Las Fuentes Assisted Living

Based on record review, documentation review and interview, the manager failed to ensure compliance with the requirements in A.R.S. § 36-411. The deficient practice posed a risk if E2 or E3 were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411.C states: "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. 2. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459." 2. A record review of E2 and E3's 's personnel records, revealed an APS Central Registry nor Department of Public Safety (DPS) Fingerprint Clearance Card verification was not available for review. 3. A documentation review by the Compliance Officer of the Department’s website, AZ Care Check https://azcarecheck.azdhs.gov/s/ revealed that E2 and E3, were not on the APS Central registry. 4. An online check by the Compliance Officer on August 15, 2025, of the Arizona Department of Public Safety (DPS) web portal at https://psp.azdps.gov/services/cardStatusRequest revealed that E2 and E3 had a valid DPS fingerprint Clearance Card. 5. In an interview, E1 acknowledged that the manager did not ensure E2 and E3 complied with the requirements in A.R.S. § 36-411(C).

Based on record review, documentation review, and interview, the manager failed to ensure that a manager, a caregiver, assistant caregiver, or a volunteer provide documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E2’s personnel record revealed, one negative TB skin test from June 9, 2025. A second negative TB test was not provided for review. 2. A documentation review of the facility's Policies and Procedure titled, "Tuberculosis Education for initial screening and two step TB test" required Tb testing to be completed for newly hired employees and newly admitted residents. 3. In an interview, E1 acknowledged documentation of freedom from infectious Tuberculosis (TB) was not provided for E2.

Based on documentation review, record review and interview, the manager failed to ensure a caregiver provide documentation of completion of a caregiver training program approved by the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA), for one of one individual sampled who was hired as a caregiver. The deficient practice posed a risk if the individuals were not qualified to provide the required services and the Department was provided false and misleading information. Findings include: 1. A Department review of the Arizona Nursing Care Institution Administrators and Assisted Living Managers (NCIA) revealed, training school ALTP # 0144 Adult Care Learning Systems, Incorporated, Pamela Davis, Instructor, dates of operations: Wednesday December 10, 2008 to Friday August 2, 2013. 2 . A record review of the personnel record for E2 revealed, a caregiver certificate from Adult Care Learning Systems, Incorporated ALTP # 0144, signed by instructor Ernest Esteban, RN. Training dates May 20, 2013 to June 22, 2013. 3. A notarized copy of the Arizona Board of Nursing Welcome page had a hand written note on the left margin. The note stated, "AZ DHS Is not under the Board of Nursing. However, this never expires-DHS & ALTP 0144 AZ DHS for certified caregiver + AZ state post secondary education V1436. Must have taken classes dated + completed. prior to August 1, 2013. verified + validated memo from Board of Nursing. Signed and notarized by Ernest Esteban, 10/07/21." The notary of the signed document, writer of the note, and school instructor was the same person, Ernest Esteban. 4. In an interview, E2 did not deny the caregiver certificate was not valid. E2 enrolled in a caregiver program during the compliance inspection. 5. In an interview, E1 acknowledged the manager failed to ensure a caregiver provide documentation of completion of a caregiver training program approved by the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA).

