Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Sierra Vista during CMS and state inspections, most recent first.
Failure to Protect Resident from Resident-to-Resident Abuse: A resident with no cognitive impairment threatened to kill his roommate over TV volume, then later tried to strike the roommate with a detached wheelchair leg. Staff intervened, but the resident fell from his wheelchair and the other resident pushed the leg away, causing a head wound and skin tear to the aggressive resident. The DON stated the aggressive resident had psychiatric issues and that no behavioral interventions were documented in the care plan.
A resident with multiple cardiac conditions and intact cognition discovered unauthorized charges on a credit card after discharge, totaling about $900 for personal items. Law enforcement obtained video showing a woman in scrubs making the purchases, and facility leadership identified her as a CNA employed there. Staff interviews confirmed awareness that an employee had taken a resident’s credit card and used it at a local store, describing this as financial abuse. The facility had a policy addressing abuse, exploitation, and misappropriation of resident property, yet the resident’s card was misused by staff, resulting in financial misappropriation.
A resident with severe cognitive impairment and a history of unpredictable, sometimes aggressive behavior physically assaulted another cognitively impaired resident in a hallway. Staff were present but not close enough to prevent the incident, resulting in the victim sustaining a busted lip and bruising. The care plan for the perpetrator did not include interventions specific to preventing resident-to-resident aggression, and the facility's abuse prevention measures were insufficient to protect the victim.
Unattended unlocked medication cart exposed resident medical information. An LPN left a med cart with an unlocked computer displaying multiple residents’ records, including medical history, DOB, and medications. Staff and the DON stated computers should be locked or logged out, and the facility policy states residents have a right to secure and confidential personal and medical records.
Unlocked Medication Cart and Improper Storage of Medications: An observation found an unlocked medication cart behind the nurse's station with mixed medications, loose unidentified pills, and medications labeled for residents who were no longer in the facility. An LPN identified several unsecured medications in the cart, and the DON identified a benzodiazepine in the separately locked drawer, stating it required double locking. Staff also noted the cart should be kept locked when unattended.
Unlabeled Frozen Food Item: A partially full bag of broccoli was found in the freezer without a label or date. A kitchen staff member and the kitchen manager confirmed that opened food items should be labeled with the date opened and stored properly, and the facility policy required food items to be dated and labeled when stored.
A resident with multiple medical conditions was suspected of being financially exploited by a frequent visitor. Although the concern was reported to another agency and the visitor was restricted from entry, facility staff did not document an internal investigation or submit a required report to the State Agency, contrary to facility policy. Several staff members were unaware of the incident, and no incident report or investigation was found.
A resident with mild cognitive impairment was suspected of being financially exploited by a frequent visitor, but the facility did not report the allegation to the State Agency as required. Staff interviews indicated a lack of awareness about the incident, and no incident report or investigation documentation was provided, despite facility policy mandating immediate reporting and investigation of such allegations.
A facility did not investigate an allegation of exploitation involving a resident, despite receiving a report from another agency and having a policy requiring thorough investigation of such incidents. Staff interviews confirmed no investigation was conducted, and no documentation or self-report was submitted to the State Agency.
A resident with paraplegia and schizophrenia had a Level I PASRR completed, but no documented Level II referral was found despite antipsychotic use, auditory hallucinations, and a diagnosis of schizophrenia/schizoaffective disorder. The SSD stated the resident had not had inpatient psych treatment in the past 2 years, and facility policy stated a positive Level I screen requires a Level II evaluation.
Medication Given Despite BP Hold Parameter An LPN administered isosorbide to a resident with heart failure, HTN, and orthostatic hypotension even though the MAR and physician order required the dose to be held for SBP less than 110 or HR less than 60. The resident’s BP was 106/66 before the dose was given, and staff interviews showed confusion about the order’s hold parameters.
Hand hygiene was not performed at the expected times during medication administration observation, and a glucometer was not sanitized after use. An LPN checked a resident’s blood sugar and administered insulin, then later performed hand hygiene only after leaving the room with the resident’s water pitcher. The LPN stated she normally cleans the glucometer but did not have the usual wipe available. Interviews with the IP, ADON, DON, and another LPN confirmed the facility expectation to perform hand hygiene before and after resident care and to clean and disinfect glucometers between resident uses.
