The Peaks Health & Rehabilitation
3150 North Winding Brook Road, Flagstaff, AZ 86001 · Non profit - Other · 58 certified beds · (928) 774-7106 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- nursing-staff turnover (59%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.9% | 10.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.5% | 5.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.8% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.6% | 3.9% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.7% | 2.1% | 3.3% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.7% | 21.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.4% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 21.5% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.9% | 10.6% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 93.1% | 87.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 12.7% | 23.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.1% | 10.4% | 12.0% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
61.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 194 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 85.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 83 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 21% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.4%CMS range 53.9–68.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.0%CMS range 8.7–15.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 85.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 71.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 77.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 85.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 93.3% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 90.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.8%CMS range 3.2–10.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.89 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 58 beds and averages 41.5 residents a day — about 72% occupied, or roughly 16 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.06 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.88 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.01 hrs/resident/day on weekends vs 4.74 on weekdays — 15% thinner on weekends. RN hours go from 1.26 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 59% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · G2022-08-11 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documents and closed clinical record review, staff interviews, and review of policies, the facility failed to ensure one resident (#81) was free from a significant medication error. The deficient practice could result in adverse medication side effects for a resident. Findings include: Resident #81 was admitted to the facility on [DATE] and discharged from the facility on December 3, 2021. Diagnoses included dementia with Lewy bodies, mood disorder, anxiety disorder, and Parkinson's disease. Review of the resident's care plan revealed an undated problem: Black Box Warnings for Antipsychotics: Seroquel; Adverse cardiovascular effects, risk for infections, falls, blood glucose and lipid elevations, abnormal involuntary movement, cerebrovascular adverse events like stroke, sedation. The goal included: Side effects and adverse reactions for antipsychotics will be minimized, recognized early, or prevented daily. Interventions stated to observe for dizziness, sedation, unsteady gait, especially…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-10 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of clinical record, and review of facility policy, the facility failed to ensure an allegation of abuse was reported to mandated entities within 2 hours for one resident (#5). The deficient practice could lead to an allegation of abuse not being investigated by all mandated entities timely, resulting in possible ongoing abuse to a resident.-Findings include:Resident #5 was admitted to the facility February 29, 2024, with diagnoses that included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, aphasia following unspecified cerebrovascular disease, bipolar disorder, dysarthria, and acquired absence of right leg above knee.An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #5 had a brief interview for mental status (BIMS) score of 10, indicating moderate cognitive impairment. Section E revealed no potential indicators of psychosis and no behavioral symptoms were present.A care plan dated March 13, 2024,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-29 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, review of facility documentation, and policy, the facility failed to ensure that facility documents regarding grievances, reportables and resident council meeting minutes were available. The deficient practice could result in documentation regarding residents' issues and concerns pertaining to life and safety not being readily available. Findings include: The copy of the December 2023 self-reports and investigations, December 2023 grievance logs, and December 2023 Resident Council Meeting Minutes was requested from the facility on January 29, 2025 at 8:24 a.m. An email from the Executive Director (ED/staff #96) was received on January 29, 2025 at 10:13 a.m. The email stated that they are unable to locate the December 2023 reportables, grievance logs, and resident council meeting minutes. During an interview with the Interim Director of Nursing (Interim DON/staff #100) conducted on January 29, 2025 at 4:55 p.m., staff #100 stated that they did not know how long they have to keep documentation such as grievances or resident council meeting minutes. