Inspection Reports for Orchard Pointe at Surprise

AZ, 85374

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Inspection Report Summary

The most recent inspection on September 17, 2025, was an off-site review to change the facility’s licensed capacity and had no deficiencies cited. Earlier inspections showed a mix of results, with some complaints investigated and a few deficiencies noted, primarily related to management designation and documentation practices. Inspectors cited issues such as failure to designate a certified manager in writing and deficiencies in resident medical records, acceptance criteria, and caregiver notifications after incidents. Complaint investigations included both substantiated and unsubstantiated cases, with the substantiated ones leading to the cited deficiencies. The inspection history suggests some improvement, as the most recent review found no deficiencies following earlier issues.

Deficiencies (last 2 years)

Deficiencies (over 2 years) 2.5 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

32% better than Arizona average
Arizona average: 3.7 deficiencies/year

Deficiencies per year

4 3 2 1 0
2024
2025

Inspection Report

Modification
Capacity: 130 Deficiencies: 0 Date: Sep 17, 2025

Visit Reason
Off-site desktop review completed to change licensed capacity from 130 directed care to 20 directed care and 110 personal care. No deficiencies cited.

Findings
Off-site desktop review completed to change licensed capacity from 130 directed care to 20 directed care and 110 personal care. No deficiencies cited.

Inspection Report

Complaint Investigation
Capacity: 130 Deficiencies: 0 Date: Jan 17, 2025

Visit Reason
On-site compliance inspection and complaint investigation found no deficiencies.

Complaint Details
Complaint AZ00222110 investigated.
Findings
On-site compliance inspection and complaint investigation found no deficiencies.

Inspection Report

Complaint Investigation
Capacity: 130 Deficiencies: 1 Date: Aug 28, 2024

Visit Reason
On-site investigation of complaints AZ00214632 and AZ00214723 found deficiency for failure to designate a certified manager in writing.

Complaint Details
Complaints AZ00214632 and AZ00214723 investigated.
Findings
On-site investigation of complaints AZ00214632 and AZ00214723 found deficiency for failure to designate a certified manager in writing.

Deficiencies (1)
A. A governing authority shall: 3. Designate, in writing, a manager who: b. Except for the manager of an adult foster care home, has either a: i. Certificate as an assisted living facility manager — failure to designate a certified manager

Inspection Report

Complaint Investigation
Capacity: 130 Deficiencies: 4 Date: Feb 14, 2024

Visit Reason
On-site compliance inspection and complaint investigation found four deficiencies related to resident medical records, acceptance of residents, and caregiver notifications/documentation after incidents.

Complaint Details
Complaints AZ00199018, AZ00201053, and AZ00203885 investigated.
Findings
On-site compliance inspection and complaint investigation found four deficiencies related to resident medical records, acceptance of residents, and caregiver notifications/documentation after incidents.

Deficiencies (4)
C. A manager shall ensure that a resident's medical record contains: 17. Documentation of notification of the resident of the availability of vaccination — failure to ensure documentation
B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided — failure to ensure facility did not accept or retain a resident confined to bed or chair
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 immediately notifies the resident's representative — failure to ensure caregiver notification
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 documents any action taken to protect the resident — failure to ensure caregiver documentation

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