Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Haven Of Sierra Vista, Llc during CMS and state inspections, most recent first.
Surveyors identified that the facility failed to ensure its low-temp dish machine consistently reached required sanitizing temperatures and that staff accurately monitored and reported those temperatures. Review of temperature logs and direct observations showed recorded wash/rinse temperatures of 120°F did not match actual readings around 100°F, and prior log entries documented substandard temperatures without being reported to supervisors. Dietary staff admitted to recording inaccurate temperatures, pre-filling logs, and not notifying management when readings were below the required range, despite facility policy requiring monitoring, accurate documentation, and prompt reporting of dish machine issues.
Multiple cognitively intact residents reported receiving cold and unappetizing meals, a finding confirmed by direct temperature checks of food items during meal service, which were often below the facility's preferred standard. Staff interviews revealed inconsistent understanding of safe food temperatures, and observations showed that food sometimes became cold before reaching residents. The facility's own policy required hot foods to be served at 120 degrees or more, but this standard was not consistently met.
A staff member diverted medications belonging to two residents, including a controlled substance prescribed for pain management and an oral antihyperglycemic agent. Security footage showed the staff member removing medication and documentation from the medication cart, ingesting a pill, and failing to follow required procedures for medication counts and documentation. Nursing staff confirmed that these actions violated facility policy regarding controlled substances.
The facility failed to document a resident's nutritional intake, risking unmonitored nutritional deficiencies. Despite interventions, documentation for the resident's cereal intake was missing or marked as not applicable on multiple occasions, as confirmed by staff interviews and task sheet reviews.
The facility failed to maintain a sanitary kitchen environment due to peeling paint over the tray line counter. The issue was known for over six months, but no action was taken despite a work order being placed. The Executive Director admitted to not noticing the problem previously, and a review of the work order log did not show any requests for repair.
A facility failed to ensure accurate completion of PASRR Level I and Level II assessments for a resident with multiple mental health diagnoses, leading to a lack of proper care. The PASRR Level I Screening Tool was inadequately filled out, and no subsequent PASRR was conducted despite new diagnoses. Staff interviews confirmed the deficiency, and the facility's policy on PASRR was not followed.
The facility failed to ensure a resident received necessary services to maintain good bathing and grooming hygiene. The resident, who requires assistance for personal hygiene, had not been shaven for 3 to 4 days and had not received a shower for approximately three weeks, contrary to the facility's policy of two showers per week.
A resident with multiple diagnoses reported not being invited to activities and being unaware of what activities were offered. The Activities Manager did not track or document resident participation, and the resident could not see the activities calendar from his bed or get out of bed without assistance. The facility's policy to provide activity schedules individually to residents who cannot access the bulletin board was not followed.
The facility failed to ensure that the QAA committee collected and monitored data for performance improvement. Despite meeting quarterly and collecting data from various sources, the facility could not provide evidence of data tracking for PIPs related to call-light response and showers. This lack of documentation was identified as a deficiency.
The facility failed to provide evidence that three newly hired therapists received training on resident rights. Personnel file reviews and interviews confirmed the absence of documentation or sign-in sheets for the required training.
The facility failed to provide evidence that a physical therapist hired in June 2023 received the required dementia training. Personnel file review and staff interviews confirmed the absence of documentation for the training, despite the facility's policy mandating participation in initial orientation and in-service training classes.