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-07 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of facility policy, the facility failed to ensure that care and services met professional standards of practice regarding medication administration for one of six sampled residents (#3). The deficient practice could result in residents not receiving the appropriate medication and for additional errors in medication administration. Findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes without complications, essential hypertension, hyperlipidemia, and Alzheimer's disease. Review of physician order summary revealed the following active orders: -Ascorbic Acid (supplement) tablet 500 milligrams (mg) give two tablets by mouth one time a day for supplement; -Bupropion hydrochloride (antidepressant) ER (extended release) give 150 mg orally in the morning for mood disorder; -Levothyroxine (thyroid hormone) 50 mcg (microgram), take one tablet by mouth once daily in the morning and to take one hour before a meal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-07 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for one resident (#3). The medication error rate was 21.43%. Six medication administration errors were identified out of 28 opportunities during medication administration observation. The deficient practice could result in further medication errors. Findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes without complications, essential hypertension, hyperlipidemia, and Alzheimer's disease. Review of the physician order dated March 6, 2024 revealed an order for Ascorbic Acid tablet 500 mg give two tablets by mouth one time a day for supplement Review of the physician order summary revealed an order for the following: -Atorvastatin Calcium oral tablet 40 mg give one tablet orally in the morning for hyperlipidemia. -Bupropion hydrochloride (antidepressant) ER…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-07 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY -During a medication room observation conducted with a Registered Nurse (RN/staff #6), on November 6, 2024 at 12:39 p.m., there were two Semglee insulin glargine pens in Ekit #1 in the fridge with an expiration date of June 2024; and, Moderna covid-19 vaccines in a black locked box in the fridge had a sticker on the box indicating the expiration date to be June 30, 2023. During the medication room observation with RN (staff #6) conducted on November 6, 2024 at 12:39 p.m., the following supplies were found having exceeded their expiration date: -Autoshield duo cap for insulin pen in Ekit #1 from fridge with an expiration date of February 2023; -Statlock intravenous kit with an expiration date of December 28, 2023; -Entraflo safety spike plus pump set with enfit with an expiration date of June 28, 2023; -Powerloc port access kit with an expiration date of October 31, 2024; and, -Even care blood glucose test strips with an expiration date of September 6, 2024 In an interview with RN (staff #6) conducted on November…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure one sampled resident (#5) was assessed for medication self-administration. The deficient practice could result in resident not taking or able to take the medication needed for treatment. Findings include: Resident #5 was admitted to the facility on [DATE], with diagnoses of chronic respiratory failure with hypoxia, acute and subacute allergic otitis media, unspecified ear, and acute post hemorrhagic anemia The admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderate cognitive impairment. Reviewed of the care plan revealed no evidence of a focus for medication self-administration. Physician orders revealed the following active medications: - Systane Solution eye drop (ocular lubricant) applied in both eyes with an order date of March 22, 2023; and. - Fluticasone Propionate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, review of clinical record, facility documentation, and facility policy, the facility failed to ensure policies were implemented regarding investigating and timely reporting of allegations of abuse for 3 sampled residents (#13, #19, and #29). The deficient practice could lead to allegations of abuse not being investigated timely, and could lead to continued harm to residents. Findings include: -Resident #13 admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis, collapsed vertebra, depression, and myasthenia gravis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 11, indicating moderate cognitive impairment. Review of the clinical record revealed no evidence of any documentation on October 29, 2024, regarding a resident-to-resident incident. A communication note dated October 31, 2024 revealed that an RN and an MDS coordinator spoke with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-07 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, review of clinical record, facility documentation, and facility policy, the facility failed to ensure alleged violations of abuse were reported to proper authorities within prescribed timeframes for 3 residents (#13, #19, and #29). The deficient practice could lead to allegations of abuse not being investigated timely, and could lead to continued harm to residents. Findings include: -Resident #13 admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis, collapsed vertebra, depression, and myasthenia gravis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 11, indicating moderate cognitive impairment. Review of the clinical record revealed no evidence of any documentation on October 29, 2024, regarding a resident-to-resident incident. A communication note dated October 31, 2024 revealed that an RN and an MDS coordinator spoke with the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated, and to prevent further abuse from occurring during the investigation for two residents (#19 and #29). The deficient practice could lead to allegations of abuse not being investigated thoroughly, and residents not being protected from further abuse and retaliation. Findings include: -Resident #13 admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis, collapsed vertebra, depression, and myasthenia gravis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 11, indicating moderate cognitive impairment. Review of the clinical record revealed no evidence of any documentation on October 29, 2024, regarding a resident-to-resident incident. A communication note dated October 31, 2024 revealed that an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview, and policies and procedures, the facility failed to ensure a comprehensive person-centered care plan with interventions was developed and implemented related to dialysis care and assessment for one resident (#22); and, oxygen use for one resident (#29). The deficient practice could result in staff not being aware of changes in interventions and asessments. Findings include: Resident #22 was readmitted to facility September 9, 2024 with diagnoses of urinary tract infection, type 2 diabetes mellitus, end stage renal disease (ESRD) and kidney