A resident with sepsis and other medical conditions did not receive prescribed IV Ceftriaxone as ordered, with only one dose administered during their stay. Nursing staff failed to fax the order to the pharmacy, resulting in the medication not being delivered or given, despite the drug being present in the facility. Documentation showed missed doses and lack of communication with the physician or pharmacy about the unavailability, and the resident was later transferred to the hospital with worsening symptoms.
A resident with severe cognitive impairment and a history of exit-seeking behavior eloped from the facility twice due to inadequate supervision and unsecured, unalarmed exits. Despite being identified as an elopement risk and requiring additional supervision, the resident was able to leave through both the front and back doors, with staff only responding after the resident had exited. Staff interviews confirmed that doors and gates were found unlocked and alarms were disabled at the time of the incidents.
A resident with multiple complex medical conditions did not receive prescribed IV Ceftriaxone as ordered, despite the medication being available in the facility. Nursing staff and the DON confirmed that the required process of faxing IV medication orders to the pharmacy was not completed, resulting in the resident receiving only one dose during their stay.
A resident with severe cognitive impairment was hospitalized after a fall resulting in a hip fracture, but the POA was not notified by facility staff. Interviews and record reviews confirmed that while staff notified the DON and physician, they failed to inform the resident's representative, and there was no documentation of the incident or notifications in the EHR, contrary to facility policy.
A resident with severe cognitive impairment experienced a fall that resulted in hospitalization and a hip fracture, but the event and change in condition were not documented in the EHR by nursing staff. Interviews with CNAs, an LPN, and the DON confirmed the fall occurred and should have been recorded, but no progress note or incident report was found, despite facility policy requiring such documentation.
A resident with severe cognitive impairment and a history of abuse was not adequately protected from sexual abuse by a family member/POA during a visit. Despite a care plan requiring supervised visits, the family member was not supervised, leading to an incident of sexual assault. The facility's policies on abuse prevention and visitor management were not effectively implemented, resulting in the resident's exposure to harm.
A resident with cognitive impairment and a history of abuse was left unsupervised with a family member, contrary to the care plan requiring supervision. This led to a reported sexual assault, with injuries consistent with abuse found during a hospital examination. The facility failed to enforce its abuse prevention policies, allowing unsupervised access by the alleged perpetrator.
A resident with severe cognitive impairment was prescribed Droxidopa upon hospital discharge, but due to a transcription error, was administered Droxia instead. The error was identified after the resident received the incorrect medication six times. Interviews with staff revealed that the facility's process for entering and verifying medication orders failed to catch the discrepancy between the hospital's discharge instructions and the facility's records.
Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect Resident #10 from resident-to-resident abuse by Resident #25. Resident #25, who had diagnoses including pulmonary embolism, acute respiratory failure, heart failure, and hypertension, had a BIMS score of 15 and was documented as having no cognitive impairment. Resident #10, who had diagnoses including heart failure, atrial fibrillation, aneurysms, insomnia, depression, and hypertension, had a BIMS score of 14 and was also documented as having no cognitive impairment. The record showed that Resident #25 became upset over Resident #10's TV volume, yelled and threatened to kill his roommate, and later continued yelling at the nursing station. During the incident, a housekeeper called for help and staff found Resident #25 holding a detached wheelchair leg and trying to go after Resident #10. A CNA attempted to pull Resident #25's wheelchair back, and Resident #25 slipped out of the chair. Resident #10 pushed the wheelchair leg away, and it struck Resident #25 in the head, causing a bleeding head wound and a skin tear on his forearm. Staff interviews confirmed that Resident #25 was aggressive, had threatened to kill his roommate, and that police, emergency services, and the crisis team were involved. The DON stated there were no behavioral interventions documented in the care plan and that Resident #25 had psychiatric issues and was receiving community mental health services.
Failure to Protect Resident From Financial Misappropriation by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from misappropriation of property by staff. The resident was admitted with multiple cardiac and related diagnoses, including congestive heart failure, atrial fibrillation, ventricular tachycardia, thyrotoxicosis, and pulmonary embolism, and had a BIMS score of 15, indicating no cognitive impairment. After the resident was discharged, she reported unauthorized charges on her credit card on three occasions over two days, totaling approximately $900 for items such as toys, whiskey, and anime from a local department store. A local police officer informed facility leadership that video footage showed a woman in scrubs making the purchases and requested assistance in identifying the individual. Upon review of the video, facility leadership identified the person as a CNA employed at the facility. Staff interviews confirmed awareness among staff that an employee had taken a resident’s credit card and used it at a local store, and staff characterized this conduct as financial abuse. The Executive Director reported that the police traced the receipts to this employee, and the facility’s own investigation substantiated that the staff member had misappropriated the resident’s credit card and used it for personal purchases. The facility had an existing policy on abuse, neglect, exploitation, and misappropriation of resident property, but the incident occurred despite this policy, resulting in the misappropriation of the resident’s financial property by a staff member.
Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of unpredictable and sometimes aggressive behavior physically assaulted another resident with significant cognitive impairment. The incident took place in a hallway, where the victim was moving towards the perpetrator. The victim verbally expressed concern, telling the perpetrator not to hit her, but was subsequently punched in the face twice by the other resident. Staff members were present in the area but were not within immediate reach to prevent the altercation. Clinical records and staff interviews revealed that the perpetrator had a documented history of agitation and had previously exhibited aggressive behaviors, including cursing and swinging at staff, though there was no prior documentation of physical aggression towards other residents. The care plan for the perpetrator noted severe cognitive impairment and the need for simple instructions, but did not indicate specific interventions to address the risk of resident-to-resident aggression. The victim sustained a busted lip, bruising, and increased pain, requiring a physician assessment and medication adjustment. Facility documentation and interviews confirmed that the staff responded quickly after the incident, but the initial failure to prevent the altercation resulted in physical harm to the victim. The facility's policy prohibits all forms of abuse, including resident-to-resident abuse, but the measures in place were insufficient to protect the victim from harm in this instance.
Unattended unlocked medication cart exposed resident medical information
Penalty
Summary
The facility failed to ensure resident personal privacy and the confidentiality of medical records when medication Cart #2 was observed left unattended with an unlocked computer displaying medical information for Residents #8, #14, #2, #10, #6, #4, and #12. During the observation, LPN #33 returned to the medication cart after coming out of a resident room while the screen remained open to resident information. The residents whose information was displayed had diagnoses including chronic kidney disease, dementia, anxiety, anxiety disorder, muscle weakness, acute respiratory failure with hypoxia, heart failure, bipolar disorder, type 2 diabetes, hyperlipidemia, COPD, borderline personality disorder, depression, type 1 diabetes, and other listed conditions. During interviews, LPN #33 stated the computer screen should be locked when going into a resident room and noted that anyone could click on a resident and see medical history, date of birth, and medications. A CNA stated staff receive HIPAA training and should log out of the computer rather than leave documentation that displays resident files, medical history, and medication, and another CNA stated the risk is that resident information is exposed to anyone. The DON stated staff receive HIPAA training covering privacy protection and confidentiality, and that computers should be logged out or locked; she also stated that when computers are not locked or logged out, the risk could be a breach of protected health information. The facility policy titled Social Services and Resident Rights, revised June 2022, states that the resident has a right to secure and confidential personal and medical records.
Unlocked Medication Cart and Improper Storage of Medications
Penalty
Summary
The facility failed to ensure medications, including controlled substances, were stored according to regulation and facility policy. During an observation of the hallway between the 100 and 300 hall units, an open doorway allowed access between the units, and behind the nurse's station there was a medication cart that was not locked. A bottle labeled iron tablets was on top of the cart, and no staff were observed in proximity to the nurse's station while the cart remained in view. When an LPN later came to the nurse's station, he observed that the cart was unlocked, the drawers were open, and the contents were mixed together. Inside the cart, the LPN found three loose pills in the top drawer that he could not identify, along with multiple medication bottles including ibuprofen 200 mg, acetaminophen 500 mg, and aspirin 325 mg. He also observed a bag of vancomycin 750 mg IV solution labeled for a resident who had been discharged and a bottle of prednisolone acetate 1% eye drops labeled for another resident who was no longer in the facility. In the separately locked drawer, the DON identified one white pill as alprazolam 0.25 mg, a benzodiazepine, and stated that this type of medication required double locking. The DON also stated that the medication cart was unlocked and that the iron pills were on top of the cart.
