Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Havasu Nursing Center during CMS and state inspections, most recent first.
The facility did not provide required notifications to the State Long-Term Care Ombudsman for three residents who were discharged, including those who left AMA. Despite documentation of the discharges and completion of AMA forms, there was no evidence that the Ombudsman was notified, as required by facility policy. Administrative staff confirmed the omission following the departure of social services personnel.
The facility did not implement Enhanced Barrier Precautions (EBP) for several residents with indwelling medical devices or wounds, as required by facility policy and professional standards. Care plans lacked EBP protocols, there was no interdisciplinary communication or signage to alert staff, and personal protective equipment was not readily available. Staff interviews revealed inconsistent understanding of EBP requirements, and the DON confirmed that EBP was not applied as outlined in policy.
An LPN failed to lock or minimize a computer screen displaying a resident's personal and medical information during medication administration, leaving the screen unattended and visible on the medication cart. This action was inconsistent with facility policy and HIPAA training, which require staff to protect resident privacy and confidentiality.
A resident with cognitive impairment and multiple chronic conditions was prescribed continuous supplemental oxygen, but the facility failed to include oxygen therapy in the resident's care plan. Staff interviews and record reviews confirmed the omission, despite facility policy requiring care plans to address such needs.
A resident with a history of falls and multiple health conditions experienced two unwitnessed falls, one resulting in a fractured rib and ER transfer. Although staff initiated new interventions such as frequent monitoring and requiring staff assistance for transfers, these changes were not documented or updated in the care plan as required by facility policy. Interviews with staff and review of facility policies confirmed that the care plan was not revised after the falls.
The facility failed to protect residents' property, resulting in the misappropriation of $110 from the petty cash box. Despite an internal investigation and the termination of the Receptionist, the incident was not reported to the appropriate agencies as required by policy.
The facility failed to ensure residents' property was not misappropriated. A resident's petty cash box was found missing $110.00, and despite an internal investigation and the termination of the responsible staff member, the incident was not reported to the applicable agencies as required by policy and regulations.
The facility failed to prevent the misappropriation of a resident's property, resulting in $110.00 missing from the petty cash box. An internal investigation was conducted, but no staff were placed on leave, and the incident was not reported to the applicable agencies as required by policy.
A resident with depressive episodes, diabetes, and hypertension exhibited inappropriate behaviors such as smearing feces and being argumentative. Despite these behaviors being documented, the psychiatric reassessment did not address them, and the PASRR was incomplete. The facility's policy on behavior monitoring was not followed, leading to inadequate mental health care for the resident.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure that required transfer and discharge notifications were made to the Office of the State Long-Term Care Ombudsman for three residents who were discharged, including those who left against medical advice (AMA). Closed record review and staff interviews revealed that, although the facility's policy required notification of the Ombudsman for all resident discharges, there was no documentation that such notifications occurred for these cases. The residents involved had significant medical needs, including severe cognitive impairment, recent orthopedic surgeries, and conditions such as hemiplegia, acute kidney failure, and mobility issues. In each case, the discharge process was documented in the residents' records, including AMA forms and progress notes, but the required notification to the Ombudsman was not completed. Interviews with facility administration confirmed that social services staff, who were responsible for Ombudsman notifications, had left their positions without notice, resulting in administrative staff dividing these responsibilities. Despite this, the administrator acknowledged that there was no documentation to show that the Ombudsman had been notified of the AMA discharges. Facility policy review further confirmed the requirement for such notifications, but the lack of compliance was evident in the records reviewed.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices and Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for seven residents who had conditions or medical devices that, according to facility policy and professional standards, required such precautions. These residents included individuals with nephrostomy tubes, PICC lines, Foley catheters, G-tubes, tracheostomies, and chronic wounds. Despite physician orders for care related to these devices, the care plans did not reflect the need for EBP protocols or interventions. There was also no evidence of interdisciplinary communication to ensure EBP measures were in place, and no signage was posted outside the rooms of affected residents to alert staff to the need for EBP. Personal protective equipment was not readily accessible for staff use in these cases, and documentation did not indicate any resident refusals regarding infection control care plans. Observations and staff interviews revealed inconsistent understanding and implementation of EBP protocols. Some staff reported following EBP procedures only when signage was present, while others relied on verbal instructions from nursing staff. The DON/Infection Preventionist stated that EBP was only applied to residents with active multidrug-resistant organisms (MDROs), despite the facility's policy requiring EBP for all residents with certain indwelling devices or wounds, regardless of MDRO status. The DON acknowledged a lack of signage and EBP implementation for residents who met the criteria, confirming that the current practice did not align with federal guidelines or facility policy.
