Pathways Assisted Living LLC

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for one of five sampled personnel for fall prevention and fall recovery. The deficient practice posed a risk if facility staff were not properly trained to assist a resident who had fallen and was unable to recover independently. The deficient practice posed a risk as the designated standards were not followed. Findings include: 1. A review of E2's personnel record revealed no documentation of fall prevention and fall recovery training. 2. In an interview, E1 acknowledged there was no documentation to reflect that E2 received training in fall prevention and fall recovery. This is a repeat deficiency from the compliance inspection and complaint investigation conducted on February 14, 2024.

Based on record review, documentation review, and interview, the governing authority failed to notify the Department according to A.R.S. § 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. Findings Include: 1. A review of E2's personnel record revealed E2 was hired as the facility's manager; however, there was no hire date reflected in E2's personnel record. 2. A review of Department documentation revealed that there was no notification sent to the Department reflecting that E2 would be the facility's manager, which included the name and qualifications of the new manager. 3. In a telephonic interview, E2 reported being the manager of the facility. 4. In a telephonic interview, E6 reported no longer being the manager of the facility. 5. In an interview, E5 could not provide evidence to indicate that the Department was provided notification according to A.R.S. § 36-425(I) of the name and qualifications of the new manager when the manager changed from E6 to E2. This is a repeat deficiency from the complaint investigation conducted on December 12, 2022.

Based on observation, documentation review, and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present. The deficient practice posed a risk as no individual on-site was designated to act on behalf of the governing authority in the management of the assisted living facility. Findings include: 1. The Compliance Officer arrived at the facility and observed E3 and E4 to be the only staff members in the facility, with four residents present. E5 arrived at the facility approximately an hour and a half later. 2. The Compliance Officer observed a document titled "Manager's designee" posted on the facility’s wall. The "Manager's designee" form did not indicate that E3 or E4 was accountable for the facility when the manager was not present. 3. In an interview, E5 acknowledged the "Manager's designee" form did not include E3 or E4.

Based on observation, record review, and interview, the manager failed to ensure that, before providing personal care services or directed care services to a resident, a caregiver provided documentation of valid cardiopulmonary resuscitation (CPR) training certification specific to adults, for one of three caregivers sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E3’s personnel record showed that E2 was hired as a caregiver. 2. A review of E3's personnel record revealed CPR training certification dated February 23, 2024, from the NationalCPRFoundation. However, this was an online-only course that did not include a return demonstration of the employee's ability to perform CPR as required in A.A.C. R9-10-803.C.1.e.i. This training was therefore invalid. 3. In an interview, E1 acknowledged E3's CPR training certification was from the NationalCPRFoundation, and there was no additional documentation available for review.

Based on record review and interview, the manager failed to ensure individuals employed by the facility completed Documentation of a negative Mantoux skin test or other tuberculosis screening test that was recommended by the U.S. Centers for Disease Control and Prevention (CDC) for two of five sampled employees. Findings include: 1. According to the CDC’s website (https://www.cdc.gov/tb/hcp/testing-diagnosis/tuberculin-skin-test.html), reflected “Two-step testing if the first TB (tuberculosis) skin test result is negative, a second TB skin test should be done 1 to 3 weeks later.” 2. A review of E2’s and E4‘s medical records revealed there was no documentation that a second TB test was completed. 3. In an interview, E5 acknowledged that there was no documentation available for review during the survey to reflect that E2 and E4 had completed a second TB test. This is a repeat deficiency from the compliance inspection conducted on December 17, 2021.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area, which posed a health and safety risk for medications to be stored inappropriately. Findings Include: 1. During a facility tour, the compliance officer observed box inside the facility's refrigerator containing syringes of Lorazepam that belonged to R5. The syringes were left unlocked and accessible to residents. 2. In an interview, E3 reported the box that contained R5's medication lock was not properly working which prevented the box from being locked. E3 acknowledged R5's medications were left unlocked and accessible to residents.

Based on documentation review, observation, and interview, the manager failed to ensure meals and snacks for each day were planned using the applicable guidelines in http://www.health.gov/dietaryguidelines/2015.asp. Findings include: 1. During a review of the Dietary Guidelines for Americans 2015, the guidelines state: "Consume a healthy eating pattern that accounts for all foods and beverages within an appropriate calorie level. A healthy eating pattern includes: · A variety of vegetables from all of the subgroups-dark green, red and orange, legumes (beans and peas), starchy, and other · Fruits, especially whole fruits · Grains, at least half of which are whole grains · Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages · A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), and nuts, seeds, and soy products · Oils" 2. During the on-site compliance investigation conducted on August 13, 2025, the compliance officer observed residents being served hot dogs and juice for lunch, and a 7-ounce single-serving chicken pot pie with crackers for dinner. 3. In an interview, E3 reported the residents are usually served a bigger meal during lunch and a lighter meal during dinner, and acknowledged the residents were not served a variety of vegetables, fruit, or protein for meals.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. Findings include: 1. A review of documentation revealed that there was no documentation of the facility's disaster plan being reviewed within the last 12 months. 2. In an interview, E5 acknowledged that the disaster plan required in subsection (A)(1) was not reviewed at least once every 12 months, and there was no documentation available for review at the time of the survey to reflect compliance. This is a repeat deficiency from the compliance inspection conducted on December 12, 2022.

Based on observation, documentation review and interview, the manager failed to ensure a disposable fire extinguisher was replaced when its indicator reached the red zone. Findings include: 1. During a facility tour, the compliance officer observed a extinguisher with the indicator in the red zone, mounted on the wall near the facility's office area. 2. In an interview, E5 acknowledged the disposable fire extinguisher was not replaced when the indicator reached the red zone.