Unlabeled Frozen Food Item
Penalty
Summary
Food items in the freezer were not properly labeled and dated. During an initial walk-through on September 7, 2025, a partially full plastic bag of broccoli was observed sitting on a shelf inside the freezer without a label or date. The observation was made with a staff member present on behalf of the kitchen manager, and the staff member confirmed that opened food items should be labeled with the date they were opened and stored in either a sealed container or a zipper bag. On September 8, 2025, the kitchen manager stated that opened food items must be labeled with the date they were opened and stored in a sealed container or zip bag, and that leftovers are wrapped, labeled with the date opened and the date by which they should be used, then stored on a first-in, first-out basis. He also stated that cooking with unlabeled food items posed a risk to residents' health and confirmed that the unlabeled bag of broccoli had been discarded. The facility policy required pre-packaged food to be placed in a leak-proof, pest-proof, non-absorbent NSF-sanitary container with a tight-fitting lid and labeled with the contents and transfer date, and specified that food items must be dated when placed on the shelves in the food storage room.
Failure to Investigate and Report Alleged Financial Exploitation
Penalty
Summary
The facility failed to follow its own policies regarding the investigation and reporting of an allegation of financial exploitation involving a resident. The clinical record and staff interviews revealed that there was suspicion of financial exploitation by a frequent visitor, which was reported to another state agency. However, there was no documentation in the State Agency database that the facility itself submitted a self-report regarding the allegation. When requested, the Executive Director confirmed that there were no incident reports or investigations found related to the allegation. Multiple staff members, including an LPN, CNA, and social services staff, were either unaware of the exploitation issue or only learned of it due to non-payment concerns. The Assistant Director of Nursing recalled concerns about exploitation but noted a lack of specific details and was unsure if an investigation was conducted, especially since the alleged perpetrator was not affiliated with the facility. Facility policy requires that all suspected abuse, neglect, or exploitation be reported immediately and thoroughly investigated. Despite this, the facility did not document an investigation or submit a required report to the State Agency. The only action taken was restricting the visitor from entering the facility, as indicated by a posted notice at the reception desk. The lack of a documented investigation and failure to report the allegation as required by policy and regulation constituted the deficiency.
Failure to Timely Report Alleged Financial Exploitation
Penalty
Summary
The facility failed to report an allegation of financial exploitation involving a resident within the required timeframe. The resident, who had diagnoses including fatty liver, hypertension, and protein-calorie malnutrition, was noted to have intact memory on a recent MDS assessment and mild cognitive impairment on a care plan. An alert note documented that another state agency was contacted regarding suspicion of financial exploitation by a frequent visitor, but there was no evidence in the clinical record or the state agency database that the allegation was reported to the appropriate State Agency as required. Additionally, the resident's care plan did not address any risk for exploitation. Interviews with facility staff, including an LPN, CNA, Social Services staff, and the ADON, revealed that staff were either unaware of the specific exploitation issue or believed that all abuse allegations should be reported immediately. The Social Services Director confirmed that the concern arose due to non-payment issues and that another agency investigated the matter, with the visitor being restricted from the facility. However, the facility was unable to provide any incident report or investigation documentation related to the allegation. Facility policy requires immediate reporting and thorough investigation of abuse, neglect, or exploitation, but these procedures were not followed in this case.
Failure to Investigate Allegation of Exploitation
Penalty
Summary
The facility failed to ensure that an allegation of exploitation involving a resident was fully investigated. The incident began when a report from another state agency regarding possible exploitation of the resident was received by the State Agency. Upon review, it was found that the facility did not submit a self-report or a thorough investigation related to the allegation. When requested, the Executive Director confirmed that there were no incident or investigation records available for the case. Interviews with staff, including an LPN, CNA, Social Services staff, and the ADON, revealed that while staff understood the importance of investigating abuse and exploitation allegations, they were either unaware of the specific incident or confirmed that no investigation had been conducted. The Social Services Director noted awareness of the exploitation concern due to non-payment issues and mentioned that a friend of the resident was restricted from visiting, but no facility-led investigation was documented. The facility's policy, reviewed in November 2024, requires that all alleged violations be thoroughly investigated to prevent further abuse, neglect, exploitation, or mistreatment. Despite this, the facility did not follow its own procedures in this case, as evidenced by the lack of documentation and investigation into the reported exploitation. The failure to investigate was confirmed through staff interviews and the absence of required reports in the facility's records and the State Agency database.
