Claremont Assisted Living.

“Based on the documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include:  1. A review of the facility's policy and procedure revealed no documentation indicating that the policies and procedures were reviewed and updated as needed. 2. In an interview, E1 acknowledged that the policies and procedures were not reviewed at least once every three years.”

“Based on documentation review and interview, the manager failed to ensure a disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees.   Findings include: 1. A review of facility documents revealed no documentation to indicate the facility's disaster plan was reviewed at least once within the past 12 months that included the date and time of the disaster plan review, the name of each employee participating in the disaster plan review, a critique of the disaster plan review, and any recommendations for improvement.   2. In an interview, E1 acknowledged that documentation indicating that the facility's disaster plan was reviewed within the last 12 months was not available.”

“Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411.C , for two of six personnel records sampled. The deficient practice posed a risk if the personnel were a danger to a vulnerable population. Findings include: A.R.S. \'a7 36-411 C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 1. Review of E5's personnel record revealed no documentation that owners had attempted to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Review of E6's personnel record revealed a document titled "References" which included the contact information for four professional references. However, no documentation that the owners had contacted E6's references was available. 3. In an interview, E1 acknowledged documentation of compliance with A.R.S. \'a7 36-411(C) was missing.”

“Based on record review and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, for two of six employees reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs. Findings include: 1. Review of E5's personnel record revealed documentation of E5's skills and knowledge was not available for review. 2. Review of E6's personnel record revealed documentation of E6's skills and knowledge was not available for review. 3. In an interview, E1 acknowledged E5's and E6's skills and knowledge were not documented before the caregiver or assistant caregiver provided physical health services.”

“Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for one of six employees reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 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)..." 2. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. Review of E5's personnel record revealed no documentation of freedom from infectious TB was available for review. 4. In an interview, E1 acknowledged E5 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or before the date the individual began providing services at or on behalf of the assisted living facility.”

“Based on documentation review, record review, and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility, for four of four residents reviewed. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. Review of Department documentation revealed a change of ownership from AL0574 to AL13133 on August 28, 2024. 2. Review of R1's medical record revealed a residency agreement between R1 and AL0574 prior to the change of ownership. However, an updated residency agreement between R1 and AL13133 was not available for review. 3. Review of R2's medical record revealed a residency agreement between R2 and AL0574 prior to the change of ownership. However, an updated residency agreement between R2 and AL13133 was not available for review. 4. Review of R3's medical record revealed a residency agreement between R3 and AL0574 prior to the change of ownership. However, an updated residency agreement between R3 and AL13133 was not available for review. 5. Review of R4's medical record revealed a residency agreement between R4 and AL0574 prior to the change of ownership. However, an updated residency agreement between R4 and AL13133 was not available for review. 6. In an interview, E1 acknowledged R1's, R2's, R3's, and R4's residency agreements were not updated after the change of ownership.”

“Based on documentation review and interview, the manager failed to ensure a fire inspection was conducted by the local fire department according to the time-frame established by the local fire department. Findings include: 1. Review of facility documentation indicated a fire inspection was conducted by Lake Havasu City Fire Department on May 9, 2023. 2. In an email interview, O1 a representative of the Lake Havasu City Fire Department reported that fire inspections were required annually in Lake Havasu City. 3. In an interview, E1 acknowledged that a fire inspection was not conducted by the local fire department according to the time-frame established by the local fire department.”