COTTAGES OF TUCSON

INSP-0132225

Complete

Date: 5/22/2025

Type: Complaint

Worksheet: Assisted Living Center

SOD Sent: 2025-06-30

Summary:

The following deficiencies were found during the on-site investigation of complaint 00131293 conducted on May 22, 2025:

Deficiencies Found: 7

Deficiency #1

Rule/Regulation Violated:

R9-10-803.A.9. Administration A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411.

Evidence/Findings:

Based on record review and interview, the Governing Authority failed to ensure compliance with A.R.S. § 36-411 by failing to make documented good faith efforts to contact previous employers to obtain information or recommendations which may be relevant to a person's fitness to work in a residential care institution. The deficient practice posed a risk if E3, E4, E6, E7, or E8 was a danger to a vulnerable population. Findings include: 1. A review of E3’s, E4’s, E6’s, E7’s, and E8’s personnel records revealed each employee had a valid fingerprint clearance card on each employee's respective date of hire. Further review revealed applications for employment for each employee, which included previous employment and dates of employment. However, evidence of documentation of good faith efforts to contact previous employers was unavailable for review. 2. In an interview, E1 advised that efforts were made to contact E3’s, E4’s, E6’s, E7’s, and E8’s previous employers, but those efforts had not been documented. E1 agreed E3’s, E4’s, E6’s, E7’s, and E8’s employment records did not include documented good faith efforts to contact previous employers as required in A.R.S. § 36-411.

Temporary Solution:

Angelica Mireya Montano, Executive Director, has reviewed and understands Rule (R9-10-03.A.9) Angelica Mireya Montano is aware of and understands the rule on making food faith efforts to contact previous employees to obtain information or recommendations which may be relevant to a person's fitness to work in a residential care institution. The Executive Director has created a worksheet, that will be utilized for future / previous hires.

Permanent Solution:

The Executive Director will also maintain in-person files as required. She acknowledges the rule and will implant immediately.

Person Responsible:

Angelica Mireya Montano, Executive Director

Deficiency #2

Rule/Regulation Violated:

R9-10-804.2.a-b. Quality Management A manager shall ensure that: 2. A documented report is submitted to the governing authority that includes: a. An identification of each concern about the delivery of services related to resident care, and b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care;

Evidence/Findings:

Based on document review and interview, the manager failed to ensure a documented report identifying concerns about the delivery of services, and any changes or actions taken, was submitted to the governing authority. Findings include: 1. A review of facility policy and procedures, last reviewed February 2023, revealed a policy outlining quality management. The policy indicated a report, compliant with the facility’s quality management program, was to be sent to the governing authority on an annual basis. 2. A request was made to review the facility’s most recent quality management report to the governing authority. However, evidence of documentation of such a report was unavailable for review. 3. In an interview, E1 acknowledged the annual quality management report to the governing authority had not been prepared and was unavailable for review.

Temporary Solution:

The Executive Director Immediately contacted the appropriate governing authorities to establish training due to policy

Permanent Solution:

I, Angelic Mireya Montano, Executive Director, acknowledges and uphold the establish rule and policies. Upon being made aware of the relevant policy, I immediately contacted the appropriate governing authorities. We have since established a policy template, Which would be implemented as the policy takes effect.

Person Responsible:

Angelica Mireya Montano, Executive Director

Deficiency #3

Rule/Regulation Violated:

R9-10-806.A.4.a-b. Personnel A. A manager shall ensure that: 4. A caregiver's or assistant caregiver's skills and knowledge are verified and documented: a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and b. According to policies and procedures;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services for two of five certified caregivers. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of facility staff schedules revealed E3 and E4 each worked numerous shifts in 2025. 2. A review of E3's and E4’s personnel records revealed evidence of documentation of verification of skills and knowledge was unavailable for review. 3. In an interview, E1 agreed documentation of verification of E3's and E4’s skills and knowledge was unavailable for review.

Temporary Solution:

The Executive Director immediately conducted an audit on all personal files to ensure documented evidence of skills and knowledge verification prior to any care staff performing care on residents.

Permanent Solution:

I, Angelica Mireya Montano, Executive Director, Acknowledges and uphold the established rule R9-10-806. a.4.a-b. The Executive Director will ensure that skills and knowledge is verified before a employee is schedule on a continuously bases. Skills and knowledge verification will be conducted by a current caregiver/medtech.

