Deficiencies (last 5 years)
Deficiencies (over 5 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
68% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 81
Capacity: 120
Deficiencies: 0
Date: Jun 19, 2025
Visit Reason
Complaint investigation conducted June 18-19, 2025 with no deficiencies cited.
Complaint Details
Investigation of complaint 00134014
Findings
Complaint investigation conducted June 18-19, 2025 with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 81
Capacity: 120
Deficiencies: 0
Date: May 14, 2025
Visit Reason
Complaint investigation conducted May 14, 2025 with no deficiencies cited.
Complaint Details
Investigation of complaints AZ00224501 and SF00130547
Findings
Complaint investigation conducted May 14, 2025 with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 81
Capacity: 120
Deficiencies: 0
Date: Feb 4, 2025
Visit Reason
Complaint survey conducted February 4, 2025 with no deficiencies cited.
Complaint Details
Investigation of intakes AZ00222013, AZ00221885, AZ00221882
Findings
Complaint survey conducted February 4, 2025 with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure adequate supervision and care during perineal care, which resulted in a resident falling out of bed and sustaining injuries.
Complaint Details
The complaint investigation was substantiated with findings that resident #1 fell during perineal care on January 4, 2024, due to inadequate supervision and failure to follow facility policy requiring a two-person assist for residents with morbid obesity. Staff training records showed missing signatures and lack of evidence of required fall management and peri care training for staff #87. Hospital records were requested but not received.
Findings
The facility failed to provide adequate supervision during perineal care for resident #1, who fell out of bed and was subsequently hospitalized. The investigation revealed that the resident was assisted by only one CNA instead of the required two-person assist, and that staff training documentation was incomplete or missing for key personnel.
Deficiencies (1)
Failure to ensure adequate supervision and care during perineal care resulting in resident fall and injury.
Report Facts
Date of fall incident: Jan 4, 2024
Date of admission MDS: Dec 20, 2023
Date of care plan focus for falls: Sep 27, 2023
Date of fall prevention training: Apr 16, 2023
Date of skills checklist completion: Dec 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (staff #87) | Performed peri care on resident #1 during fall incident; lacked documented training and skills assessment | |
| Registered Nurse (staff #64) | Recalled incident and assisted with hospital notification; uncertain about recent training | |
| Director of Nursing (staff #106) | Provided fall prevention training documentation and interviews; acknowledged missing training sign-offs and lack of skills training for staff #87 |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 120
Deficiencies: 1
Date: Oct 10, 2024
Visit Reason
Complaint survey conducted October 10, 2024 with one deficiency cited related to care plan supervision and nursing care.
Complaint Details
Investigation of intake AZ00217078, AZ00216487, AZ00217077
Findings
Complaint survey conducted October 10, 2024 with one deficiency cited related to care plan supervision and nursing care.
Deficiencies (1)
R9-10-414.B — Care plan supervision and nursing care
Inspection Report
Complaint Investigation
Census: 81
Capacity: 120
Deficiencies: 0
Date: Oct 20, 2023
Visit Reason
Complaint investigation conducted October 19-20, 2023 with no deficiencies cited.
Complaint Details
Investigation of complaints AZ00187919 and AZ00187737, AZ00187918 and AZ00187736
Findings
Complaint investigation conducted October 19-20, 2023 with no deficiencies cited.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Oct 13, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with training requirements for nursing staff, including nurse aides and registered nurses, ensuring they receive required in-service training and maintain continuing competence.
Findings
The facility failed to ensure that one of two Certified Nursing Assistants and one of two Registered Nurses sampled received the required 12 hours of in-service training per year. Specifically, the CNA lacked dementia and communication training, and the RN had no training completed and was terminated for refusing fingerprint clearance. The facility's overall nurse staffing training program was reviewed and found to cover multiple competency areas.
Deficiencies (2)
Failure to ensure one CNA received required in-service training for at least 12 hours per year, lacking dementia and communication training.
Failure to ensure one RN received required in-service training for at least 12 hours per year; RN refused fingerprint clearance and was terminated.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding staff training deficiencies and employee termination |
| RN staff #33 | Registered Nurse | Failed to complete required training and fingerprint clearance; employment terminated |
| CNA staff #106 | Certified Nursing Assistant | Did not receive required dementia and communication in-service training |
Inspection Report
Annual Inspection
Census: 81
Capacity: 120
Deficiencies: 4
Date: Oct 13, 2023
Visit Reason
Recertification survey conducted October 10-13, 2023 with four deficiencies cited related to personnel policies, tuberculosis screening, personnel records, and nurse aide training.
Complaint Details
Investigation of multiple complaints including AZ00185362, AZ00185413, AZ00185414, AZ00187549, AZ00187610, AZ00187612, AZ001877702, AZ00187704, AZ00188894, AZ00188895, AZ00190597, AZ00190638, AZ00190639, AZ00191429, AZ00191431, AZ00193866, AZ00193867, AZ00198013, AZ00198015, AZ00198116
Findings
Recertification survey conducted October 10-13, 2023 with four deficiencies cited related to personnel policies, tuberculosis screening, personnel records, and nurse aide training.
