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 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 to include continued competency. Findings include: 1. A review the facility's policies and procedures revealed a policy titled "Fall Prevention Program" (dated December 20, 2022). The policy stated "2. Our associates are trained upon hire with shadowing alongside trained associates ... 3. The Communities hold skills fairs, whether annually, quarterly, monthly, or as needed for continued education." 2. A review of E1's (began working at AL10380 in 2023), E2's, (hired in 2023), E4's (hired in 2023), E5's (hired in 2023), and E8's (hired in 2023) personnel records revealed documentation of initial training and continued competency training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 reported E1 completed a fall prevention and fall recovery training at "Surprise" community. 4. In an interview, E1 acknowledged a training program for all staff regarding fall prevention and fall recovery to include continued competency, and documentation to demonstrate E1, E2, E4, E5, and E8 were administered training regarding fall prevention and fall recovery was not available for review.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years. The deficient practice posed a risk as policies and procedures reinforce and clarify the health care institution's standards. Findings include: 1. A review of the facility's policies and procedures manual revealed documentation to demonstrate the policies and procedures were reviewed at least once every three years was not available for review. 2. A review of the facility's policies and procedures manual revealed a sample of policies and procedures. The following sample of policies and procedures stated: -"On-going Associate Training ... Revised: 12/9/16 ... Printed: 1/28/2019;" "Orientation and Training ... Printed: 3/15/2019;" "Personnel Files ... Revised: 4/1/2019 ... Printed: 3/19/2019;" -"Qualified Associates ... Printed: 1/28/2019;" and -"Staffing Policy ... Printed: 1/28/2019." 3. In an interview, E1 stated the policies and procedures were currently under review and kept in "SharePoint" by corporate. 4. In an interview, E1 acknowledged policies and procedures were not reviewed at least once every three years.

Based on record review and interview, the manager failed to ensure documentation required by Article 8 was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection. Findings include: 1. The Compliance Officer requested, on July 20, 2023 at 8:50AM, the following documentation to be provided to the Department: -E1's complete personnel record to include documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1); and -E1's documentation of initial training and continued competency training in fall prevention and fall recovery. However, the required documentation was not provided for review within two hours after a Department request. 2. In an interview, E1 reported E1's previous employers were contacted and documented, and this information was not available in E1's personnel record. 3. In an interview, E1 reported E1 completed a fall prevention and fall recovery training at E1's previous place of employment, and this information was not available in E1's personnel record. 4. In an interview, E1 acknowledged documentation required by Article 8 was not provided to the Department by 1:55 PM and no additional information was provided.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included the individual's date of birth, for one of nine personnel records sampled. The deficient practice posed a risk as the Department was unable to determine compliance with R9-10-806.A.1.a. Findings include: 1. A review of E3's personnel record revealed E3's date of birth were not available for review. 2. In an interview, E1 acknowledged E3's personnel record did not include E3's date of birth.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee of volunteer included documentation of the individual's completed in-service education required by policies and procedures, for one of ten personnel members sampled. Findings include: R9-10-101.116. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer. 1. A review the facility's policies and procedures revealed a policy titled "Fall Prevention Program" (dated December 20, 2022). The policy stated "2. Our associates are trained upon hire with shadowing alongside trained associates ... 3. The Communities hold skills fairs, whether annually, quarterly, monthly, or as needed for continued education." 2. A review of E1's (hired in 2023) personnel record revealed documentation of initial training and continued competency training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 reported E1 completed a fall prevention and fall recovery training at E1's previous place of employment, and the training was not available in E1's personnel record. 4. In an interview, E1 acknowledged E1's personnel record did not include documentation of initial training and continued competency training in fall prevention and fall recovery.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation training (CPR) and first aid training, for two of nine personnel members sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "On-going Associate Training" (dated December 9, 2016). The policy stated "6. CPR training is required for all direct care associates, life enrichment and associates who may work with residents out of the facility such as transportation staff. a. Associates will provide proof of having received training in cardiovascular pulmonary resuscitation (CPR) and adult first aid. b. The training must be current and must be renewed as required." 2. A review of E5's personnel record revealed E5 was hired as an assistant caregiver. E5's documentation of CPR training and first aid training was issued February 9, 2021, and expired February 8, 2023. However, documentation of current CPR training and first aid training was not available for review. 3. A review of E7's personnel record revealed E7 was hired as a caregiver. E7's documentation of CPR training and first aid training was issued August 1, 2020, and expired August 31, 2022. However, documentation of current CPR training and first aid training was not available for review. 4. In an interview, E1 acknowledged E5's and E7's personnel records did not include documentation of current CPR training and first aid training.

Based on 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. \'a7 36-411(A) and (C), for seven of nine personnel records sampled. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: A.R.S. \'a7 36-411(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. 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. 2. Verify the current status of a person's fingerprint clearance card. 1. A review of E1's (hired in 2023) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1) was not available for review. 2. In an interview, E1 reported E1's previous employers were contacted and documented, and this information was not available in E1's personnel record. 3. A review of E2's (hired in 2023) personnel record revealed documentation of a valid fingerprint clearance card. However, documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1) was not available for review. 4. A review of E3's (hired in 2022) personnel record revealed documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) and (C) was not available for review. 5. A review of the Arizona Department of Public Safety fingerprint clearance card website, conducted on July 27, 2023, revealed E3's fingerprint clearance card was not valid. 6. In an interview, E1 acknowledged E3's documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) and (C) was not available for review. 7. A revie

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record, for one of ten residents sampled. Findings include: 1. A review of R8's medical record revealed a service plan for personal care services (dated in March 2023). The service plan stated the following service was to be provided to R8: -"Total: Resident is dependent upon others to do all dressing/undressing ... Ted Hose/Compression Wear ... AM and PM." 2. A review of R8's medical record revealed an ADL sheet for July 2023. However, " Total: Resident is dependent upon others to do all dressing/undressing ... Ted Hose/Compression Wear ... AM and PM" was documented as "TNC" on the following dates and the following shifts: -July 7, 2023 on the day shift; -July 14, 2023 on the day shift and evening shift. The ADL sheet stated "TNC" as "Task Not Completed." 3. In an interview, E1 acknowledged the aforementioned service was not documented as provided in R8's medical record.