Failure to Maintain and Accurately Monitor Dish Machine Sanitizing Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure the dishwashing machine operated at appropriate temperatures in accordance with manufacturer instructions and facility policy, resulting in food ware not being properly sanitized. During an initial kitchen observation, surveyors reviewed the dish machine temperature log and noted an entry for a wash and rinse temperature of 120°F with 100 PPM, initialed by a dietary aide. Later that morning, direct observation and temperature checks of the dish machine with a cook showed temperatures of 106°F and then 101°F using a temperature puck, which did not match the recorded log entry. The cook stated that the log entry must be incorrect because the aide who supposedly recorded it had not yet started her shift at the time indicated. Further interviews revealed that the dish machine was a low-temperature unit requiring a wash/rinse range of 120–150°F, and that staff were expected to stop the machine and notify the dietary manager and maintenance if temperatures were out of range. Review of the temperature log with the dietary manager showed a recorded temperature of 117°F on a prior day, below the required 120°F, and the manager reported she had not been notified of this low reading. The facility’s written policy stated that dishwashing staff must monitor and record dish machine temperatures at each meal to assure proper sanitizing, that the food director would spot check logs for accuracy, and that staff would be trained to report dish machine issues as soon as they occur. Interviews with dietary aides confirmed inaccurate documentation and failure to report low temperatures. One aide stated that when she checked the dish machine temperature on one day, it was a little under 120°F but she recorded 120°F on the log so that staff would not be upset, and she also admitted to pre-filling the log sheet for the following day. She reported that the dish machine temperatures had been inconsistent since the previous kitchen manager left and that she did not inform the current manager, only some co-workers. Another aide reported recording a temperature of 117°F on a separate day and acknowledged that she did not notify anyone, despite knowing the temperature should have been 120°F or more. Staff interviewed acknowledged that improper dishwashing and unsanitary dishes could expose residents to germs and bacteria and lead to foodborne illness.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that resident meals were served at appropriate and safe temperatures, as evidenced by multiple resident interviews and direct observations. Several cognitively intact residents reported that their food was consistently cold, unidentifiable, or unappetizing in temperature, texture, and flavor. These concerns were substantiated by temperature checks conducted during meal service, which revealed that hot foods such as roast beef, mashed potatoes, sausage patties, and biscuits were served below the facility's preferred standard of 120 degrees for palatability, with some items measured as low as 96 degrees. Staff interviews revealed a lack of consistent knowledge regarding safe food temperatures. One cook believed that food on the steam table needed to be at least 145 degrees, but was unsure of the required temperature at the point of service to residents. Another staff member stated that food should be maintained at 135 degrees on the steamer, but that palatability depended on resident preference. Both staff acknowledged that food sometimes became cold before reaching residents, and that residents could request a new tray if dissatisfied with the temperature. Review of the facility's in-room dining policy indicated a preference for hot foods to be served at 120 degrees or more for palatability, with procedures for checking temperatures at the point of service and offering meal substitutions if concerns were raised. Despite these policies, observations and interviews demonstrated that the facility did not consistently meet its own standards for food temperature, resulting in residents receiving meals that were not at safe or appetizing temperatures.
Medication Diversion by Staff Member
Penalty
Summary
The facility failed to protect the medications of two residents from diversion by a staff member, resulting in a deficiency. One resident, admitted with malignant neoplasm of the vulva, rheumatoid arthritis, and chronic pain syndrome, was receiving hospice care and had an order for Oxycodone to be administered as needed for pain. Another resident, admitted with acute kidney failure, type 2 diabetes, and essential tremor, had an order for Metformin to be administered twice daily. Both residents were cognitively intact according to their BIMS scores. The incident was discovered when a staff member noticed that the controlled substance sheet and the bottle of Oxycodone for the first resident were missing from the medication cart. A review of security footage revealed that a staff member was observed counting medications alone at the narcotic cart, removing a bottle with a red top (indicating a narcotic), and subsequently taking the bottle down the hallway and returning without it. The same staff member was also seen taking the narcotic sheet and placing it in his backpack, as well as taking a pill from a bottle and ingesting it. The staff member later admitted, via text message, to taking another resident's Metformin as well. Interviews with nursing staff confirmed that controlled medications are to be counted by both the oncoming and outgoing nurses together, and that taking medications not intended for administration is inappropriate and constitutes diversion. The facility's policy on controlled substances requires that discrepancies be reported to the Director of Nursing and that counts be reconciled at the end of each shift by two nurses. The staff member involved was observed acting alone, removing medication and documentation, and ingesting a controlled substance, all in violation of facility policy and procedure.