Deficiencies (4)
R9-10-403.C — Policies and procedures for personnel
R9-10-406.E — Personnel tuberculosis screening
R9-10-406.F — Personnel record maintenance
§483.95(g) — Required in-service training for nurse aides
Inspection Report
Census: 81
Capacity: 120
Deficiencies: 3
Date: Oct 13, 2023
Visit Reason
Recertification survey for Medicare under Life Safety Code conducted October 18, 2023 with three deficiencies cited related to kitchen fire suppression, fire doors, and HVAC smoke dampers.
Findings
Recertification survey for Medicare under Life Safety Code conducted October 18, 2023 with three deficiencies cited related to kitchen fire suppression, fire doors, and HVAC smoke dampers.
Deficiencies (3)
Cooking Facilities — Kitchen hood and fire suppression system
Corridor - Doors — Fire door maintenance
HVAC — Smoke dampers and fusible links inspection and maintenance
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Aug 25, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly document resident transfer and discharge procedures, care plan implementation, medication security, infection control, COVID-19 testing compliance, and pest control.
Complaint Details
The complaint investigation focused on multiple issues including improper resident transfer documentation and notification, failure to implement care plans, medication security lapses, infection control failures, inadequate COVID-19 testing of staff during outbreak, and pest control deficiencies.
Findings
The facility failed to provide adequate transfer/discharge documentation and notification, did not consistently implement care plan interventions for contracture prevention, left medications unsecured during administration, failed to sanitize blood pressure cuffs between residents, did not conduct COVID-19 testing for staff per outbreak guidelines, and had an ineffective pest control program resulting in visible insect infestations.
Deficiencies (6)
Failure to provide documentation of notification to receiving provider of transfer reason and follow transfer process for resident #168.
Failure to consistently implement care planned interventions for application of a hand roll to prevent contracture for resident #7.
Medications left unsecured and unattended on top of medication cart during administration.
Blood pressure cuff not sanitized between resident uses, increasing risk of infection transmission.
Failure to conduct COVID-19 testing for staff according to outbreak frequency guidelines.
Ineffective pest control program with ongoing insect infestations including cockroaches observed in facility.
Report Facts
Deficiencies cited: 6
COVID-19 outbreak period: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Admissions | Director of Admissions | Interviewed regarding vaccination verification and transfer documentation failures for resident #168 |
| John Smith | Registered Nurse | Observed leaving medications unattended on medication cart during administration |
| Director of Nursing | Director of Nursing | Interviewed regarding failures in discharge procedures, care plan implementation, medication security, infection control, and COVID-19 testing compliance |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control practices and COVID-19 testing policies |
| Maintenance Director | Maintenance Director | Interviewed regarding pest control program and response to pest sightings |
| Certified Nursing Assistant | Certified Nursing Assistant | Reported pest sightings and resident concerns about insects |
Inspection Report
Routine
Census: 55
Deficiencies: 8
Date: Mar 4, 2021
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, and facility operations at Archstone Care Center.
Findings
The facility was found deficient in multiple areas including failure to ensure informed consent for psychoactive medications, unresolved maintenance issues affecting resident bathroom sinks, incomplete care plans for seizures and elopement risks, inconsistent shower provision, improper wound care treatment administration, oxygen use without physician order, and lapses in infection control practices.
Deficiencies (8)
Failed to ensure resident/representative was informed of risks and benefits of psychoactive medications prior to administration.
Failed to ensure resident's bathroom sink was in working order, causing inconvenience and hygiene issues.
Failed to develop a comprehensive care plan for seizures for one resident.
Failed to provide opportunity for resident and representative participation in care planning and failed to revise care plan to include elopement risk and wander guard placement.
Failed to ensure consistent showers for one resident as scheduled.
Failed to administer bilateral heel pressure ulcer treatment as ordered by physician.
Failed to have a physician order for oxygen use for one resident receiving oxygen therapy.
Failed to maintain infection control standards regarding hand hygiene and failed to document tuberculosis screening for staff member.
Report Facts
Census: 55
Deficiencies cited: 8
Wound measurements: 1.4
Wound measurements: 3
Wound measurements: 0.5
Wound measurements: 1
Wound measurements: 0.1
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #88 | Licensed Practical Nurse | Signed consent form for psychoactive medication for resident #55 |
| Staff #27 | Assistant Director of Nursing | Interviewed regarding consent process and wound care |
| Staff #26 | Director of Nursing | Interviewed regarding care planning and wound care |
| Staff #73 | MDS Coordinator | Interviewed regarding care planning process |
| Staff #45 | Certified Nursing Assistant | Interviewed regarding shower schedule and oxygen care |
| Staff #12 | Certified Nursing Assistant | Observed and interviewed regarding hand hygiene breach |
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