HIGHGATE SENIOR LIVING OF PRESCOTT LAKES

INSP-0133694

Complete

Date: 6/10/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-06-27

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00107180 conducted on June 10, 2025:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

R9-10-806.A.4.a-b. Personnel A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented: a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and b. According to policies and procedures;

Evidence/Findings:

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, for one of nine personnel sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1 . A review of E3's personnel record revealed documentation of a skills and knowledge verification form titled "Care Team New Hire Checklist." The document was signed by the manager and employee. However, the individual skills were not marked as "Met" or "Not Met" on the form. 2 . In an interview, E1 acknowledged the "Care Team New Hire Checklist" was not completed for E3.

Temporary Solution:

Effective immediately, the Community Resource Manager (CRM) will audit all current caregiver personnel files to ensure that skills and knowledge verification forms are fully completed, with all individual skills marked as "Met" or "Not Met." Any incomplete documentation will be addressed and completed by 8/28/2025.

Permanent Solution:

The ED, Resident Care Coordinators (RCC), and Healthcare Director (HD) will implement a new standardized onboarding checklist to ensure full completion before caregivers begin providing physical health services. Any new hire's checklist will be reviewed by the CRM within 48 hours of completion.

Person Responsible:

Jennifer West, Executive Director

Deficiency #2

Rule/Regulation Violated:

R9-10-815.F.2.a-c. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and

Evidence/Findings:

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that provided access to an outside area which controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed the facility was licensed for directed care services. 2 . During an environmental inspection of the facility, the Compliance Officer observed two exits to a central courtyard area outside from the memory care unit. The doors had a control. However, the control was not engaged and there was no alert on the doors. 3 . In an interview, E1 reported the facility keeps the doors unlocked to allow more able-bodied residents to go outside if they wish. E1 acknowledged the doors were not controlled or alerted.

Permanent Solution:

On June 11, 2025, the facility installed door alert systems on both sets of memory care patio doors. These systems comply with directed care licensing requirements, including audible alerts that activate upon egress. This ensures resident safety while still allowing appropriate individuals controlled access to the outdoor courtyard.

Person Responsible:

Daniel Poulin, Maintenance Manager

Deficiency #3

Rule/Regulation Violated:

R9-10-819.A.11. Environmental Standards A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and were inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed an unattended cleaning cart in the ground floor hallway of the facility. The door of the cart was unlocked, and a bottle of "Fabuloso" was hanging on the side of the cart. The following items were located inside the cart:-A bottle of "Clorox" disinfectant with bleach;-A bottle of "Finito" multi-pest elimination;-A bottle of "Ecolab" glass cleaner; and-A bottle of "Sparclean" dish detergent. 2 . During an environmental inspection of the facility, the Compliance Officer observed an unattended cleaning cart in the second floor hallway of the facility. The top sliding door was unlocked, and the following chemicals were located inside the cart:-A bottle of "Clorox" disinfectant with bleach;-A bottle of "Sparclean" dish detergent;-A bottle of "Keystone" glass cleaner; and -A bottle of "Biorenewables" glass cleaner. 3 . In an interview, E1 acknowledged poisonous or toxic materials were accessible to residents.

Temporary Solution:

On 6/11/2025, staff were re-trained on chemical cart use. The maintenance manager checeked all carts to ensue the locks were functioning and operable. All carts were immediately locked, and daily checks were implemented by housekeeping leads to ensure compliance.

Permanent Solution:

Beginning July 2025, recurring in-service trainings on chemical safety and secure cart protocols will be conducted quarterly with all housekeeping staff.

Person Responsible:

Daniel Poulin, Maintenance Manager

INSP-0070571

Complete

Date: 4/16/2024

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2024-05-24

Summary:

The following deficiencies were found during the compliance inspection and investigation of complaints AZ00204672 and AZ00204845 conducted on April 16, 2024:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition
A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

Evidence/Findings:

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 as required in A.R.S. \'a7 36-420.01.

Findings include:
1. Review of facility documentation failed to reveal that the health care institution had developed a fall prevention and recovery training program policy and procedure as required in A.R.S. \'a7 36-420.01.
2. During an interview, E2 acknowledged the required documentation was not available for review.

This is a repeat deficiency from the compliance inspection conducted on February 2, 2023.