PASRR Level II Referral Not Completed
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for one resident with a history of paraplegia, paranoid schizophrenia, and schizophrenia disorder. The resident was initially admitted with these diagnoses, and a Level I PASRR completed in September 2023 did not include a referral for a Level II determination. The resident’s care plan noted use of antipsychotic medications related to schizophrenia with auditory hallucinations, and an order dated February 18, 2025 showed risperidone 0.5 mg at bedtime for schizoaffective disorder and auditory hallucinations. A quarterly MDS documented the resident as cognitively intact, with schizophrenia, and using antipsychotic medications. A later Level I PASRR completed on August 1, 2025 included a check mark indicating a referral for Level II determination for mental illness only, but the Social Service Director stated that she could not find documentation showing the resident had been referred for a Level II determination to the state-designated authority. During interview, she stated that new admissions come with PASRR documents and that she reviews diagnoses to determine whether a resident qualifies for Level II review, but for this resident she stated there was no Level II referral because the resident had not received inpatient psych treatment within the past two years. Facility policy stated that a positive Level I screen necessitates an in-depth evaluation by the state-designated authority as PASARR Level II.
Medication Given Despite Hold Parameter
Penalty
Summary
The facility failed to ensure medications were administered as ordered for one resident with diagnoses including heart failure, hypertension, and orthostatic hypotension. The resident had an active physician order for Isosorbide Mononitrate ER 30 mg, 0.5 tablet by mouth daily, with instructions to hold the medication for systolic blood pressure less than 110 or heart rate less than 60. The resident’s blood pressure was documented as 106/66 with a pulse of 80 at 6:14 AM on September 8, 2025. During a medication administration observation, an LPN dispensed the isosorbide ER 30 mg tablet and administered it by mouth to the resident at 7:43 AM. The resident’s September 2025 MAR documented the medication as administered at the 8:00 AM scheduled time. Despite the documented blood pressure being below the ordered systolic parameter, the medication was given rather than held. Interviews with CNA and nursing staff described the morning workflow for obtaining vital signs and administering medications with blood pressure parameters. The LPN stated she reviewed vital signs before medication pass and identified isosorbide as a medication with parameters, but during the interview she said she believed the order was to hold only for pulse less than 60 and that the resident’s pulse was 80. The DON later stated that if staff were going off the blood pressure of 106/66, the isosorbide medication should not have been given, and that the expectation was to take the resident’s blood pressure and hold or give the medication based on the ordered parameters.
Hand Hygiene and Glucometer Disinfection Failure
Penalty
Summary
The facility failed to ensure hand hygiene was performed during medication administration observation and failed to sanitize a glucometer after use. During an observation on September 9, 2025, an LPN administered insulin to Resident #26, who had diagnoses including hypertension, UTI, and diabetes mellitus. The resident had physician orders for insulin glargine 10 units daily and insulin lispro 4 units before meals. The LPN obtained the resident’s blood sugar using a glucometer, then administered two subcutaneous insulin injections in the resident’s abdomen. After leaving the resident’s room, the LPN removed her gloves, returned the insulin pens and glucometer to the medication cart, and later re-entered the room with the resident’s water pitcher. She exited the room after giving the resident ice water and then performed hand hygiene with alcohol-based hand sanitizer. During interview, the LPN stated she normally wipes the glucometer before and after use, but did not have the purple Sani wipe at the time and did not explain the risk of not sanitizing the device. She also stated the glucometer may have been placed in her pocket or on a bedside table while she assisted the resident with water. Interviews with another LPN, the IP, the ADON, and the DON confirmed the facility expectation that hand hygiene be performed before and after resident care and that glucometers be cleaned and disinfected between resident uses. Facility documents stated that blood glucose meters should be cleaned and disinfected after use on each patient, and that if one device is used for several residents, it must be cleaned and disinfected after every use according to manufacturer instructions. The hand hygiene policy stated that associates perform hand hygiene before and after contact with residents, after removing PPE, and before performing an aseptic task.
