Orchard Pointe at Arrowhead.

“Based on documentation review and interview, the manager failed to ensure that policies and procedures were established and documented to protect the health and safety of a resident that covered how a caregiver would respond to a resident’s sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. 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 documentation revealed that a policy and procedure was not available that covered how a caregiver would respond to a resident’s sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. 2. In an exit interview, the findings were reviewed with E1, who showed the Compliance Office documentation of third-party trainings, however, E1 could not provide a policy covering this rule. No additional information was provided.”

“Based on record review and interview, the manager failed to ensure that a resident service plan was signed and dated by the resident or resident’s representative; the manager; and the nurse or medical practitioner who reviewed the service plan, for four out of four residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed a service plan dated December 22, 2025. This service plan did not include the signature and date by the resident or resident’s representative, the manager, the nurse or medical practitioner. The service plan revealed R1 required medication administration. 2. A review of R2's medical record revealed a service plan dated October 28, 2025. This service plan did not include the signature and date by the resident or resident’s representative, the manager, the nurse or medical practitioner. The service plan revealed R2 required medication administration. 3. A review of R3's medical record revealed a service plan dated September 11, 2025. This service plan did not include the signature and date by the resident or resident’s representative, the manager, the nurse or medical practitioner. The service plan revealed R3 required medication administration. 4. A review of R4's medical record revealed a service plan dated December 5, 2025. This service plan did not include the signature and date by the resident or resident’s representative or the manager. 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure an entry in a resident's medical record was not changed to make the initial entry illegible, for one of eight sampled residents. The deficient practice posed a risk to the residents' health and safety if the documentation in the medical records was not accurate and legible.  Findings include: 1. A review of R7’s residency agreement revealed corrective tape over the area where the resident’s name was written. R7’s name was written over the corrective tape. 2. In an interview, E1 acknowledged that R7’s residency agreement was changed to make the initial entry illegible.”

“Based on documentation review, observation, record review, and interview, the manager failed to ensure the premises at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of Department documentation revealed the facility was licensed for directed level of care. 2. The Compliance Officers observed ambulatory residents in the facility. 3. The Compliance Officers observed R1’s bedroom door unlocked and open. In R1's room, a bottle of Locite superglue was observed in the bathroom. Additionally, the Compliance Officers observed the following unlocked medications in R1’s drawer; Imodium A-D, Loperamide, Hydrochloride Tablets 2 mg, Alendronate Sodium 70 mg, and Dulcolax Laxative 5 mg. 4. A review of R1’s medical record revealed that R1 received medication administration. 5. In an interview, E1 reported R1's spouse brought in the medications that were found in R1's room. 6. The Compliance Officers observed R9's bedroom door unlocked and open. In R9's bathroom, a tube of Preparation H and two tubes of Neosporin were observed. 7. The Compliance Officers observed R10's bedroom door unlocked and open. In R10's room, the floor was damaged and peeled up. In R10's drawer, a bottle of Tide laundry detergent and nail polish remover were observed. In R10's bathroom, hair spray, a box of Efferdent anti-bacterial dental appliance cleanser, multiple bottles of Perineal & skin cleanser, and Ammens original medicated powder were observed. 8. In an interview, E1 acknowledged the premises at the assisted living facility were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.”

“Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. The Compliance Officers observed an oxygen container unsecured in R9’s room. 2 . In an interview, E1 acknowledged the oxygen container was not secured in R9’s room.”

“Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. § 36-411, for four of eight personnel sampled. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include:   1. A.R.S. § 36-411(C) states "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. A review of E2's (hired in 2023) personnel record revealed documentation of a valid fingerprint clearance card. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E2's fitness to work in a residential care institution.   3. A review of E4's (hired in 2024) personnel record revealed documentation of a valid fingerprint clearance card. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E4's fitness to work in a residential care institution.   4. A review of E5's (hired in 2024) personnel record revealed documentation of a valid fingerprint clearance card. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E5's fitness to work in a residential care institution.   5. A review of E6's (hired in 2023) personnel record revealed documentation of a valid fingerprint clearance card. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E6's fitness to work in a residential care institution.    6. In an interview, E1 and E9 acknowledged E2's, E4's, E5's, and E6's personnel records did not include documentation of compliance with the requirements in A.R.S. § 36-411(C)(1).”