HIGHGATE FLAGSTAFF

<p>Based on documentation review, <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">record review, </span>and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of eight personnel records reviewed. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population.</p><p> </p><p><br></p><p>Findings include:</p><p> </p><p><br></p><p>1. A review of A.R.S. § 36-411 states: "A... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work...4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee.</p><p> </p><p> </p><p>2. A review of E4's personnel record revealed E4 was hired as a caregiver in May of 2025.</p><p> </p><p><br></p><p>3. A review of E4’s personnel record revealed no documentation of a fingerprint clearance card.</p><p><br></p><p><br></p><p>4. A review of E1's, E2’s, E3's, E4's, E5's, E6's, E7's, and E8's personnel records revealed no documentation of an Adult Protective Services (APS) Central Registry check.</p><p>  </p><p><br></p><p>5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p><p><br></p><p><br></p><p>6. This is a repeat deficiency from the inspections conducted on December 7, 2023, and March 25, 2024.</p>

<p>Based on record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services on behalf of the facility, for one of seven sampled caregiver. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to ensure the health and safety of residents.</p><p><br></p><p> </p><p>Findings include:</p><p> </p><p><br></p><p>1. A review of E2's personnel record revealed E2 was hired in April 2023, as a caregiver.  Review of E2's personnel record revealed no documented verification of E2's skills and knowledge.</p><p><br></p><p> </p><p><span style="background-color: rgb(255, 255, 255);">2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</span></p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for two of eight personnel reviewed. The deficient practice posed a potential illness risk to residents. </p><p> </p><p> </p><p>Findings include: </p><p> </p><p> </p><p>1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..."</p><p> </p><p> </p><p>2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read."</p><p> </p><p> </p><p>3. A review of E4's personnel record revealed a hire date of May 2025. E4's personnel record included a negative TST within 12 months prior to hire, an assessment of risks of prior exposure to infectious TB, and a determination of signs or symptoms of TB. However, no second TST was available for review.</p><p><br></p><p><br></p><p>4. A review of E5's personnel record revealed a hire date of January 2025. E5's personnel record included a negative TST within 12 months prior to hire, an assessment of risks of prior exposure to infectious TB, and a determination of signs or symptoms of TB. However, no second TST was available for review.</p><p>  </p><p> </p><p>5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p>

<p>Based on observation and interview, the manager failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. The Compliance Officer observed the kitchen door was unlocked and accessible to directed care residents.</p><p><br></p><p><br></p><p>2. The Compliance Officer observed, in the kitchen, there was a white bucket full of broken glass and sharp kitchen knives on the counter accessible to the directed care resident.</p><p><br></p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p>

Based on record review and interview, the governing authority failed to ensure that one of two sample personnel records included documentation of a fingerprint clearance card or an application for a fingerprint clearance card completed within 20 working days of employment.

Findings include:
1. The record for E2 (start date as an assistant caregiver December 29, 2023) contained no documentation reflecting that the employee had a valid fingerprint clearance card or had submitted an application for fingerprint clearance to the DPS.
2. During an interview, E1 stated, "I don't have a copy of a card or an application."
3. During an interview with DPS it was determined that E2 did not have a fingerprint clearance card, and no application was on file.
4. During an interview, E1 acknowledged the required documentation was not available for review.

This is a repeat deficiency from the complaint investigation and compliance inspection conducted on December 7, 2023.

Based on record review and interview, the governing authority failed to ensure that one of three sample personnel records included documentation of a copy of the employee's current fingerprint clearance card.

Findings include:
1. The record for E3 (start date July 7, 2021) contained a DPS fingerprint clearance card that expired on September 5, 2023. No additional documentation was present in the record reflecting that DPS was contacted to renew the fingerprint clearance card.
2. During an interview, E5 acknowledged the required documentation was not in the record.

Based on observation and interview, the manager failed to ensure that a current list of resident rights were conspicuously posted.

Findings include:
1. Observation of the postings in the locked memory unit failed to reveal that the resident rights were posted.
2. During an interview E5 stated, "They were posted, I don't know where they went."
3. During an interview, E5 acknowledged that the resident rights were not conspicuously posted.

Based on observation and interview, the manager failed to ensure that the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection could be found, was conspicuously posted.

Findings include:
1. Observation of the locked memory unit failed to reveal a posting indicating the location at which a copy of the most recent Department inspection report could be found.
2. During an interview E5 stated, "That was posted, I don't know where it went."
3. During an interview, E5 acknowledged that the required documentation was not conspicuously posted.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the plan that includes an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care.

Findings include:
1. Review of the facility quality management plan revealed that a report was to be submitted to the governing authority on a "quarterly" basis.
2. No reports were available for review that contained an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care.
3. During an interview, E4 stated, "I have monthly reports with incident report data."
4. During an interview, E5 acknowledged that the required documentation was not included in the reports.

Based on record review and interview, the manager failed to ensure for two of three records that before providing personal care services or directed care services to a resident, a manager or caregiver provides documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification.

Findings include:
1. The record for E1 (hired November 6, 2023), failed to reveal documentation of CPR certification.
2. The record for E3 (hired July 7, 2021), revealed documentation of first aid certification that expired on August 25, 2023.
3. During an interview, E5 acknowledged that the employees provided services to residents without documentation of first aid and CPR training certification

Based on record review and interview, the manager failed to ensure that one of three sample resident records contained evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy.