Person Responsible:

Angelica Mireya Montano, Executive Director

Deficiency #4

Rule/Regulation Violated:

R9-10-806.C.1.a-c. Personnel C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: a. The individual's name, date of birth, and contact telephone number; b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and c. Documentation of: i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties; ii. The individual's education and experience applicable to the individual's job duties; iii. The individual's completed orientation and in-service education required by policies and procedures; iv. The individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures; v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115; vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8); vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures; viii First aid training, if required for the individual in this Article or policies and procedures; and ix. Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C);

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation training (CPR) for one of nine caregivers and assistant caregivers sampled. Findings include: 1. A review of E4’s personnel record revealed evidence of documentation of cardiopulmonary resuscitation training (CPR) was not available for review. 2. A request was made to review E4's CPR card. E1 requested E4's CPR card from E4. E1 was able to produce an image of E4's current CPR training card on E1's cell phone. 3. In an interview, E1 acknowledged E4's personnel record did not include documentation of E4's current CPR training.

Temporary Solution:

The Executive Director promptly located/requested current, valid CPR Training card and filed in appropriate personal file while surveyor was at building.

Permanent Solution:

Angelica Mireya Montano, Executive Director acknowledges and understands the importance on Rule (R9-10-806.C1.a.b) Based on the evidence reviewed, The Executive Director will ensure proper CPR card is given to hiring manager. And Hiring manager will be properly trained to observed differences between child/adult CPR training.

Person Responsible:

Angelica Mireya Montano, Executive Director

Deficiency #5

Rule/Regulation Violated:

R9-10-815.F.2.a-c. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is 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 meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and

Evidence/Findings:

Based on documentation review, observation, and interview, the manager failed to ensure the 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, controlled or alert 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 the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During a tour of the facility, the Compliance Officer observed a door leading to the outside patio in the center of the residential facility. The door was equipped with an electronic device designed to alert caregivers when the door was opened. However, the door was propped open with what appeared to be a detachable footrest from a wheelchair. 3. In an interview, E2 agreed there was a means of exiting the facility, which allowed residents to be at least 30 feet away from the facility, which did not control or alert employees of the egress of a resident. E2 closed the door and informed staff to ensure the door is kept closed, so the alert functions as designed.

Temporary Solution:

The Executive Director immediately went to the Cottages and moved the propping object that was affecting the electronic door system. Also explained to care staff the importance of having the electronic door system ring.

Permanent Solution:

The executive Director will person daily tours and continuous education on the importance of Door systems.

Person Responsible:

Angelica Mireya Montano, Executive Director

Deficiency #6

Rule/Regulation Violated:

R9-10-816.B.3.a-c. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: a. Is administered by an individual under direction of a medical practitioner, b. Is administered in compliance with a medication order, and c. Is documented in the resident's medical record.

Evidence/Findings:

Based on record review and interview the manager failed to ensure medication was administered to a resident in compliance with a medication order, and documented in the medical record. 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 R1’s medical record revealed an order for “LORazepam Oral Concentrate 1MG/0.5ML, give 0.5 ml by mouth every 4 hours as needed for AGITATION/RESTLESSNESS.” Further review revealed a medication administration record (MAR) for documenting the administration of medications during April 2025, including “LORazepam Oral Concentrate Give 0.5ml by mouth every 4 hours…” The record reflected Lorazepam was administered once on April 14, 2025, twice on April 18, 2025, and once each on April 19, 21, and 22, 2025. 2. A review of facility documentation revealed a Controlled Substance Count Sheet for R1, dated April 2025, used for tracking the administration of Lorazepam. The record documented the withdrawal of Lorazepam once on April 14, 2025, three withdrawals on April 15, 2025, two withdrawals on April 16, 2025, two withdrawals on April 18, 2025, two withdrawals on April 19, 2025, and one withdrawal each on April 20, 21, and 22, 2025. 3. A review of R4’s medical record revealed a service plan which indicated R4 received directed care services, including medication administration. R4’s medical record contained an order written May 4, 2025, for “QUEtiapine Fumarate 25 MG Tablet ½ tab Orally twice a day.” A review of R4’s medical record revealed a MAR which included a section for documenting the administration of "Quetiapine Fumarate 25 MG Take 1/2 tablet by mouth twice daily.” The record reflected the mediation was withheld from the evening of May 7, 2025, through the morning of May 12, 2025. Further review of R4’s medical record revealed a hold order, or documentation of a verbal hold order for Quetiapine was unavailable for review. R4’s medical record contained an order written May 13, 2025, which indicated R4 was to stop taking Quetiapine. 4. A review of facility progress notes revealed an entry on May 7, 2025, regarding the administration of Quetiapine to R4. The progress note indicated “waiting for pharmacy.” 5. In an interview, E1 advised R4’s medical provider had given a verbal hold order to stop administering Quetiapine, but the verbal order had not been documented. E1 indicated there was an issue with obtaining R4’s Quetiapine from the pharmacy, before the verbal order to hold R4’s medication. E1 said caregivers had not correctly documented the administration of Lorazepam to R1. E1 agreed R4 had not received medication as ordered.

