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Health Inspection Summary

Haven of Sierra Vista, LLC

660 South Coronado Drive

Sierra Vista, AZ 85635

(520) 459-4900

Deficiency Category	Inspection Date: 12/8/23 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 9/8/22 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 5/6/21 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	2	0	0
Quality of Life and Care Deficiencies	3	3	4
Infection Control Deficiencies	0	0	2
Resident Assessment and Care Planning Deficiencies	2	1	0
Nursing and Physician Services Deficiencies	0	0	1
Resident Rights Deficiencies	1	0	2
Nutrition and Dietary Deficiencies	1	0	0
Pharmacy Service Deficiencies	0	0	0
Environmental Deficiencies	0	0	1
Administration Deficiencies	1	0	0

Detailed result for inspection on 12/8/23

Date of last standard health inspection:	12/8/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	No complaint inspections
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	10
Average number of Health Deficiencies in Arizona:	6.3
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	12/8/23	2/19/24	2 - Minimal harm or potential for actual harm	Few
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.	12/8/23	2/19/24	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	12/8/23	2/19/24	2 - Minimal harm or potential for actual harm	Few
Provide care and assistance to perform activities of daily living for any resident who is unable.	12/8/23	2/19/24	2 - Minimal harm or potential for actual harm	Few
Provide activities to meet all resident's needs.	12/8/23	2/19/24	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure services provided by the nursing facility meet professional standards of quality.	12/8/23	2/19/24	2 - Minimal harm or potential for actual harm	Some
PASARR screening for Mental disorders or Intellectual Disabilities	12/8/23	2/19/24	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.	12/8/23	2/19/24	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	12/8/23	2/19/24	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	12/8/23	2/19/24	2 - Minimal harm or potential for actual harm	Few

Detailed result for inspection on 9/8/22

Date of last standard health inspection:	9/8/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	12/8/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	4
Average number of Health Deficiencies in Arizona:	7
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide safe and appropriate respiratory care for a resident when needed.	9/8/22	11/1/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	9/8/22	11/1/22	2 - Minimal harm or potential for actual harm	Few
Assist a resident in gaining access to vision and hearing services.	9/8/22	11/1/22	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
PASARR screening for Mental disorders or Intellectual Disabilities	9/8/22	11/1/22	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 5/6/21

Date of last standard health inspection:	5/6/21Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	No complaint inspections
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	10
Average number of Health Deficiencies in Arizona:	8.1
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide care and assistance to perform activities of daily living for any resident who is unable.	5/6/21	7/2/21	2 - Minimal harm or potential for actual harm	Some
Provide safe and appropriate respiratory care for a resident when needed.	5/6/21	7/2/21	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	5/6/21	7/2/21	2 - Minimal harm or potential for actual harm	Some
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.	5/6/21	7/2/21	2 - Minimal harm or potential for actual harm	Some

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	5/6/21	7/2/21	2 - Minimal harm or potential for actual harm	Few
Develop and implement policies and procedures for flu and pneumonia vaccinations.	5/6/21	7/2/21	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	5/6/21	7/2/21	2 - Minimal harm or potential for actual harm	Some

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.	5/6/21	7/2/21	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	5/6/21	7/2/21	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.	5/6/21	7/2/21	2 - Minimal harm or potential for actual harm	Some

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	12/8/23	2/19/24	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	12/8/23	2/19/24	2 - Minimal harm or potential for actual harm	Few

Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.

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