Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Archstone Care Center during CMS and state inspections, most recent first.
Two residents did not receive necessary care and services according to their assessed needs and physician orders. One resident with severe cognitive impairment, mobility limitations, and a two‑person assist care plan rolled from bed while a CNA was changing sheets alone, was assisted to the floor, and later lifted back to bed without a documented nursing assessment. The resident subsequently complained of severe leg pain and had visible swelling, but an x‑ray was not obtained until the next morning, when a distal femur fracture was identified, and the physician and family were not notified until the following day. Another resident with Parkinson’s disease, dementia, and prior humeral fracture had active orders for a PRAFO boot, AFO, and left hand roll with shift skin checks, yet was repeatedly observed in a WC without any of these devices in place and with a contracted left hand and feet turned inward. MAR/TAR entries indicated the devices were applied, but staff interviews revealed they had stopped using them due to perceived discomfort and possible skin issues without documenting intolerance, consulting the family, or notifying the physician, and no documentation was produced to show consistent use or modification of the DME orders.
A resident with severe cognitive impairment, multiple comorbidities, and a care plan requiring two-person assist for transfers fell from bed while a CNA was changing sheets and providing care without a second staff member. The resident reported being dropped, and another CNA later observed the resident crying with visible swelling of the left leg and reported this to an LPN and the ADON. Documentation showed that the resident was returned to bed without a documented timely nursing assessment, that physician and family notifications were not recorded at the time of the incident, and that diagnostic imaging confirming a distal femoral fracture and transfer to the ER occurred only the following day, contrary to staff-stated expectations and facility policies for post-fall assessment, notification, and timely evaluation.
Surveyors found that a resident with multiple medical conditions and moderate cognitive impairment had an over-the-counter nasal spray and a dermal wound cleanser at the bedside without any corresponding physician orders or documented assessment or authorization for self-administration, despite a care plan stating medications were to be administered as ordered. Staff interviews confirmed these items were considered medications and should not be kept at bedside without proper assessment and orders. Separately, a treatment cart containing prescription treatments and a medication cart were observed left unlocked and unattended in common areas while staff, residents, and visitors were nearby, contrary to facility policies requiring medication and treatment carts to be locked when not in use and not left unattended.
Surveyors found that the facility failed to properly maintain its dumpster and surrounding refuse area, observing an open dumpster lid with numerous flies, trash debris and soiled gloves on the ground, a rusted section of the receptacle leaking a foul-smelling milky liquid that pooled beneath it, and an additional bucket filled with garbage and flies. A diet technician stated that maintenance is responsible for the refuse area but that all staff are expected to close the lid when disposing of trash, and acknowledged that an open lid and unclean area can attract pests. A dietary supervisor described cleaning the area as a collaborative effort but could not identify who is responsible for maintaining it, while facility policy requires that waste be handled and disposed of appropriately.
A resident with multiple medical conditions, including morbid obesity, experienced a fall during perineal care due to inadequate supervision. The resident, who required a two-person assist, was being assisted by a single CNA, resulting in the resident rolling out of bed and being transferred to the hospital. The facility's policies on perineal care and fall prevention were not followed, and the CNA involved had not participated in required training sessions.
Failure to Provide Post‑Fall Assessment and Timely Diagnostics and Failure to Apply Ordered DME for Contracture Prevention
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services after a fall for one resident and failure to apply ordered durable medical equipment (DME) for another resident. For the first resident, who had multiple diagnoses including a periprosthetic fracture around an internal right knee prosthesis, severe cognitive impairment, muscle weakness, and difficulty walking, the care plan identified the resident as a two‑person assist and at risk for falls. Despite this, a CNA changed the resident’s sheets alone during the early morning hours, during which the resident rolled out of bed and was assisted to the floor by the CNA. The CNA then had the resident sit on the floor and later, along with another staff member, lifted the resident back into bed without a documented nursing assessment prior to the transfer, contrary to staff statements that a nurse should assess a resident before moving them after a fall. Later that morning, another CNA observed the resident crying and reporting that she had been dropped by staff and that the staff member tried to pick her up but could not, then left to find help. This CNA observed swelling of the resident’s left leg from the knee to the thigh and reported it to the charge nurse, who stated he would take care of it. The same CNA later reported to the ADON that the resident had not yet been checked on, and the resident told the ADON she heard a cracking sound like a stick breaking when she fell. The resident was also observed to be wet, and the CNA expressed fear of causing more pain because the resident was crying and begging not to be moved. Documentation shows that the resident complained of left knee pain from the fall and had visible swelling, but the x‑ray was not completed until the following morning, at which time a distal femoral shaft fracture with slight malalignment was identified and the resident was then sent to the emergency room. The ADON later confirmed that the physician and family were not notified until the day after the incident and that the x‑ray had not been ordered as STAT, which did not align with facility policies requiring prompt notification of changes in condition and labeling emergency diagnostic requests as STAT. For the second resident, who had diagnoses including a right humeral neck fracture, Parkinson’s disease, dementia with severely impaired cognition, difficulty walking, and need for assistance with personal care, the physician had ordered multiple DME items: a PRAFO boot to the left lower extremity to be worn all day with shift skin checks, an AFO to the left lower extremity when up in a wheelchair, and a left hand roll to be on at all times except during meals, with skin checks. The care plan included interventions to encourage use of the affected limb, maintain range of motion, and monitor for muscle rigidity and decline in range of motion. On multiple observations over several days, the resident was seen in the hallway, dining room, and activities area without the PRAFO boot, AFO, or left hand roll in place, and with a left hand contracture and both feet turned inward while seated in a wheelchair. Review of the MAR/TAR for January showed check marks indicating that the AFO, PRAFO, and hand roll orders were carried out on certain shifts, but surveyors’ observations did not corroborate that the devices were in use. Review of the MAR/TAR for the prior month showed no documentation of administration of these ordered devices. An LPN stated that the PRAFO boot is used to keep the feet straight and that the hand roll is to stop the hand from contracting, and acknowledged that the devices had not been placed on the resident despite documentation indicating otherwise. The LPN reported that staff had stopped placing the devices because the resident would remove them and because the boots were believed to be causing leg wounds, but also stated there was no documentation that the family had been consulted, that the physician had been notified, or that the resident did not tolerate the devices. A CNA confirmed that the resident had not worn the boots for a while because they were hurting her legs, but that she had not been informed to stop placing the DME. The ADON stated that staff were expected to follow physician orders or notify if there was a concern and acknowledged that failure to follow DME orders could cause further contracture or limited range of motion, but no documentation was provided to show that the ordered DME had been consistently applied or that the orders had been modified.
Failure to Follow Two-Person Assist Care Plan and Timely Post-Fall Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance to prevent a fall and to follow professional standards for post-fall assessment and notification for one resident. The resident was admitted with multiple significant diagnoses, including a periprosthetic fracture around an internal prosthetic right knee joint, hypertension, type 2 diabetes mellitus, chronic kidney disease, acute kidney failure, nonrheumatic mitral valve insufficiency, muscle weakness, and difficulty walking. An annual MDS showed a BIMS score of 7, indicating severe cognitive impairment, and documented that the resident was dependent on staff for toileting hygiene and transfers, requiring the effort of two or more helpers. The care plan identified the resident as at risk for falls due to recent illness, deconditioning, and a new environment, and specified that the resident was a two-person assist for transfers. On the date of the incident, a 5-day report documented that in the early morning hours the resident "rolled" out of bed and began falling while a CNA was changing the resident’s sheets. The CNA reported that the resident was unable to balance her legs, dropped both legs to the floor, and that he held the resident by the shoulders and let her sit on the floor, then called a nurse, who performed a physical "checkup" and assisted the CNA to put the resident back into bed. Later that morning, another CNA observed the resident crying; the resident stated she had been dropped while a staff member was working with her, that the staff member tried to pick her up but could not, and that he left to find someone else to assist before returning with another staff member to get her back into bed. This CNA observed swelling of the resident’s left leg from the knee to the thigh and reported it to the charge nurse, who stated he would take care of it. The same CNA later reported to the ADON that the resident had not yet been checked on, and the resident told the ADON that when she fell she heard a crack that sounded like a stick breaking. The resident was also observed to be wet, and the CNA expressed fear of causing further pain because the resident was crying and begged not to be moved. Progress notes and radiology documentation showed delays and gaps in post-fall assessment and notification. A health status note entered that evening documented that the resident complained of left knee pain from a recent fall and was awaiting an x-ray, with swelling noted in the left knee. A fall review note created after midnight the following day indicated that the family, physician, and DON were notified, but there was no evidence in the progress notes of notifications at the time of the incident. A radiology report dated the following day documented a fracture of the distal femoral shaft with slight malalignment. A subsequent health status note recorded that an x-ray performed that morning revealed an acute femoral fracture and that an order was given to send the resident to the emergency room, with transport arriving later that morning. Interviews with nursing staff, including LPNs, CNAs, and the ADON, consistently described facility expectations that care plans be followed for transfers and brief changes, that CNAs not move residents post-fall before a nurse assessment, that pain, swelling, and suspected injury be promptly reported to a physician, and that STAT x-rays or immediate hospital transfer be arranged when serious injury is suspected. The ADON specifically stated that the dates and timing of the x-ray and notifications for this resident did not meet her expectations and that the care plan was not followed, including the requirement for a two-person assist.
Unsecured Medications, Inadequate Self-Administration Assessment, and Unlocked Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were properly labeled, stored, and controlled, and that residents were not in possession of medications at bedside without appropriate assessment and physician orders. One resident with diagnoses including a right artificial hip joint, atrial fibrillation, hypertension, encephalopathy, urinary tract infection, hypertensive heart disease, and a BIMS score of 11 indicating moderate cognitive impairment was observed to have Equate nasal spray and a dermal wound cleanser on the bedside table. Review of the physician’s orders showed an order only for Fluticasone Furoate nasal suspension as needed for allergies, with no orders for Equate nasal spray or the dermal wound cleanser, and no orders for self-administration of medications. The electronic health record contained no assessment for self-administration, and the care plan documented impaired cognitive function/dementia and interventions stating that medications were to be administered as ordered and monitored for side effects and effectiveness. Staff interviews confirmed that the items at bedside were considered medications and should not have been left with the resident without appropriate assessment and orders. A CNA stated that medications, including nasal spray, should not be at the bedside and acknowledged the risk of inappropriate use. An LPN stated that both the nasal spray and dermal wound cleanser were medications and should not be at bedside, and further explained that residents must be assessed for the ability to self-administer medications, with an order put in place and reassessments every six months or sooner with a change in condition. The ADON similarly stated that medications are to be administered as ordered and that a resident would need to be assessed to self-administer medications, noting that medications at bedside without an assessment could result in inaccurate dosing, use outside the intended purpose, or access by others. Additional deficiencies were identified related to unsecured medication and treatment carts. A treatment cart was observed unlocked and facing away from the nurse’s station while staff, residents, and visitors walked past; an LPN confirmed it was a treatment cart containing prescription treatments and acknowledged it was supposed to be locked. The ADON reported that there are multiple medication and treatment carts, with access controlled by keys or codes, and stated that residents could get into the cart and the medications in it. On another occasion, a nurse left a medication cart unsecured while walking away from it into a room, leaving a resident in a wheelchair behind the cart; the LPN involved acknowledged the cart was left unsecured and stated that the risk of not securing the cart is that someone could grab something. Facility policies on storage and administration of medications require that compartments containing drugs and biologicals, including carts, be locked when not in use and not left unattended, and that residents may self-administer medications only if the physician and interdisciplinary team determine they have the decision-making capacity to do so safely.
Improper Maintenance of Dumpster and Refuse Area
Penalty
Summary
The facility failed to properly maintain its garbage and refuse area, resulting in unsanitary conditions around the dumpster used for kitchen waste. During a kitchen walkthrough with a diet technician, surveyors observed two soiled gloves under the garbage receptacle and trash debris scattered around the outside perimeter. The dumpster lid was open, and a large number of flies were present. On the lower left exterior of the receptacle, there was a rusted area approximately 6–7 inches in length that was leaking a milky-colored liquid, which had formed a small puddle beneath the receptacle and emitted a strong rancid odor, with flies present around the puddle. Additionally, a Home Depot bucket filled with empty soda cans, empty food bags, and other garbage was observed in the area, with multiple flies inside the bucket. In interviews, the diet technician stated that the refuse area is maintained by the maintenance department but that anyone disposing of garbage is expected to ensure the dumpster lid is closed at all times. The diet technician reported being unaware of the source of the leaking substance but acknowledged that an open lid and unclean surrounding area can attract vermin and pests. The dietary supervisor described the cleaning of the garbage receptacle area as a collaborative effort but was unaware of who is specifically responsible for maintaining the area. The dietary supervisor also stated that failure to maintain a clean perimeter, keep the lid closed, and prevent leakage from the receptacle can attract pests. Review of the facility’s “Waste Disposal” policy, revised January 2012, showed that all infectious and regulated waste is to be handled and disposed of in its appropriate manner.
Inadequate Supervision During Perineal Care Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and care for a resident during perineal care, leading to an accident. The resident, who had multiple medical conditions including morbid obesity and was designated as a Hoyer lift transfer, was being assisted by a single CNA instead of the required two-person assist. During the care, the resident rolled out of bed and landed on her knees, necessitating a transfer to the hospital for further assessment. The resident had a history of falls and was identified as a moderate fall risk. The care plan included interventions to prevent falls, but it did not specify the need for a two-person assist during perineal care. The CNA involved in the incident did not participate in the facility's fall prevention training and was unaware of the requirement for a two-person assist for residents with morbid obesity. The facility's policy on perineal care was not followed, as the resident was positioned incorrectly during the procedure. Additionally, there was a lack of documentation for the CNA's participation in required training sessions, and no skills assessment was conducted for the CNA in 2023. These oversights contributed to the inadequate supervision and care that led to the resident's fall.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chandler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sante Of Chandler | 0 mi | ★★★★★ | 3 | 0 |
| Chandler Post Acute And Rehabilitation | 0.4 mi | ★★★★★ | 9 | 0 |
| Desert Cove Nursing Center | 0.8 mi | ★★★★★ | 18 | 0 |
| River Park Post Acute | 3.7 mi | ★★★★★ | 0 | 0 |
| Tempe Post Acute | 6 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.