Deficiency #2

Rule/Regulation Violated:

E. A manager of an assisted living center shall ensure that:
3. A fire inspection is conducted by a local fire department or the State Fire Marshal before licensing and according to the time-frame established by the local fire department or the State Fire Marshal;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that a fire inspection was conducted by the local fire department or the State Fire Marshal according to the time-frame established by the local fire department or the State Fire Marshal.

Findings include:
1. Facility documentation indicated the last fire inspection was conducted by the local fire department on May 26, 2022.
2. During an interview with a representative from the local Fire Department it was determined that fire inspections are required on an annual basis.
3. During an interview, E1 acknowledged that the fire inspection was not conducted as required.

INSP-0070570

Complete

Date: 7/18/2023

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2023-07-27

Summary:

No deficiencies were found during the investigation of complaint #AZ00197928 conducted on July 18, 2023.

✓ No deficiencies cited during this inspection.

INSP-0070568

Complete

Date: 2/2/2023

Type: Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-02-16

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on February 2, 2023:

Deficiencies Found: 7

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

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 December 2, 2022), failed to reveal documentation of fall prevention and fall recovery training.
2. Review of the record for E2 (hired August 19, 2020), failed to reveal documentation of fall prevention and fall recovery training.
3. Review of the record for E3 (hired July 12, 2017), failed to reveal documentation of fall prevention and fall recovery training.
4. Review of the record for E4 (hired June 18, 2012), failed to reveal documentation of fall prevention and fall recovery training.
5. During an interview, E1 acknowledged that the required documentation was not available for review.

Deficiency #2

Rule/Regulation Violated:

D. A manager shall ensure that the following are conspicuously posted:
4. The location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection may be viewed.

Evidence/Findings:

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 can be found, was conspicuously posted.

Findings include:
1. Inspection of the facilities memory unit failed to reveal the posting indicating the location at which a copy of the most recent Department inspection report can be found.
2. During an interview, E1 stated, "We had that posted."
3. During an interview, E1 acknowledged the required documentation was not conspicuously posted.

Deficiency #3

Rule/Regulation Violated:

A manager shall ensure that:
1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes:
d. A method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care; and

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that a plan is established, documented, and implemented for an ongoing quality management program that, includes a method to make changes or take action 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 the plan did not include a method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care.
2. During an interview, E1 acknowledged the required documentation was not included in the facility quality management plan.

Deficiency #4

Rule/Regulation Violated:

D. A manager shall ensure that:
2. A current toxicology reference guide is available for use by personnel members.

Evidence/Findings:

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 EMRA Medical Toxicology Guide, copyright date 2018.
2. The Internet web site for the toxicology guide revealed that a more current edition was available for distribution.
3. During an interview, E3 acknowledged that a current toxicology reference guide was not available for use by personnel members.

Deficiency #5

Rule/Regulation Violated:

A. A manager shall ensure that:
1. A food menu:
c. Is conspicuously posted at least one calendar day before the first meal on the food menu is served,

Evidence/Findings:

Based in observation and interview, the manager failed to ensure that a food menu was conspicuously posted at least one calendar day before the first meal on the food menu is served.

Findings include:
1. No menu was observed posted in the facility's memory unit.
2. During an interview, E1 acknowledged that no menu was posted in the memory unit.

Deficiency #6

Rule/Regulation Violated:

A. A manager shall ensure that:
2. Meals and snacks provided by the assisted living facility are served according to posted menus;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that meals and snacks provided by the assisted living facility were served according to posted menus.

Findings include:
1. A review of 60 days of posted menus failed to reveal a record of breakfast and snacks provided.
2. No additional snack menu documentation was available for review.
3. During an interview, E1 stated, "We serve the same breakfast every day and lots of snacks are available, we just don't have the documentation."
4. During an interview, E1 acknowledged that the required documentation was not available for review.

Deficiency #7

Rule/Regulation Violated:

A. A manager shall ensure that:
2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that the disaster plan was reviewed at least once every 12 months.

Findings include:
1. Review of facility disaster plan review documentation indicated that the last review was conducted on December 21, 2021.
2. During an interview, E2 acknowledged that the documentation failed to reflect that a review had been conducted at least once every 12 months.

HIGHGATE SENIOR LIVING OF PRESCOTT LAKES

Facility Information

Inspection History

INSP-0161556

Summary:

INSP-0161167

Summary:

INSP-0133694

Summary:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0070571

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

INSP-0070570

Summary:

INSP-0070568

Summary:

Deficiencies Found: 7

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings: