Inspection Reports for
Archstone Care Center

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 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.

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.

Investigation of intake AZ00217078, AZ00216487, AZ00217077

Complaint survey conducted October 10, 2024 with one deficiency cited related to care plan supervision and nursing care.

The facility failed to ensure that one out of two Certified Nursing Assistants and one out of two Registered Nurses sampled received the required 12 hours of in-service training per year. The RN refused fingerprint clearance and was terminated. The facility has a program to train and monitor nursing staff competencies in various care areas.

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.

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

Recertification survey conducted October 10-13, 2023 with four deficiencies cited related to personnel policies, tuberculosis screening, personnel records, and nurse aide training.

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.

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 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.

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.

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.