standards; one resident was administered another resident's medication.
Failed to ensure one resident had home health agency in place prior to discharge.
Failed to provide adequate activities of daily living care/incontinence care to one resident.
Failed to coordinate necessary hospice services for one resident.
Failed to post current nurse staffing information daily.
Failed to ensure medication regimen was free from unnecessary drugs; one resident received pain medication outside ordered parameters.
Failed to ensure one resident was free from a significant medication error resulting in overdose and hospitalization.
Failed to consistently monitor and document walk-in freezer and refrigerator temperatures.
Failed to provide specialized rehabilitative services in a timely manner for one resident.
Failed to notify residents' representatives and families of a resident's positive COVID-19 test result.
Report Facts
Deficiencies cited: 14
Medication error dose: 200
Medication error dose: 25
Pain medication administration: 6
Pain medication administration: 3
Physical therapy treatments: 9
Physical therapy order frequency: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN staff #98 | Registered Nurse | Administered incorrect dose of Seroquel resulting in medication error and hospitalization |
| RN staff #99 | Registered Nurse | Failed to secure medication cart leading to medication error |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding deficiencies and medication errors |
| Executive Director | Executive Director | Provided interview regarding COVID-19 notification deficiency |
| Director of Therapy | Director of Therapy | Provided interview regarding delayed physical therapy evaluation |
| Kitchen Director | Kitchen Director | Interviewed regarding failure to document food storage temperatures |
| Licensed Nursing Assistant staff #32 | LNA | Interviewed regarding inadequate incontinence care |
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