Inspection Reports for
Archstone Care Center

The Risk-Based complaint survey was conducted on October 21, 2025, for investigation of intakes # AZ00155820 (2277970), AZ00159957 (2277975), AZ00160460 (2277978), AZ00162260 (2277981), AZ00163563 (2277985), AZ00163625 (2277987), AZ00167538 (2277933), AZ00173616 (2277995), AZ00176112 (2277997), AZ00177770 (2278000), AZ00178249 (2278001), AZ00180552 (2278005). There was no deficiencies were cited.

This inspection resulted in no deficiencies or citations.

The complaint investigation was conducted on June 18, 2025 through June 19, 2025, with investigation of complaints: 00134014 and AZ00224924. There were no deficiencies cited.

This inspection resulted in no deficiencies cited.

The complaint investigation was conducted on May 14, 2025, with investigation of complaints: AZ00224501 and SF00130547. There were no deficiencies cited.

This inspection found no deficiencies.

A complaint survey was conducted on February 4, 2025 of intakes AZ00222013, AZ00221885, and AZ00221882. There were no deficiencies cited.

This inspection resulted in no deficiencies or citations.

The investigation was substantiated with findings that resident #1 fell during peri care on January 4, 2024, due to inadequate supervision and failure to follow the facility's two-person assist policy. Staff training records were incomplete, and the resident was transferred to the hospital after the fall.

The facility failed to ensure adequate supervision and care during peri care for resident #1, resulting in the resident falling out of bed and sustaining injuries requiring hospital transfer. Staff training documentation was incomplete, and the resident was not assisted by the required two staff members during peri care.

The investigation of complaint AZ00187919 and AZ00187737 was conducted on October 19, 2023. A complaint survey was conducted on October 19, 2023, for the investigation of intake #AZ00187918 and AZ00187736. There were no deficiencies found or cited.

No deficiencies were found during this complaint investigation.

The Recertification survey was conducted October 10, 2023 through October 13, 2023, in conjunction with the investigation of Complaints AZ00185362, AZ00185413, AZ00185414, AZ00187549, AZ00187610, AZ00187612, AZ001877702, AZ00187704, AZ00188894, AZ00188895, AZ00190597, AZ00190638, AZ00190639, AZ00191429, AZ00191431, AZ00193866, AZ00193867, AZ00198013, AZ00198015, AZ00198116. The census was 81.

The inspection found four deficiencies related to staff training, tuberculosis screening, fingerprint clearance documentation, and continuing competence of nursing staff. The facility failed to ensure required in-service training and proper documentation for several employees.

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.

The inspection found three deficiencies related to fire safety and maintenance issues, including lack of a kitchen hood and fire suppression system for a deep fat fryer, damaged fire doors with missing hardware, and failure to inspect and maintain smoke dampers. Plans of correction were provided for all deficiencies.

The complaint investigation focused on issues related to resident discharge procedures, care plan implementation, medication security, infection control practices, COVID-19 testing compliance, and pest control effectiveness. The complaint was substantiated with findings of minimal harm or potential for harm.

The facility failed to provide adequate transfer/discharge documentation and notification for a resident discharged due to COVID-19 vaccination status. Care plan interventions for contracture prevention were not consistently implemented. Medications were left unsecured on medication carts. Blood pressure cuffs were not sanitized between resident use. COVID-19 testing of staff during an outbreak was not conducted per guidelines. The facility had ongoing pest control issues with cockroaches and other insects.

The visit was complaint-related focusing on issues including informed consent for psychotropic medications, maintenance of resident facilities, care planning, shower provision, wound care, oxygen orders, and infection control practices.

The facility failed to ensure informed consent was obtained prior to administering psychotropic medications for one resident, failed to maintain a resident's bathroom sink in working order, did not develop or revise comprehensive care plans for some residents, did not consistently provide showers as scheduled, failed to administer wound care as ordered, administered oxygen without a physician order, and failed to maintain infection control standards including tuberculosis screening for staff.

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.