Life Care Center of Sierra Vista

Inspectors wroteBased on clinical record reviews, facility documentation, resident, family, and staff interviews, and facility's policy review, the facility failed to protect the rights of one resident (Resident #10) to be free from abuse by another resident (#25). This deficient practice could place residents at risk for resident-to-resident abuse and potential physical harm.

Inspectors wroteBased on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to protect the resident's (#1) rights to be free from misappropriation from staff. This deficient practice could result in further incidents of staff to resident financial abuse.

Inspectors wroteBased on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the resident's (#100) rights to be free from abuse by another resident (#200). This deficient practice could result in further incidents of resident to resident abuse.

Inspectors wroteBased on a review of the clinical record, staff and resident interviews, and facility policy, the facility failed to ensure the resident's personal privacy and confidentiality of their medical records. The deficient practice could result in the exposure of personal/private medical information. Findings Include:An observation was conducted on September 09, 2025, at 4:18 AM, where medication Cart # 2 was left unattended with an unlocked computer displaying Residents' # 8,14,2,10,6,4, and 12 medical information. Licensed Practical Nurse (LPN/Staff #33) went to medication cart # 2 after coming out of a resident room. Resident # 8 was admitted to the facility on [DATE], with diagnoses of chronic kidney disease, dementia, and anxiety. Resident # 14 was re-admitted to the facility on [DATE], with diagnoses of anxiety disorder, muscle weakness, and acute respiratory failure with hypoxia. [...]

Inspectors wroteBased on observation, interviews, and review of facility policy and procedure, the facility failed to ensure medications including controlled substances were stored according to regulation and facility policy. The deficient practice could lead to residents gaining access to medications.

Inspectors wroteBased on observations, staff interviews, facility documentation, and a review of policies and procedures, the facility failed to ensure that food items in the freezer were properly labeled and dated. This deficient practice had the potential to result in food contamination, which could cause illness or food poisoning among residents. Findings Include:On September 7, 2025, at 10:15 a.m., during an initial walk-through visit with [NAME] #27, who was present on behalf of the kitchen manager (Staff #42), a partially full plastic bag of broccoli without a label or date, was observed sitting on a shelf inside the freezer. An interview was conducted immediately following the observation, on September 7, 2025, at 10:20 a.m., with [NAME] #27. [...]

Inspectors wroteBased on clinical record, staff interviews, review of facility documentation, policy and procedures and the State Agency (SA) database the facility failed to implement their policy regarding conducting thorough investigation of abuse/neglect allegation, protecting residents from further abuse for one resident (#46), and reporting allegations of abuse. The deficient practice could result in abuse/neglect continuing and not being prevented.

Inspectors wroteBased on closed record review, staff interviews, review of facility documentation, policy and procedures, the facility failed to report allegations of exploitation for one resident (#46) within the required timeframe. The deficient practice in abuse allegations not being reported and further abuse continuing.

Inspectors wroteBased on clinical records, review of facility documentation, review of the State Agency (SA) database, staff interviews, and review of policy and procedure the facility failed to ensure an allegation of exploitation (resident #46) was fully investigated. The deficient practice could result in allegations of abuse to include exploitation not being investigated and abuse/exploitation occurring in the facility.

Inspectors wroteBased on record review, staff interviews, review of facility documents and policy, the facility failed to ensure one resident (#43) was referred for Level II Pre-admission Screening and Resident Review (PASRR). The deficient practice could result in residents not receiving appropriate services to meet their needs. Findings Include:Resident #43 was initially admitted to the facility on [DATE] with diagnoses that included paraplegia, Paranoid Schizophrenia and Schizophrenia Disorder. A review of record dated September 25, 2023 revealed a Level 1 PASRR (Pre-admission Screening and Resident Review) was completed, but no referral for any Level II.The care plan initiated on October 5, 2023 revealed that Resident uses antipsychotic medications related to Schizophrenia as evidence by auditory hallucinations. [...]

Inspectors wroteBased on record review, staff interviews, review of facility documents and policy, the facility failed to ensure medications for one resident (#38) were administered as ordered by the physician. The deficient practice could place residents' safety at risk and could result in resident's not receiving the treatment that they need. Findings Include:Resident #38 was admitted to the facility on [DATE] with an active diagnoses that included Heart Failure, Hypertension, and Orthostatic Hypotension. A review of admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental status score of 12.0, moderately impaired. A review of physician's order dated August 22, 2025 revealed an order for Isosorbide Mononitrate ER (Extended Release) oral tablet 30 mg (milligram) give 0.5 tablet by mouth one time a day related to atherosclerotic heart disease. [...]