disease. A review of physician orders dated September 9, 2024 revealed the following: - Dialysis appointment: Patient on hemodialysis (Tuesday, Thursday, Saturday) at (US Renal) Dialysis Center. Please complete pre-dialysis form and fax to dialysis center then place the form in MD box. - POST DIALYSIS: Assess dialysis site Q 30 mins x 4 hours post dialysis treatment. Assess for bruit/thrill and for sign/symptom…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · D2024-11-07 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that a care plan was revised after each fall for two sampled residents (#18 and #22). The deficient practice could result in resident not getting the appropriate care they need. Findings include: -Resident #22 was readmitted to facility September 9, 2024 with diagnoses of urinary tract infection, type 2 diabetes mellitus, end stage renal disease (ESRD) and kidney disease. An admission evaluation dated September 9, 2024 revealed that the resident was a fall risk related to poor vision. Interventions included the following: -4P's rounding (pain concerns, positioning needs, personal items are within reach and personal needs are being met) -Mat next to bed -Hi/low bed A care plan initiated on September 10, 2024 revealed the resident had the potential for falls related to ESRD, T2 DM and PVD. Interventions included 4P's rounding (pain concerns, positioning needs, personal items are within reach and personal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and review of facility policy, the facility failed to ensure that one medication was disposed of in accordance with professional standards of practice, the deficient practice could result in medications not being disposed of properly. The sample was 28 medication administrations observed. Findings include: During a medication administration observation with a Registered Nurse (RN/Staff #8) conducted on November 6, 2024 at 7:23 AM, the RN dispensed a multiple vitamins capsule into a medication cup with other medications and then verified on the order that it was the incorrect medication. The RN then used gloved hands to retrieve the capsule and put it back into the multiple vitamins container. An interview was conducted with a RN (Staff #8) on November 6, 2024 at 9:43 AM who stated that he usually does not put the medication back into the container after it being dispensed and that he would dispose of it in the drug buster. He further stated that he should not have put the capsule back into the container because of aseptic technique and that it…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, facility document review, and facility policy review, the facility failed to ensure that one sampled resident (#342) did not receive a pneumococcal vaccine. The deficient practice could result in residents not receiving vaccines. Findings included: Resident #342 was admitted on [DATE] with diagnoses of type 2 diabetes mellitus, fracture of unspecified part of neck of right femur, and muscle weakness. A progress note dated September 20, 2024, revealed that the resident would like to receive a pneumococcal vaccination during skilled nursing facility stay. The admission Minimal Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Review of an Immunization Informed Consent-V7 form dated October 29, 2024, revealed a signed consent by the resident's sister to receive the pneumonia vaccine Prevnar 20. Despite documentation that the family agreed to the vaccination, there was no evidence that the medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-22 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of employee personnel file, staff interviews and policy review, the facility failed to ensure personnel records for 2 staff (#4 and #101) included documentation of orientation and in-service education as required by policies and procedure. The deficient practice could result in incompetent care of residents. The facility census was 32 and the sample was 12. Findings include: The personnel file of a certified nurse assistant (CNA/staff # 4) revealed a hire date of August 06,2007. The file revealed no evidence of Abuse/neglect/exploitation, Resident rights, Dementia care, Infection control and Communication training since April 25, 2021. The personnel file of a certified nurse assistant (CNA/staff # 101) revealed a hire date of May 31,2023. The file revealed no evidence of Abuse/neglect/exploitation, Resident rights, Dementia care, Infection control and Communication training. An interview was conducted on September 20, 2023 around 3:25 p.m. with the Business Office Manager (staff # 26), he stated that staff # 4's, last in-service training was done on April 25,2021 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-08-11 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure a written notice of transfer/discharge was provided to one resident (#182) and that a copy was sent to the Office of the State Long Term Care Ombudsman for two residents (#12 and #133). The deficient practice could result in residents/representatives not being provided written notice of transfers/discharges and the ombudsman not receiving a copy of the notices. Findings include: -Resident #12 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, acute and chronic respiratory with hypoxia, and acute kidney failure. Review of a nursing note dated May 28, 2022 at 11:30 a.m. stated that the resident was sent to the emergency room for difficulty breathing, with oxygen saturation decreasing to 87% even with O2 at 3.5 LPM (liters per minute). At the time of discharge the resident was oriented to person, place and time. The resident was informed of the reason for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-11 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and review of policy, the facility failed to ensure one resident (#85) was provided with the required information concerning the formulation of advance directives. The sample size was 3. The deficient practice could result in residents not being informed of the right to formulate advance directives. Findings include: Resident #85 was admitted to the facility on [DATE] with diagnoses that included Methicillin Resistant Staphylococcus Aureus infection, acquired absence of left leg below knee, and encounter for orthopedic aftercare. Review of the physician's orders revealed an order for a Full