Highgate Senior Living of Prescott Lakes

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.

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.

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.

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.

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.