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if facility staff were not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of E1's, E2's, E3's, E4's, E6's, and E7's personnel records revealed no documentation of fall prevention and fall recovery training. 2. In an interview, E1 acknowledged there was no documentation to reflect E1, E2, E3, E4, E6, or E7 received training in fall prevention and fall recovery.

Based on documentation review, record review, and interview, the manager failed to provide written notification to the Department of a resident's unexpected death within one working day after the resident's death. The deficient practice posed a risk as the Department was unable to assess potential dangers to other residents at the facility in a timely manner. Findings include: 1. A review of R1's medical record revealed a document titled "Progress Notes" dated February 11, 2024, which stated "Resident passed away". A review of R1's record revealed R1 was not on hospice. 2. A review of Department documentation revealed no written notice of R1's death submitted by the facility. 3. In an interview, E1 reported R1 was not on hospice and acknowledged the Department was not notified of R1's death.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided valid documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for two of seven caregivers sampled. The deficient practice posed a risk if the employees were not qualified to provide the required services. Findings include: 1. A review of facility documentation revealed a document titled "Employee work schedule" dated February 1, 2024 through February 15, 2024. The scheduled reflected E7 was scheduled to work alone from 9:00 AM to 10:00 AM and 5:00 PM to 8:00 PM, on February 3, 2024, and from 9:00 AM to 8:00 PM on February 4, 10, and 11, 2024. The schedule also reflected E6 was scheduled to work alone from 5:00 PM to 9:00 AM on February 1 and 2, 2024, from 9:00 AM to 8:00 PM on February 4, 2024, and from 9:00 AM to 9:00 PM on February 5-8, 2024. 2. A review of E7's personnel record revealed there was no documentation of completion of a caregiver training program approved by the Department or the NCIA Board. 3. A review of E6's personnel record revealed a certification issued to E6 from American Caregiver Association dated November 24, 2023. However, American Caregiver Association training program was not approved by the Department or NCIA Board. 4. In an interview, E1 reviewed E6's and E7's personnel records and was unable to find documentation of E7's caregiver certification, or documentation of an approved program certificate issued to E6.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver or an assistant caregiver received orientation specific to the duties to be performed before providing assisted living services to a resident, for one of seven sampled caregivers. The deficient practice posed a health and safety risk to the residents if the caregiver was not informed of the duties to be performed. Findings include: 1. A review of facility documentation revealed a document titled "Employee work schedule" dated February 1, 2024 through February 15, 2024. The scheduled reflected E4 was scheduled to work from 9:00 AM to 5:00 PM on February 1-2, 2024, from 10:00 AM to 5:00 PM on February 3, 2024, and from 9:00 AM to 9:00 PM on February 9, 2024. 2. A review of E4's personnel record revealed no documentation to indicate E4 received orientation before E4 provided assisted living services. 3. In an interview, E1 reviewed E4's personnel record and acknowledged E4's personnel record did not contain documentation of completed orientation for E4.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record included documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-411(A), for one of seven personnel members sampled. The deficient practice posed a risk if the individual was a danger to a vulnerable population. Finding include: 1. A.R.S. \'a7 36-411(A) states: "A. Except as provided in subsection F of this section, 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 valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." 2. A review of E1's personnel record revealed a fingerprint clearance card with an expiration date of February 2, 2024. 3. A review of the Arizona Department of Public Safety's website revealed E1's fingerprint clearance card was no longer valid. 4. In an interview, E1 confirmed there was no other documentation available for review to reflect E1 had a valid fingerprint clearance card at the time of the inspection.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of four residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R3's medical record revealed a medication order dated February 9, 2024 to discontinue "Quetiapine furmarate oral 25 mg (milligrams) tablet once every day", "Prozac 20 mg once daily", and "Synthroid 137 mcg (micrograms) one tablet daily". 2. A review of R3's medical record revealed a medication administration record (MAR) dated February 2024. The MAR revealed R3 was administered "Quetiapine 25 mg", "Prozac 20 mg", and "Synthroid 137 mcg" on February 10-14, 2024. 3. The Compliance Officer observed R3's medication container included "Quetiapine 25 mg", "Prozac 20 mg", and "Synthroid 137 mcg". 4. In an interview, E1 reviewed and acknowledged R3's February 2024 MAR reflected R3 was administered the aforementioned discontinued medications.

Based on interview and record review, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider and emergency contact. The deficient practice posed a risk if the resident did not receive adequate follow-up care. Findings include: 1. In an interview, E1, E2, E3 E6, E7, and E8 reported R1 and R2 went to the emergency room via emergency medical transport on January 28, 2024. E1 reported the on-site personnel member called for emergency medical services for both R1 and R2. 2. A review of R1's and R2's medical records revealed no documentation to indicate R1's and R2's primary care providers and emergency contacts were notified of the incident in January 2024. 3. In an interview, E1 acknowledged R1 and R2 were sent to the hospital, but no incident report was created to document R1's and R2's primary care providers and emergency contacts were notified.

Based on interview and record review, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident, the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future. Findings include: 1. In an interview, E1, E2, E3 E6, E7, and E8 reported R1 and R2 went to the emergency room via emergency medical transport on January 28, 2024. E1 reported the on-site personnel member called for emergency medical services for both R1 and R2. 2. A review of R1's and R2's medical record revealed no documentation to indicate the date and time of the incident, the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future for the incident in January 2024. 3. In an interview, E1 acknowledged R1 and R2 were sent to the hospital, but no incident report was created to document the date and time of the incident, the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future.