code, dated July 25, 2022. The active care plan was reviewed, it did not include the resident's advance directives/code status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. However, a clinical record review was conducted on August 8,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-11 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review, staff interviews, and policy review, the facility failed to ensure the physician was notified of one resident's (#182) fall. The deficient practice could result in physicians not being notified of changes in residents' conditions. Findings include: Resident #182 was admitted to the facility on [DATE] with diagnoses that included fracture of the left femur, orthopedic after care, seizures, major depressive disorder, type 2 diabetes mellitus, and weakness. The clinical record indicated that the resident was his own responsible party. Review of the admission Evaluation dated October 26, 2021 revealed the resident was alert and oriented x 4 (person, place, time, and situation). Review of the medical record revealed a nursing note dated October 27, 2021, stating that the resident was found lying on the floor, flat on his back at 9:20 AM. Further review of the clinical record revealed no evidence that the physician was notified regarding the resident's fall at 9:20 AM on October…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-11 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and review of policy, the facility failed to ensure required notifications were made at the time of Medicare A discharge and/or payment changes for 3 residents (#82, #91, #92). The deficient practice could result in unforeseen charges to the resident. Findings include: -Resident #82 was admitted to the facility on [DATE] and discharged on March 26, 2021 with diagnoses that included right femur fracture, acute post-hemorrhagic anemia, and acute kidney failure. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] included the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. A Notice of Medicare Non-Coverage (NOMNC) form was provided: The Effective Date Coverage of your current Skilled Nursing Facility Services will end February 4, 2021 and liability begins on February 5, 2021. Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-11 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility records, closed clinical record review, staff interviews, and review of policy, the facility failed to ensure the services provided by the facility met professional standards of quality related to medication administration for one resident (#81) by failing to ensure resident #81 was not administered another resident's medication. The deficient practice could result in medication errors and insufficient resident supply of medication. Findings include: Resident #81 was admitted to the facility on [DATE] and discharged from the facility on December 3, 2021. Diagnoses included dementia, mood disorder, anxiety disorder, and Parkinson's disease. Review of a Facility Self Report investigation regarding an incident that occurred on December 27, 2020 included: Resident #81 was exhibiting behaviors including aggression. The Registered Nurse (RN/staff #98) called the MD (Medical Doctor) and was given orders including an order for a one-time dose of Seroquel (antipsychotic) 25 milligrams (mg).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-11 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure one resident (#133) had a home health agency (HHA) in place prior to discharge. The deficient practice has the potential to result in an ineffective transition to post-discharge care and increases the risk factors leading to preventable readmission. Findings include: Resident #133 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease of the native coronary artery without angina pectoris and chronic respiratory failure. The admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. The clinical record contained an order dated July 7, 2021 for home health, physical therapy, and nursing evaluation and treat. Review of a note written by the Social Services Assistant (staff #79) dated July 8, 2021 on a Post-It revealed that the resident lived…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#82) received Activities of Daily Living (ADL) care/incontinence care to maintain good grooming/personal hygiene. The deficient practice could result in negative medical and psychosocial impact. Findings include: Resident #82 was admitted to the facility on [DATE] and discharged on March 26, 2021 with diagnoses that included right femur fracture, post hemorrhagic anemia, and acute kidney failure. Review of a Nurse Practitioner (NP) admission note dated January 6, 2021 included the resident had urinary incontinence and came to them with a Foley catheter. The note also included will discontinue and use briefs. Review of the physician's orders revealed an order dated January 6, 2021 to discontinue the Foley catheter. Review of a nurse progress note dated January 6, 2021 revealed the urinary catheter was removed per provider's order. Review of the Occupational Therapy Plan of Care dated January…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure the necessary hospice services were coordinated with the facility for one sampled resident (#8). The deficient practice could result in residents not receiving needed services and treatment. Findings include: Resident #8 was admitted to the facility on [DATE], with diagnoses that included secondary malignant neoplasm of unspecified lung, pulmonary hypertension due to lung diseases and hypoxia, and chronic pulmonary embolism. Review of the hospice binder located at the nurse station and the resident's clinical record did not reveal documentation of nurse and certified nurse assistant orders or visits to the resident. The combined disciplinary plan of care dated June 15, 2022 revealed an order for hospice aide visit frequency of 2 visits per week dated May 29, 2022. Hospice Nurse progress note dated July 14, 2022 stated the resident will continue to receive assistance from facility staff and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-11 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs, by failing to ensure one resident (#20) received pain medication as ordered by the physician. