Inspection Reports for Highgate Senior Living – Flagstaff
1831 N Jasper Dr, Flagstaff, AZ 86001, United States, AZ, 86001
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Inspection Report
Complaint Investigation
Capacity: 105
Deficiencies: 20
Aug 7, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2022-11-29 to 2025-08-07 with deficiency history and complaint investigations.
Findings
Across multiple inspections, deficiencies were found related to personnel record compliance, training documentation, environmental safety, resident care documentation, and regulatory postings. Some inspections found no deficiencies, while others identified repeated issues with fingerprint clearance, tuberculosis testing, and emergency preparedness.
Complaint Details
The inspections include investigations of multiple complaints with IDs such as 00138843, 00123056, 00138933, AZ00214616, AZ00214617, AZ00208035, AZ00207926, AZ00204487, AZ00205433, AZ00193537, AZ00198788, and AZ00188813.
Deficiencies (20)
| Description |
|---|
| R9-10-803.A.9. Administration: The governing authority failed to ensure compliance with A.R.S. § 36-411 regarding fingerprint clearance cards and APS registry checks for personnel. |
| R9-10-806.A.4.a-b. Personnel: Failed to verify and document caregiver skills and knowledge before providing physical health services. |
| R9-10-806.A.8.a-b. Personnel: Failed to provide evidence of freedom from infectious tuberculosis as specified in R9-10-113 for two personnel. |
| R9-10-820.A.1.b. Environmental Standards: Premises were not free from conditions that could cause physical injury; kitchen door unlocked with hazardous items accessible to residents. |
| A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411: Failed to ensure personnel records included documentation of fingerprint clearance card or application within 20 working days of employment. |
| D. A manager shall ensure that the following are conspicuously posted: 1. A list of resident rights; Failed to ensure resident rights were conspicuously posted. |
| D. A manager shall ensure that the following are conspicuously posted: 4. Location of most recent Department inspection report and plan of correction; Failed to ensure conspicuous posting. |
| A manager shall ensure that: 2. A documented report is submitted to the governing authority identifying concerns about delivery of services and actions taken; Failed to submit required reports. |
| A. A manager shall ensure that: 10. Documentation of first aid and CPR training certification before providing services; Failed to ensure documentation for two of three records. |
| A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis before or within seven days of occupancy; Failed for one of three resident records. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan reviewed and updated at least every six months; Failed for one of three resident records. |
| C. A manager shall ensure that a resident's medical record contains documentation of notification of availability of influenza and pneumonia vaccinations; Failed for one of two resident records. |
| B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident confined to bed or chair without required documentation; Failed to obtain required documentation for one directed care resident. |
| D. A manager shall ensure that a current toxicology reference guide is available for use by personnel; Failed to ensure current guide was available. |
| A. A manager shall ensure that a food menu is maintained for at least 60 calendar days after the last date; Failed to maintain dated menus for review. |
| A. A manager shall ensure that a disaster drill for employees is conducted on each shift at least once every three months and documented; Failed to provide documentation for all shifts. |
| A. A manager shall ensure that an evacuation drill for employees and residents is conducted at least once every six months; Failed to provide documentation of required evacuation drills. |
| A. A manager shall ensure that documentation of each evacuation drill is created and maintained for at least 12 months including evacuation time; Failed to document evacuation times for multiple drills. |
| 36-420.01. Health care institutions; fall prevention and fall recovery training programs; Failed to develop and administer fall prevention and recovery training for all staff. |
| A. A manager shall ensure that: 10. Documentation of current first aid and CPR training certification before providing services; Failed for one of three sample records with expired certifications. |
Report Facts
Inspections on page: 7
Total deficiencies: 23
Complaint inspections: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Carter | Community Resource Manager | Named in fingerprint clearance and tuberculosis testing deficiencies |
| Christina Byrne | Healthcare Director | Named in caregiver skills verification and tuberculosis testing deficiencies |
| Shaandiin Williams | Care Coordinators / Cottage Care Coordinator | Named in caregiver skills verification and environmental safety deficiencies |
| Erika Johnson | Care Coordinator | Named in caregiver skills verification deficiency |
| E1 | Interviewed in multiple deficiencies as a source of information | |
| E2 | Referenced in personnel record deficiencies | |
| E3 | Referenced in personnel record deficiencies | |
| E4 | Referenced in personnel record and resident care deficiencies | |
| E5 | Referenced in multiple interviews acknowledging deficiencies |
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