Failure to Document Nutritional Intake
Penalty
Summary
The facility failed to ensure adequate documentation of a resident's nutritional intake, which could result in unmonitored nutritional deficiencies. Resident #40, who was admitted with diagnoses including unspecified protein-calorie malnutrition and iron deficiency, had a care plan indicating a risk for nutritional and hydration problems. Despite interventions such as fortified cereal and Med Pass nutritional shakes, documentation for the resident's cereal intake was missing or marked as not applicable on multiple occasions. This lack of documentation was confirmed through staff interviews and a review of the task sheets, revealing that the resident's nutritional intake was not consistently monitored or recorded. Interviews with a CNA and an RN indicated that the percentage of food intake should be documented for every meal, and any refusal to eat should be reported. However, the CNA admitted that the resident's cereal intake might not have been documented if the cereal was not sent to the resident. The RN and the Director of Nursing acknowledged the missing documentation and the incorrect use of 'not applicable' on the task sheets. The facility's policy requires nursing staff to assess and document food and fluid intake for residents at risk for nutritional problems, but this was not adhered to in the case of Resident #40.
Sanitary Kitchen Deficiency Due to Peeling Paint
Penalty
Summary
The facility failed to ensure a sanitary kitchen environment due to peeling paint over the tray line counter. During an observation on December 6, 2023, peeling ceiling paint was noticed above the tray line counter, spanning the length of three vents. The Nutrition Services Manager acknowledged the issue, stating that it had been known for over six months and that a work order had been placed but not addressed. The Executive Director admitted to not noticing the issue previously and confirmed that the peeling paint had been present for months. The facility's policies on sanitation and maintenance require that the food service area be maintained in a clean and sanitary manner and that the building be kept in good repair and free from hazards. However, a review of the TELS work order log from May 1, 2023, to December 5, 2023, did not reveal any work order requests regarding the peeling ceiling paint in the kitchen. This oversight could potentially lead to food contamination, as acknowledged by the Nutrition Services Manager.
Failure to Complete Accurate PASRR Assessments
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I was completed accurately and a Level II was sent to the state for determination for a resident. The resident was initially admitted with diagnoses including acute stress reaction and suicidal ideations and had multiple care plans indicating the use of psychotropic medications for conditions such as schizoaffective disorder, depression, and anxiety. However, the PASRR Level I Screening Tool dated March 9, 2021, was inadequately filled out, with several sections left blank, including those related to mental illness, psychiatric treatment history, and psychotropic medications. No subsequent PASRR Level I was found in the resident's clinical record after the initial one dated March 9, 2021, despite new diagnoses that should have triggered a new PASRR assessment. Interviews with staff confirmed that the PASRR process was not followed correctly, and the most recent PASRR for the resident was outdated and incomplete. The facility's policy on PASRR was also reviewed, which indicated that updated screenings should be conducted within 14 days after a significant change in the resident's condition. However, this policy was not adhered to in the case of the resident, leading to a failure in identifying and providing necessary specialized services. The Director of Nursing acknowledged the deficiency and stated that a new PASRR should have been completed for the resident. The facility's policy emphasized the importance of conducting PASRR screenings to identify serious mental illness or intellectual disability and making referrals for Level II evaluations when necessary. However, the facility did not follow this policy, resulting in a lack of proper care for the resident. The report highlights the need for accurate and timely PASRR assessments to ensure that residents receive appropriate care and services for their mental health conditions.
