D

THE PEAKS HEALTH & REHABILITATION

3150 NORTH WINDING BROOK ROAD, FLAGSTAFF, AZ 86001
Score: 54 / 100

The Peaks Health & Rehabilitation faces challenges in its CMS ratings, earning a D grade with a score of 54/100. The facility ranks in the 33th percentile among Arizona nursing homes, suggesting significant room for improvement.

The Peaks Health & Rehabilitation provides above-average staffing with 4.44 total nurse hours per resident per day. Higher staffing levels are generally associated with better care outcomes and more attentive staff.

Recent inspections identified 28 deficiencies at The Peaks Health & Rehabilitation. While none were classified as the most serious level, families should review the detailed inspection history below.

Score Breakdown

Overall CMS Rating 16 / 40 pts
2 ★ CMS rating
Health Inspections 10 / 25 pts
2 ★ inspection rating
Staffing 16 / 20 pts
4 ★ staffing rating
Quality Measures 12 / 15 pts
4 ★ quality measures

🏥 Staffing Details

Staff Type Hours/Resident/Day National Avg Comparison
Total Nursing 4.44 3.8 Above Average
Registered Nurses (RN) 0.96 0.7 Above Average
Licensed Practical Nurses (LPN) 0.66 0.7 Average
Certified Nursing Assistants (CNA) 2.83 2.4 Above Average
Weekend Total Nursing 3.95 3.8 Average
Weekend RN Hours 0.56 0.7 Below Average

🔍 Inspection & Deficiency History

28
Total Deficiencies
Jul 9, 2025
Most Recent Inspection
⚪ 1 Minor 🟠 27 Moderate
View recent deficiencies (5 shown)
  • Tag 0609 Severity D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    Jul 9, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
  • Tag 0842 Severity E
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standar
    Jan 28, 2025 · Resident Assessment and Care Planning Deficiencies
  • Tag 0658 Severity E
    Ensure services provided by the nursing facility meet professional standards of quality.
    Nov 6, 2024 · Resident Assessment and Care Planning Deficiencies
  • Tag 0759 Severity E
    Ensure medication error rates are not 5 percent or greater.
    Nov 6, 2024 · Pharmacy Service Deficiencies
  • Tag 0761 Severity E
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologi
    Nov 6, 2024 · Pharmacy Service Deficiencies

📊 Resident Outcome Measures

Based on CMS quality measure data. Lower percentages are better for most metrics.

Measure This Facility Nat'l Avg
Residents with pressure ulcers 13.0% 4.5% Worse
Falls with major injury 1.6% 3.0% Better
On antipsychotic medication 13.2% 14.5% Average
Urinary tract infections 2.5% 2.5% Average
ADL decline (daily activities) 7.1% 14.0% Better
Excessive weight loss 5.6% 7.5% Better
New/worsened incontinence 30.1% 45.0% Better

How This Grade Was Calculated

This facility's grade of D is based on a score of 54 out of 100, calculated from official CMS Nursing Home Compare data:

  • Overall CMS Rating: 2★ → 16 pts (max 40)
  • Health Inspection Rating: 2★ → 10 pts (max 25)
  • Staffing Rating: 4★ → 16 pts (max 20)
  • Quality Measures Rating: 4★ → 12 pts (max 15)

Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40

Facility Details

Ownership
Non profit - Other
Certified Beds
58
Provider Type
Medicare and Medicaid
Resident Council
Yes
Family Council
No
Sprinkler System
Yes
Last Inspection
Nov 6, 2024
Deficiencies (Cycle 1)
12