Inspectors wroteBased on observation, record review, staff interviews, review of facility documents and policy, the facility failed to ensure hand hygiene was performed during medication administration observation and the facility failed to sanitize a glucometer after use. The deficient practice could place residents at risk for infections. Findings Include:Resident #26 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Urinary Tract Infection (UTI), and Diabetes Mellitus (DM). A review of orders revealed the following physician orders:- Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Milliliter) inject 10 unit subcutaneously one time a day related to Type 2 Diabetes Mellitus; and- Insulin Lispro Injection Solution 100 UNIT/ML inject 4 unit subcutaneously before meals related to Type 2 Diabetes Mellitus. [...]

Inspectors wroteBased on clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications were available as ordered for one resident (#100). The deficient practice could result in not receiving medications that are physician ordered and necessary.

Inspectors wroteBased on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident was free from preventable accidents including elopement. This deficient practice could result in preventable injuries as a result of elopement.

Inspectors wroteBased on clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications were available as ordered for one resident (#100). The deficient practice could result in not receiving medications that are physician ordered and necessary.

Inspectors wroteBased on clinical record review, interview, and a complaint submitted via the State Agency's (SA) online complaint portal, the facility failed to ensure that resident #1's Power of Attorney (POA) was notified of the resident's hospitalization. The deficient practice prevented the POA from being informed of the resident's care and change in condition.

Inspectors wroteBased on clinical record review, interview, and a complaint submitted via the State Agency's (SA) online complaint portal, the facility failed to ensure that resident #1's electronic health record (EHR) contained accurate information about the resident's condition including changes in their condition. The deficient practice could prevent the resident from obtaining accurate services based on their medical condition.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to protect the rights of one resident (#2) from sexual abuse by a visitor. The deficient practice resulted in the resident being sexually abused.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure abuse policies and procedures were implemented to protect the rights of one resident (#2) from sexual abuse by a visitor. The deficient practice could result in appropriate action not taken and further abuse of the resident.

Inspectors wroteBased on clinical record review, interviews, facility documentation and policy review, the facility failed to ensure medications were administered as ordered for one resident (#1). The deficient practice could result in resident not receiving treatment for their assessed needs.

Inspectors wroteBased on clinical record review, staff interviews, review of facility documentation, facility policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure there was a physician order for a narcotic medication that was administered to one resident (#2). The deficient practice could result in residents receiving unnecessary medication.

Inspectors wroteBased on record review, staff interviews, facility records and facility policy, the facility failed to ensure medications were not misappropriated for 3 residents (#5, #31, #64). This deficient practice resulted in the administration of unprescribed medications.

Inspectors wrote-resident #119 was admitted on [DATE] through 10/5/23 with diagnoses of cognitive communication deficit, and generalized muscle weakness. A care plan dated 9/20/23 included ADL assistance and therapy services to maintain or attain highest level of function and included interventions of assisting with mobility and ADL's as needed. Review of the task documentation survey report for September, 2023 included that the resident was to receive bathing on Tuesdays and Friday evening shift. However, this report included that the resident was not provided showers on 3 of 4 opportunities. An interview was conducted on 12/21/23 at 1:50 PM with a Certified Nursing Assistant (CNA/staff #10) who said that when she first gets here in the morning the computer will show a list of showers, and they will say what shift they are for. She said that CNA's only document in the computer. [...]

Inspectors wroteBased on resident and staff interviews, observations, review of the clinical record, and policy and procedure, the facility failed to ensure one resident (#24) was provided an appropriately sized wheelchair and bed to accommodate the resident's needs. The deficient practice may result in lack of accommodation for residents' needs.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy, the facility failed to ensure one sampled resident (#28) received a Level II Pre-admission Screening and Resident Review (PASRR) after remaining in the facility for longer than 40 days. The deficient practice increases the risk for residents being inappropriately placed into nursing facilities and/or not receiving the services they need.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to provide consistent restorative nursing services according to the physician order for one resident (#218). The sample size was 4. The deficient practice could decrease residents' ability to carry out the activities of daily living.

Inspectors wroteBased on resident and staff interviews, clinical record review, and review of policy, the facility failed to ensure that one resident (#28) who was unable to carry out activities of daily living (ADLs) was provided services to maintain good hygiene. The sample size was 6. The deficient practice could result in residents with unmet hygiene needs.

Inspectors wroteBased on clinical record review, staff interview, and review of policy and procedures, the facility failed to ensure one sampled resident (#46) received treatment and care, consistent with professional standards of practice. The deficient practice increases the risk for rehospitalizations.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy and procedures, the facility failed to review, assess and implement interventions after falls occurred for two residents (#266 and #116). The sample size was 4. The deficient practice could result in an increased number of falls and injuries.