Based on observation, and interview, the manager failed to ensure a caregiver encouraged residents to participate in activities planned according to subsection (E). The deficient practice posed a risk if residents were not offered opportunities and encouraged to participate in planned activities. Subsection (E) requires: E. A manager shall ensure that: 1. Daily social, recreational, or rehabilitative activities are planned according to residents' preferences, needs, and abilities; 2. A calendar of planned activities is: a. Prepared at least one week in advance of the date the activity is provided, b. Posted in a location that is easily seen by residents, c. Updated as necessary to reflect substitutions in the activities provided, and d. Maintained for at least 12 months after the last scheduled activity; 3. Equipment and supplies are available and accessible to accommodate a resident who chooses to participate in a planned activity; and 4. Multiple media sources, such as daily newspapers, current magazines, Internet sources, and a variety of reading materials, are available and accessible to a resident to maintain the resident's continued awareness of current news, social events, and other noteworthy information. Findings include: 1. The posted activity calendar titled, August, 2023, indicated the residents were provided with the following: Sunday - Play Old Music Monday - Movie Night Popcorn Tuesday - Play Old Music Wednesday - Bingo Thursday - Play Old Music Friday - Ice Cream Party Saturday - Play Old Music 2. In observation, the facility had eight residents (seven ambulatory) who were observed to be walking through the facility, or in their bedrooms watching television. Six residents were observed sitting at the dining table for a 2:00pm snack. Six residents actively interacted with the compliance officer. 3. During interviews with alert and oriented residents, the following was reported to the compliance officer: - R1 reported [R1] likes to walk around the pool, watches movies and TB. Likes to paint and draw but is limited in abilities now. Likes Bingo, "had it about a month ago." - R4 reported [R4] likes bingo and sewing, and reported the facility offered bingo occasionally, maybe 3 weeks ago. - R6 reported [R6] likes to walk to build muscle, and said "nothing," when asked if activities were offered. - R7 reported [R7] used to build model airplanes, and would do that now if had the supplies, said they painted wooden bird houses about a year ago. Likes to color. - R8 reported [R8] watches Dr. Phil four times a day on TV, walks around the pool, colors sometimes, listens to the radio, and painted a bird house a long time ago. R8 expressed an interest in arts/crafts. 4. During an interview, E2 acknowledged activities were not consistently provided according to the posted activity calendar. E1 acknowledged daily social, recreational, or rehabilitative activities were not planned and implemented according to residents' preferences, needs, and abi

Based on record review, observation, and interview, for one of three residents reviewed, the manager failed to ensure medications were administered in compliance with a medication order. Findings include: 1. In record review, R2's medical record included medication orders, dated August 6, 2023 for: Quetiapine 100 mg one tab po twice dally, Escitalopram 20mg, one tab po daily, Buspirone 30 mg, po twice daily, Hydroxyzine HCL 50 mg, po every 6 hours as needed, Amlodipine 10 mg, one tab po daily, Gabapentin 800 mg, one tab po three times a day, Lactulose 10mg/15ml po 30 ml daily, Levetiracetam 50 mg, one tab po twice daily, Levothyroxine sodium 25 mcg, 1 tab po daily, Losartan potassium 50 mg, one tab po at bedtime, Oxybutynin 5 mg, one tab po twice daily. There were no current orders for Aspirin, Hydroxychloroquine 200 mg tabs, Sennoside S 8.6 mg-50mg tabs, or Reguloid Capsules. 2. In record review, R2's Medication administration record (MAR), dated August 2023, included documentation the medications (noted in paragraph #1) were administered, as ordered. 3. In observation, R2's medications were observed to be onsite, along with additional medications that were not on the August MAR. Additional medications observed were Aspirin, Hydroxychloroquine 200 mg tabs, Sennoside S 8.6 mg-50mg tabs, and Reguloid Capsules. Observation of R2's medication organizer (mediset) revealed these medications were in R2's mediset for the "AM" medication administration. 4. In record review, R2's MAR, dated August 2023, did not include documentation the Aspirin, Hydroxychloroquine, Sennoside and Reguloid medications were administered to R2. 5. During an interview, E2 reported the medications (Aspirin, Hydroxychloroquine, Sennoside and Reguloid) were administered to R2), and acknowledged they were not documented on the August MAR. The findings were reviewed with E1, who reported the medications had been discontinued, and the medication orders, dated August 6, 2023, were R2's current medication orders. E1 acknowledged the discontinued medications were in the mediset and being administered to R2.

Based on documentation review, observation and interview, the manager failed to ensure a resident bedroom was not used as a passageway. Findings include: 1. During an environmental inspection, the surveyor observed R1's bedroom had a bathroom, with a large walk in shower. 2. During an interview, E2 reported residents in need of a larger space used the bathroom for showers, and reported R3, R6 and R7 used the shower in R1's bedroom. 3. During an interview, the findings were reviewed with E1, who reported the bathroom was used by other residents, prior to October 1, 2013, however, E1 would need to research to find evidence of the usage in this capacity. No further documentation was provided during the inspection.