Inspection Reports for
The Peaks, A Senior Living Community
3150 N Winding Brook Rd, Flagstaff, AZ 86001, United States, AZ, 86001
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
116% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
2% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 2
Deficiencies: 1
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
Deficiencies: 1
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
Complaint Investigation
Deficiencies: 3
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
Routine
Census: 41
Deficiencies: 12
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
Facility census: 41
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
Census: 32
Deficiencies: 1
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
Routine
Deficiencies: 14
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 |
Report
July 10, 2025
Report
January 29, 2025
Report
November 7, 2024
Report
November 7, 2024
Report
September 22, 2023
Report
September 22, 2023
Report
August 11, 2022
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