Findings include:
1. The record for R4 contained no documentation of freedom from TB. Based on the resident's date of acceptance, this documentation was required.
2. During an interview, E5 acknowledged that the record did not contain evidence of freedom from TB before or within seven calendar days after the resident's date of occupancy.

Based on record review and interview, the manager failed to ensure that one of three sample resident records contained documentation of a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services.

Findings include:
1. The record for R3 contained a service plan review reflecting the last plan was completed on May 1, 2023.
2. During an interview, E5 acknowledged the service plan documentation did not reflect that the plan was reviewed and updated at least once every six months.

Based on record review and interview, the manager failed to ensure that one of two sample resident records contained documentation of notification to the resident of the availability of vaccinations for influenza and pneumonia.

Findings include:
1. The record belonging to R2 contained no documentation indicating that the resident had been notified of the availability of either the influenza or pneumonia vaccination on a yearly basis. No additional documentation indicating when the resident had been offered, refused or received either vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required.
2. During an interview, E5 acknowledged that the required documentation was not available for review.

Based on record review and interview for one of one sample directed care resident record, the manager failed to obtain the following documentation: documentation reflecting that the resident or resident's representative requested that the resident remain in the facility and a signed and dated statement from a medical practitioner indicating that the resident's needs were being met by the facility as per their scope of services.

Findings include:
1. During an interview, E4 indicated that R4 was non-ambulatory, had not walked for more than 30 days and could not walk even when assisted.
2. The resident's record did not contain a request from the resident or their representative to remain in the facility or a statement from the medical practitioner that the resident's needs were being met as per the facility's scope of services. Based on the resident's date of acceptance this documentation was required.
3. During an interview, E5 acknowledged that the required documentation was not in the resident's record.

Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members.

Findings include:
1. The toxicology guide available for use by personnel members was the Toxicology Handbook, 3rd. edition.
2. The Internet web site for the toxicology guide revealed that a more current edition was available for distribution.
3. During an interview, E5 acknowledged that a current toxicology reference guide was not available for use by personnel members.

Based on documentation review and interview, the manager failed to ensure that a food menu is maintained for at least 60 calendar days after the last date noted on the menu.

Findings include:
1. Two months of menus were requested. No menus dated menus were available for review.
2. During an interview, E5 stated, "We use a rotational menu."
3. During an interview, E5 acknowledged the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented.

Findings include:
1. Twelve months of facility disaster drill documentation was requested. Review of the disaster drill documentation provided revealed that disaster drills were conducted for each shift on the following dates: February 24, 2023, April 18, 2023, and May 31, 2023. No other disaster drill documentation was available for review.
2. During an interview, E5 acknowledged the requested documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for residents was conducted at least once every six months.

Findings include:
1. Evacuation drill documentation indicated that the last evacuation drill for residents had been conducted on March 24, 2023. No additional evacuation drill documentation was available for review.
2. During an interview, E5 acknowledged the documentation failed to indicate that evacuation drills for residents had been conducted at least once every six months.

Based on documentation review and interview, the manager failed to ensure that documentation of each evacuation drill was created and maintained for 12 months after the date of the evacuation drill that included the amount of time taken for employees and residents to evacuate the assisted living facility.

Findings include:
1. Facility evacuation drill documentation for the past 12 months was reviewed. The documentation failed to reveal the amount of time taken for employees to evacuate the facility for the following dates: June 28, July 21, August 25, September 22, October 31, and November 29, 2023.
2. During an interview, E5 acknowledged the required documentation was not available for review.

Based on record review and interview the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery.

Findings include:
1. Review of the record for E1 (hired November 2021), failed to reveal documentation of fall prevention and fall recovery training.
2. Review of the record for E2 (hired July 12, 2021), failed to reveal documentation of fall prevention and fall recovery training.
3. Review of the record for E3 (hired June 2, 2021), failed to reveal documentation of fall prevention and fall recovery training.
4. During an interview, E1 indicated that training for fall prevention and fall recovery had not been developed and administered to staff.

Based on record review and interview, for one of three sample records the manager failed to ensure that before providing services to a resident a manager provides current documentation of first aid training and cardiopulmonary resuscitation training certification (CPR).

Findings include:
1. The record for E1 (hired November 2021), contained documentation of CPR and First Aid training that expired on March 23, 2022.
2. During an interview, E1 acknowledged the documentation provided indicated the CPR and First Aid training had expired.

Based on record review, observation and interview, the manager failed to ensure that one of three sample service plans for residents who were storing medication in their bedrooms, included how the medication would be stored and controlled.

Findings include:
1. During an interview, E1 indicated that R3 self-administered their own medications and stored the medications in their room.
2. The record for R3 contained a service plan dated October 31, 2022 that did not include how the resident's medication would be stored and controlled.
3. During an interview, E1, acknowledged the service plan did not indicate how the resident's medication would be stored and controlled in their room.

Based on documentation review and interview, the manager failed to ensure that documentation of the current fire inspection was maintained.

Findings include:
1. Facility fire inspection documentation indicated that the last fire inspection was conducted on August 12, 2021.
2. During a telephone interview with the local fire department it was determined that fire inspections are required annually.
3. During an interview, E1 acknowledged that facility documentation failed to indicate that a fire inspection had been conducted annually.