Failure to Administer Ordered IV Antibiotic Due to Medication Unavailability and Communication Breakdown
Penalty
Summary
A resident with multiple diagnoses, including sepsis, was admitted to the facility and had a physician's order for Ceftriaxone 2GM IV daily for 12 days to treat an infection. Despite the order, the medication was not administered as prescribed, with only one dose given during the resident's stay. Clinical record review and progress notes indicated that the medication was unavailable on several occasions, and there was no evidence that the physician or pharmacy were notified about the unavailability. The medication administration record also showed missed doses, and documentation for some administrations was left blank. Interviews with nursing staff and the Director of Nursing revealed that the process for obtaining IV medications required nurses to fax orders to the pharmacy, which was not done in this case, resulting in the medication not being delivered or administered. The facility's Omnicell report showed that Ceftriaxone was present in the facility, but it was not used according to professional standards. The resident subsequently developed symptoms including a rash, grey skin color, chills, high pulse, and low blood pressure, leading to an emergent transfer to the hospital. Facility policy required medications to be administered safely and appropriately per physician's orders, which was not followed in this instance.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Unsecured Exits
Penalty
Summary
The facility failed to prevent a resident with severe cognitive impairment and a known risk for elopement from leaving the premises on two separate occasions. The resident, who had diagnoses including dementia, abdominal aortic aneurysm, diabetes mellitus type 2, and hypertension, was assessed as an elopement risk and had care plan interventions such as additional supervision and activity engagement to divert exit-seeking behavior. Despite these interventions, staff documented multiple incidents of exit-seeking behavior prior to the elopements. On the first occasion, the resident left his room, ambulated to the front lobby, and exited through the front door without staff intervention until he was already outside on the sidewalk. Staff only responded after the resident was observed outside, and there was confusion regarding the overhead page, which was not clearly identified as an elopement. On the second occasion, the resident was last seen in his wheelchair in the hallway and subsequently exited through an unlocked and unalarmed door at the back of the facility. The gate leading off the property was also found unlocked and ajar. Staff initiated a search, and the resident was eventually located at a nearby grocery store, appearing tired and wobbly. Interviews with staff confirmed that the resident was recognized as a flight risk from admission and required frequent redirection. Staff reported that doors and gates were found unlocked and alarms were disabled at the time of the second elopement. Facility policy required preparedness and supervision to prevent such incidents, but these measures were not effectively implemented, resulting in the resident's unsupervised departures from the facility.
Failure to Administer Ordered IV Antibiotic Due to Medication Ordering Process Lapse
Penalty
Summary
The facility failed to ensure that a resident received physician-ordered medication as required. The resident, who had multiple diagnoses including sepsis, COPD, asthma, anemia, endocarditis, hypothyroidism, hyperlipidemia, and hypertension, was admitted with an order for Ceftriaxone 2GM IV daily for 12 days to treat an infection. Clinical record review and the medication administration record (MAR) showed that the resident received only one dose of Ceftriaxone during their stay, despite the medication being available in the facility’s Omnicell system. Progress notes repeatedly documented that the medication was unavailable on several days, and there was no documentation of administration on other days when it was due. Interviews with nursing staff and the Director of Nursing revealed that the process for ordering IV antibiotics required nurses to fax the orders to the pharmacy, and this step was likely missed, resulting in the medication not being delivered or administered as ordered. The DON confirmed that the medication was present in the facility but was not provided to the resident as required. Facility policy states that medications are to be administered safely and appropriately per physician order, but this was not followed in this instance.
Failure to Notify POA of Resident Hospitalization After Fall
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) of the resident's hospitalization following a fall, as required by facility policy and regulatory standards. The resident, who was severely cognitively impaired with a BIMS score of 06 and diagnoses including dementia and malnutrition, experienced a change in condition that resulted in a hospital transfer for a right hip fracture. Documentation review revealed no evidence that the POA or any family member was informed of the hospitalization, and the POA only learned of the incident after being contacted by the hospital. Interviews with facility staff, including CNAs, LPNs, and the Director of Nursing (DON), confirmed that the standard procedure is to notify the resident's representative and physician in the event of a significant change in condition, such as a fall resulting in injury. However, in this case, the responsible LPN recalled notifying the DON and the physician but did not notify the POA, mistakenly believing the resident had no family. Review of the electronic health record (EHR) and incident reports found no documentation of the fall, the change in condition, or any notifications made to the POA or family. The facility's policy, revised in September 2024, requires notification of the resident's representative in the event of a change in condition or transfer. Despite this, there was a lack of documentation and communication regarding the resident's fall, injury, and subsequent hospitalization, resulting in the POA being uninformed about the resident's care and status during a critical event.