Temporary Solution:

The Executive Director Immediately conducted a all-staff training on the importance of proper medication serves.

Permanent Solution:

I, Angelica Mireya Montano, Executive Director, Acknowledge and uphold the establish rule. The Executive Director, Will continue proper trainings on medication management/ services. As needed. The executive Director, Reviewed policies.

Person Responsible:

Angelica Mireya Montano, Executive Director

Deficiency #7

Rule/Regulation Violated:

R9-10-818.D.1. Emergency and Safety Standards D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver: 1. Immediately notifies the resident's emergency contact and primary care provider; and

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified a resident's primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. Findings include: 1. A review of facility incident reports revealed an incident report for R7, dated February 15, 2025. The incident report indicated R7 was “having difficulty breathing” at 7:00 a.m., and emergency medical services were contacted. The report included a section for documenting the notification of R7’s emergency contact and primary care provider. However, the section was blank, and evidence of notification of R7's emergency contact was unavailable for review. There was a notification to R7’s primary care provider via facsimile on February 15, 2025; however, the documentation reflected the notification was made at “9:37 AM,” over two hours after the incident occurred. 2. A review of facility incident reports revealed an incident report for R8, dated February 20, 2025. The report indicated at 6 p.m., emergency medical services were called, due to R8 feeling “very weak” and experiencing “abdominal pain.” The report also indicated R8’s emergency contact was immediately notified; however, evidence of documentation R8’s primary care provider was notified was unavailable for review. 3. A review of facility incident reports revealed an incident report for R9, dated February 21, 2025. The report indicated at 4:20 p.m., emergency medical services were called due to R9’s blood sugar being too low, and R9 was “not walking right” and “was sweating.” The report reflected R9’s emergency contact was immediately notified; however, evidence of documentation R9’s primary care provider was notified was unavailable for review. 4. In an interview, E1 agreed the incident reports did not indicate R7’s emergency and primary care provider, and R8’s and R9’s primary care providers were not immediately notified as required.

Temporary Solution:

The Executive Director immediately conducted an all staff meeting to ensure that every care staff member responsible care fully understands the importance of communication / documentation during an emergency and reporting in a timely manner.

Permanent Solution:

As part of our ongoing training, staff will be instructed and trained how to thoroughly complete an incident report on both paper and Point Click Care. Additionally, management has revised policy regarding incident reports.

Person Responsible:

Angelica Mireya Montano, Executive Director

INSP-0094237

Complete

Date: 7/29/2024

Type: Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2024-08-01

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on July 30, 2024:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
a. The individual's name, date of birth, and contact telephone number;
b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and
c. Documentation of:
i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;
ii. The individual's education and experience applicable to the individual's job duties;
iii. The individual's completed orientation and in-service education required by policies and procedures;
iv. The individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures;
v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115;
vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8);
vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures;
viii First aid training, if required for the individual in this Article or policies and procedures; and
ix. Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C);

Evidence/Findings:

Based on observation, interview, and record review, the manager failed to ensure a personnel record was established and maintained to include all required documentation, for one of five personnel records reviewed. The deficient practice posed a risk as the required information could not be verified.

Findings include:

1. A review of E2's personnel file revealed E2 was hired through a staffing agency to work for the facility as a nurse.
The personnel file did not include the following required items:

- A starting date of employment;
- Contact information;
- Documentation of verification skills and knowledge;
- Documentation of compliance with the requirements in A.R.S. \'a7 36-11(C) to include documented, good faith attempts to contact prior employers: and
- Job description.