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary. Findings include: Resident #20 was admitted on [DATE] with diagnoses that included encephalopathy, diastolic heart failure, type 2 diabetes mellitus, opioid dependence, depression, major depressive disorder, and anxiety disorder, Review of the resident's care plan initiated on June 14, 2022, revealed the resident is on pain medication therapy related to chronic back pain. An intervention included administering analgesic medications as ordered by the physician. Review of the annual Minimum Data Set, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-11 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility logs, staff interviews, and policy review, the facility failed to provide evidence that temperatures for the walk-in freezer and refrigerator were consistently monitored. The deficient practice could result in foodborne illness. Findings include: During the initial kitchen observation conducted on August 8, 2022 at 10:06 AM, the kitchen log for August 2022 was reviewed. Review of the August 2022 temperature log for the walk-in freezer and refrigerator revealed no evidence the temperature was checked on: August 5, at lunch, and dinner August 6, all day August 7, breakfast and lunch During an interview conducted on August 8, 2022 at 10:12 AM with the Kitchen Director (staff #78), he stated the walk-in freezer and fridge temperatures are documented daily at breakfast, lunch and dinner, on the Temperature Log. He reviewed the log and stated that there was no documentation for August 5 Lunch/Dinner, August 6 all day, and August 7 breakfast and lunch. The Kitchen Director stated that this did not meet the facility expectation. An interview was conducted on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-11 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, and facility policy, the facility failed to ensure one sampled resident (#5) received specialized rehabilitation services in a timely manner. The deficient practice could result in the residents' decline in level of functioning. Findings include: Resident #5 was admitted on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side, unspecified osteoarthritis, and obesity. Review of the care plan for an activities of daily living self-care performance deficit related to decline in functional status related to cerebrovascular accident (CVA) with left side deficits dated August 4, 2021 included the intervention for a physical and occupational therapy evaluation and treatment as per physician orders. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-11 · tag F0885 — failed to notify residents/families about COVID-19 — isolatedReport COVID19 data to residents and families.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that residents' representatives and families were notified that one resident (#200) tested positive for COVID-19. The deficient practice can result in residents and families/representatives not being aware of new COVID-19 cases in the facility and the actions implemented to reduce the risk of transmission. Findings include: Resident #200 was admitted to the facility on [DATE] with diagnoses that included hypokalemia, spinal stenosis, lumbar region with neurogenic claudication, and stress fracture, left humerus. Review of the clinical record revealed that the resident tested positive for COVID-19 on July 26, 2022. An interview was conducted on August 11, 2022 at 3:02 p.m. with the Director of Nursing (DON/staff #97). Staff #97 stated that she is monitoring infection control and staff #68 is going to be the Infection Control Preventionist (ICP). Staff #97 said the last case for COVID-19 was on July…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2022-08-11 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews and policy review, the facility failed to ensure current nurse staffing information was posted on a daily basis. The deficient practice could result in staffing information not being readily available to residents and visitors. Findings include: During an observation conducted on August 8, 2022 at approximately 10:45 AM, no Daily Staffing Posting was observed to be posted in a prominent area in the facility. On August 8, 2022 at 10:58 AM, a Daily Staff Posting was observed posted outside of the Director of Nursing and Executive Director's offices, across from the nursing station. The posting combined information that included the daily number and hours worked for nurses and certified nursing assistants and the census for each shift. Observations were conducted on August 9, 2022 at 10:14 AM and 2:44 PM which revealed the daily staff posting was not updated from the previous day of August 8. 2022. Another observation was conducted on August 10, 2022 at 7:00 AM, the daily staff posting was dated August 8, 2022. An interview was conducted on August…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE GOODMAN GROUP — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.2 | -1.2 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 4 of 5 | 3.7 | +0.3 vs chain |
| Quality measures | 4 of 5 | 4.2 | -0.2 vs chain |
The other 8 homes this chain runs (chain average 3.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NORTHERN ARIZONA HEALTHCARE CORPORATION | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 12/24/1997 |
| NORTHERN ARIZONA SENIOR LIVING COMMUNITY, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 02/15/2017 |
| THE GOODMAN FAMILY OPERATING FOUNDATION | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2024 |
| EBEID, SADEK | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 09/16/2020 |
| FARR, CAMERON | Individual | W-2 MANAGING EMPLOYEE | — | since 04/01/2024 |
| BAVASI, CHRISTOPHER | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 11/18/2015 |
| DAVISON, LISA | Individual | CORPORATE DIRECTOR | — | since 01/13/2020 |
| LANSBURG, JACOB | Individual | CORPORATE DIRECTOR | — | since 05/27/2020 |
| SALMEN, THOMAS | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| WILSON, MARK | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| KNACKE, CLINTON | Individual | CORPORATE OFFICER | — | since 10/12/2022 |
CMS files one row per role, so the 14 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AZ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arizona Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 035257. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.