Failure to Document Resident Fall and Change in Condition in EHR
Penalty
Summary
The facility failed to ensure that a resident's electronic health record (EHR) contained accurate and complete documentation regarding a significant change in condition. The resident, who had diagnoses including dementia, malnutrition, and age-related cataract, was admitted and later assessed as being severely cognitively impaired. According to the quarterly Minimum Data Set (MDS), there were no behavioral symptoms or falls reported since the prior assessment. However, a complaint was submitted indicating that the resident was hospitalized due to a fall, and subsequent review of the resident's medical records did not reveal any documentation of a fall in April that required hospital transport. Interviews with staff members, including CNAs and an LPN, confirmed that a fall had occurred in the resident's room, resulting in the resident being sent to the hospital for further evaluation and treatment. Staff members agreed that such an event constituted a change in condition and should have been documented in the EHR. The LPN who was present at the time of the fall stated that she believed she had completed the necessary documentation, but upon review, no progress note regarding the fall could be found in the resident's record. The Director of Nursing (DON) also confirmed that there was no documentation in the EHR related to the fall or the change in the resident's condition. The DON reviewed the hospital's discharge notes, which indicated the resident had a witnessed fall and subsequent hip surgery, but found no corresponding incident report or progress note in the facility's records. The facility's own policy required timely and accurate documentation of any change in a resident's condition, which was not followed in this case.
Failure to Protect Resident from Sexual Abuse by Visitor
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a visitor, specifically a family member who was also the resident's power of attorney (POA). The resident, who had severe cognitive impairment and a history of physical and sexual abuse, was supposed to have supervised visits with the family member. However, on October 14, 2024, there was no evidence that the family member was supervised during his visit with the resident. This lack of supervision led to an incident where the resident was found to have abnormal vaginal bleeding after the visit, which was later diagnosed as consistent with sexual assault. The resident had a history of severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 03, and was known to have psychosocial well-being problems related to cognitive impairment and past abuse. Despite these vulnerabilities, the facility did not ensure that the care plan for supervised visits was followed. On the day of the incident, the resident was found to have significant vaginal bleeding during a shower, which prompted an emergency medical evaluation. The resident later reported to hospital staff that she had been sexually assaulted by the family member/POA during the visit. Interviews with facility staff revealed that the family member/POA was not consistently supervised during visits, and there was confusion among staff about where the visits took place and whether safety precautions were in place. The facility's policy on abuse and visitor management required that residents be protected from harm and that access by alleged perpetrators be restricted during investigations. However, these policies were not effectively implemented, leading to the resident's exposure to further abuse.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its abuse policies and procedures, resulting in a resident being exposed to potential sexual abuse by a visitor. The resident, who had a history of cognitive impairment and past abuse, was supposed to have supervised visits with a family member. However, on October 14, 2024, the family member visited the resident without supervision, contrary to the care plan that required such visits to be within staff's line of sight. There was no documentation or evidence that the supervision requirement was discontinued or that the family member was supervised during the visit. On the same day, two CNAs reported abnormal vaginal bleeding in the resident, which led to a hospital examination. The resident initially denied any wrongdoing by the family member but later reported a sexual assault by the family member during a hospital examination. The examination revealed injuries consistent with sexual assault. Despite the care plan's requirement for supervised visits, staff interviews indicated a lack of awareness and enforcement of these safety precautions during the family member's visit. The facility's policy on abuse protection required the removal of access by the alleged perpetrator to the alleged victim during an investigation. However, the family member continued to have unsupervised access to the resident, which was against the facility's policy. The Director of Nursing and Executive Director were only made aware of the unsupervised visit after the incident, highlighting a failure in communication and enforcement of the facility's policies designed to protect residents from harm.
Medication Administration Error Due to Transcription Mistake
Penalty
Summary
The facility failed to ensure medications were administered as ordered for a resident, leading to a deficiency in the quality of care provided. The resident was admitted with diagnoses including encephalopathy, muscle weakness, and a cognitive communication deficit. Hospital discharge instructions included an order for Droxidopa, an anti-Parkinson agent, to be administered every 8 hours. However, the physician order in the facility's records incorrectly listed Droxia, an antimetabolite, to be administered three times a day. This error was transcribed onto the medication administration record, and Droxia was administered to the resident six times before the error was identified and the medication was discontinued. Interviews with facility staff revealed that the process for entering medication orders involved obtaining discharge orders from the hospital and entering them into the electronic health record, with a second nurse verifying the orders. Despite this process, the hospital discharge order for Droxidopa did not match the order entered in the facility's records for Droxia. The Director of Nursing confirmed that this was a transcription error and did not meet the facility's expectations. There was no evidence that the physician was notified of the error, nor was there documentation explaining why Droxidopa was not administered as ordered.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sierra Vista
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Haven Of Sierra Vista, Llc | 0.7 mi | ★★★★★ | 4 | 0 |
| Quiburi Mission Nursing & Rehabilitation | 27 mi | ★★★★★ | 8 | 0 |
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