Failure to Maintain Resident's Bathing and Grooming Hygiene
Penalty
Summary
The facility failed to ensure that Resident #23 received the necessary services to maintain good bathing and grooming hygiene. Resident #23, who has diagnoses including Parkinson's Disease, unspecified dementia, and major depressive disorder, requires one-person physical assistance for personal hygiene. Observations and interviews revealed that the resident had not been shaven for 3 to 4 days, despite expressing a preference for being clean-shaven. The resident's personal razor was reportedly unavailable, and facility razors were not used due to concerns about causing 'nicks.' Additionally, the resident's last documented shower was on November 15, 2023, which did not meet the facility's expectation of two showers per week. Interviews with staff confirmed that personal hygiene tasks such as shaving are generally completed twice a week during showers and as needed. However, the last documented shower for Resident #23 was approximately three weeks ago. The facility's ADL policy and bath/shower policy require appropriate care and services for residents unable to carry out ADLs independently, including bathing and grooming. The failure to provide these services as per the facility's policies and the resident's needs led to the deficiency noted in the report.
Failure to Ensure Resident Access to Activities
Penalty
Summary
The facility failed to ensure that a resident had access to activities, which could impact the psychosocial well-being of residents. Resident #40, who was admitted with multiple diagnoses including a displaced intertrochanteric fracture of the left femur, chronic obstructive pulmonary disease, dependence on oxygen, major depressive disorder, and an anxiety disorder, reported not being invited to activities and being unaware of what activities were being offered. The activities care plan indicated that the resident enjoyed watching TV and looking outside the window, but the resident's bed was not near the window, and there was no documentation of activities attended or refused by the resident. Interviews with the Activities Manager revealed that she did not track or document resident participation in activities, despite being trained to do so. The Executive Director confirmed that he did not require the Activities Manager to track resident participation. The resident also mentioned that he could not get out of bed by himself and needed assistance to attend activities, and he could not see the activities calendar from his bed. The facility's policy stated that activity schedules should be provided individually to residents who cannot access the bulletin board, but this was not done for Resident #40.
Failure to Track and Document Data for Performance Improvement Plans
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee collected data and monitored its performance regarding adverse events for performance improvement. During an interview with the administrator and the director of nursing, it was revealed that the QAA committee meets at least quarterly and collects data from various sources, including audits and feedback from staff and residents. However, the facility was unable to provide evidence of data tracking for two performance improvement plans (PIPs) related to call-light response and showers, despite claiming these were ongoing and completed PIPs, respectively. The administrator acknowledged that both analysis and graphing of data are expected for any PIP and that failure to track and document data could result in unresolved issues. A review of the facility's Quality Assurance and Performance Improvement (QAPI) Meeting policy indicated that the purpose of QAPI is to establish data-driven, facility-wide processes to improve the quality of care. Despite this, there was no evidence of data trend tracking for the identified PIPs. This lack of documentation and data tracking was identified as a deficiency, as it hinders the facility's ability to effectively monitor and improve its performance regarding adverse events.
Lack of Resident Rights Training for New Staff
Penalty
Summary
The facility failed to provide evidence that three staff members, a physical therapist, an occupational therapist, and a speech therapist, hired on June 1, 2023, received training on resident rights. Personnel file reviews revealed no documentation of such training for these staff members. Interviews with the human resources staff and a certified occupational therapy assistant/Area Manager confirmed the absence of sign-in sheets or other evidence of training attendance. The facility's policy mandates that all personnel participate in initial orientation and regularly scheduled in-service training classes, including training on resident rights.
Lack of Dementia Training for Physical Therapist
Penalty
Summary
The facility failed to provide evidence that a physical therapist, hired on June 1, 2023, received dementia training as required by the facility's policy. This deficiency was identified through a review of the personnel file, which lacked documentation of the required training. Interviews with the human resources staff and a certified occupational therapy assistant confirmed that there was no sign-in sheet or other evidence to show that the physical therapist attended dementia training. The facility's Staff Development Program policy mandates that all personnel participate in initial orientation and regularly scheduled in-service training classes, but it did not include dementia training as a topic.
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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 Sierra Vista
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Sierra Vista | 0.7 mi | — | 14 | 0 |
| Quiburi Mission Nursing & Rehabilitation | 27.3 mi | — | 8 | 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.