2. In an interview, E3 acknowledged the personnel record of E2 provided for review had not included all required documentation.

Deficiency #2

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
1. Is completed no later than 14 calendar days after the resident's date of acceptance;

Evidence/Findings:

Based on record review, documentation review, observation, and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance, for three of three sampled residents.

Findings include:

1. A review of R1's medical record revealed a service plan dated March 1, 2024, for directed care services. The Compliance Officer observed the service plans initiated date was incorrect. The date was seven days before R1 had moved into the facility, however, the service plan was not completed within 14 calendar days after R1's date of acceptance. The service plan revealed the following:

- The Pima County Public Fiduciary signed and dated the service plan on April 9, 2024;
- The Manager signed and dated the service plan on April 10, 2024; and
- The Nurse signed and dated the service plan on April 12, 2024.

2. A review of R2's medical record revealed a service plan dated April 26, 2024, for directed care services. The Compliance Officer observed the service plans initiated date was incorrect. The date was four days before R2 had moved into the facility, however, the service plan was not completed within 14 calendar days after R2's date of acceptance. The service plan revealed the following:

- The manager signed and dated the service plan on May 23, 2024.

3. A review of R3's medical record revealed a service plan dated June 4, 2024, for directed care services. The Compliance Officer observed the service plans initiated date was incorrect. The date was three days before R3 had moved into the facility, however, the service plan was not completed within 14 calendar days after R3's date of acceptance. The service plan revealed the following:

- The manger had not signed or dated the service plan.

4. In an interview, E3 acknowledged the service plans were not completed within 14 calendar days of the resident's date of acceptance.

Deficiency #3

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f):
b. As follows:
iii. At least once every three months for a resident receiving directed care services; and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every three months, for one of three residents reviewed who received directed care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed.

Findings include:

1. A review of R1's medical record revealed a current written service plan for directed care services dated March 1, 2024. However, a service plan after June 1, 2024 was not available for review.

2. In an interview, E3 acknowledged R1 was receiving directed care services and the service plan was not updated at least once every three months

Deficiency #4

Rule/Regulation Violated:

C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes:
1. The requirements in R9-10-814(F)(1) through (3);
2. If applicable, the determination in R9-10-814(B)(2)(b)(iii);
3. Cognitive stimulation and activities to maximize functioning;
4. Strategies to ensure a resident's personal safety;
5. Encouragement to eat meals and snacks;
6. Documentation:
a. Of the resident's weight, or
b. From a medical practitioner stating that weighing the resident is contraindicated; and
7. Coordination of communications with the resident's representative, family members, and, if applicable, other individuals identified in the resident's service plan.

Evidence/Findings:

Based on record review, documentation review, and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirements in R9-10-815(C)(1-5), for three of three directed care residents sampled.

Findings include:

1. A review of R1's medical record revealed documentation of a service plan dated March 1, 2024. The service plan indicated R1 was receiving directed care services. However, the service plans did not contain the following:

- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting;
- Cognitive stimulation and activities to maximize functioning; (the service plans stated "Resident Specific Details:" this section was blank; and
- Documentation of the resident's weight. (the service plan had a section stating "Monthly Vitals/Weights", however, the weight was not entered).

2. A review of R2's medical record revealed documentation of a service plan dated April 26, 2024. The service plan indicated R2 was receiving directed care services. However, the service plans did not contain the following:

- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting;
- Cognitive stimulation and activities to maximize functioning; (the service plans stated "Resident Specific Details:" this section was blank; and
- Documentation of the resident's weight. (the service plan had a section stating "Monthly Vitals/Weights", however, the weight was not entered).

3. A review of R3's medical record revealed documentation of a service plan dated June 4, 2024. The service plan indicated R3 was receiving directed care services. However, the service plans did not contain the following:

- Incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting;
- Cognitive stimulation and activities to maximize functioning; (the service plans stated "Resident Specific Details:" this section was blank; and
- Documentation of the resident's weight. (the service plan had a section stating "Monthly Vitals/Weights", however, the weight was not entered).

4. In an interview, E3 reported being unaware the service plans did not contain all of the requirements for directed care residents and acknowledged the documents were missing these requirements.

Facility Information

Inspection History

INSP-0132225

Summary:

Deficiencies Found: 7

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0094237

Summary:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

INSP-0094236

Summary:

INSP-0094235

Summary: