Archstone Care Center

In the surveyor’s words

From the most serious findings on record at Archstone Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF552Mar 4, 2021

  Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#55) and/or their representative was informed of the risks and benefits of psychoactive medications prior to administration. The census was 55. The deficient practice could result in residents and/or the residents' representative not being aware of the risks and benefits of psychoactive medications. Findings include: Resident #55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 5, which indicated severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF657Mar 4, 2021

  Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#60) and the resident representative was provided the opportunity to participate in the care planning process and one resident's (#43) care plan was revised. The deficient practice could result in residents and their representatives not participating in the care planning process and care plans not being revised. Findings include: -Resident #60 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's care plan history revealed care plan meetings occurred on September 29, 2020, October 3, 2020, and December 28, 2020. […]

• No harm, potential for more than minimal, patternF880Mar 4, 2021

  Based on observation, personnel record review, staff interviews, and policy and procedures and the Centers for Disease Control and Prevention (CDC), the facility failed to ensure one staff (#12) maintained infection control standards regarding hand hygiene and one staff member (#18) had evidence of freedom from infectious [MEDICAL CONDITION] on or before the staff member began providing services. The deficient practice could result in the spread of infection. Findings include: -On March 1, 2021 at 10:58 a.m., a Certified Nursing Assistant (CNA/staff #12) was observed putting two white plastic bags on the floor by the air conditioner in a resident's room. The CNA removed her gloves and picked the bags up, one in each hand. The resident asked the CNA to lower her mobile tray. […]

• No harm, potential for more than minimal, isolatedF684Jan 16, 2026

  Based on clinical record review, staff interviews, and review of policy, revealed the facility failed to ensure one resident (#98) received the necessary care and services post fall and that one resident's (#25) durable medical equipment was applied to prevent a reduction in mobility and contracture. The deficient practice could result in residents not receiving the treatment and care, based on their assessed needs, resulting in increased contracture and reduced mobility.Findings Include: -Regarding Resident #98: Resident #98 was admitted on [DATE] with diagnosis including periprosthetic fracture around the internal prosthetic right knee join, hypertension, type 2 diabetes mellitus, chronic kidney disease, acute kidney failure, nonrheumatic mitral valve insufficiency, muscle weakness, and… […]

• No harm, potential for more than minimal, isolatedF689Jan 16, 2026

  Based on clinical record reviews, staff interviews, facility documentation, policy and procedures, the facility failed to ensure that one resident (#98) received adequate supervision and assistance to mitigate falls and to abide by professional standards regarding post fall protocol. The universe was 81 and the sample size was 22. The deficient practice could contribute to resident injuries and delay in treatment/ notifications. Findings include:Resident #98 was admitted on [DATE] with diagnosis including periprosthetic fracture around the internal prosthetic right knee join, hypertension, type 2 diabetes mellitus, chronic kidney disease, acute kidney failure, nonrheumatic mitral valve insufficiency, muscle weakness, and difficulty walking.A review of the annual MDS (minimum data set)… […]