Failure to Secure Resident Information During Medication Administration
Penalty
Summary
A deficiency occurred when an LPN prepared and administered medications to a resident but failed to secure the computer screen displaying the resident's personal and medical information. During the medication pass, the LPN left the computer screen unlocked and unattended on the medication cart, with the resident's name, date of birth, and medication details visible. This was observed while the LPN was inside the resident's room administering medications, and the screen remained accessible and visible until the LPN returned several minutes later. Interviews with staff, including the Director of Nursing, confirmed that facility policy requires screens displaying resident information to be minimized or closed when unattended to protect privacy and confidentiality. The facility's policies and HIPAA training program emphasize the importance of safeguarding protected health information (PHI), but the observed actions did not align with these requirements, resulting in a failure to maintain the resident's privacy during medication administration.
Failure to Care Plan Oxygen Therapy for Resident
Penalty
Summary
The facility failed to develop and implement a person-centered care plan with measurable interventions for a resident who had physician orders for supplemental oxygen. Despite the resident having multiple diagnoses, including hemiplegia, Type 2 diabetes, hypothyroidism, and anxiety disorder, and being cognitively impaired as indicated by a BIMS score of 08, the care plan did not include a focus area or interventions related to oxygen therapy. Physician orders documented the need for continuous supplemental oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 90%, but this was not reflected in the resident's comprehensive care plan. Interviews with facility staff, including a CNA, LPN, MDS Coordinator, and DON, confirmed that oxygen therapy should have been included in the care plan. Staff were aware of the resident's oxygen use through nursing reports and physician orders, but the omission in the care plan was acknowledged by the MDS Coordinator and LPN, who were unable to locate any oxygen-related interventions in the care plan. Facility policies reviewed also indicated that care plans should address special needs such as oxygen administration, but this was not done for the resident in question.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan for a resident after each fall, as required by policy and procedure. The resident, who had a history of falls, was admitted with diagnoses including type 2 diabetes mellitus, muscle weakness, unsteady gait, and abnormal mobility. Upon admission, the resident was assessed as high risk for falls, and a care plan was developed with interventions such as anticipating needs, ensuring the call light was within reach, promoting physical activity, and using non-skid socks. The resident was cognitively intact and required assistance with activities of daily living. Despite these interventions, the resident experienced two unwitnessed falls on consecutive days. The first fall resulted in the resident being found on the floor next to her bed, with no injuries reported. The second fall occurred the following day, resulting in significant injuries, including a fractured rib and bruising, and required transfer to the emergency room. Occupational therapy noted increased confusion and impaired safety awareness after the second fall, recommending that the resident use a wheelchair and call for staff assistance for all transfers. Interviews with staff confirmed that interventions such as frequent monitoring and education on using the call light were initiated after the falls. However, these new interventions were not documented or updated in the resident's care plan. The Director of Nursing acknowledged that the care plan was not revised after the falls, contrary to facility policy, which requires care plans to be updated as residents' conditions change. Review of facility policies confirmed that each fall should be followed by an update to the plan of care with new interventions.
Failure to Protect Resident Property from Misappropriation
Penalty
Summary
The facility failed to ensure residents' property was not misappropriated, as evidenced by the disappearance of $110 from the residents' petty cash box. The incident occurred between April 1, 2023, and April 14, 2023, and was discovered on March 31, 2023. The individuals with access to the petty cash were the Office Manager, Accounts Receivable, and the Receptionist. An internal investigation was conducted, which included reviewing account logs and interviewing the staff with access to the funds. However, no staff members were placed on leave during the investigation, and no additional audits were conducted to ensure other funds were not missing. The investigation concluded with the termination of the Receptionist, who admitted to improper accounting practices, but the incident was not reported to the applicable agencies as required by facility policy and state and federal regulations. The facility's policy on abuse prevention defines misappropriation of resident property and outlines the steps to be taken when such incidents occur, including suspending suspected staff members and reporting the incident immediately to the appropriate authorities. Despite this, the Administrator chose to report the incident only to the regional operations consultant and did not follow the policy's requirements. Interviews with the Office Manager and Accounts Receivable confirmed their access to the funds and their involvement in the investigation, but neither was placed on leave. The missing funds were never recovered, and the incident was not reported to local law enforcement as required for items valued at $25 or more.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that residents' property was not misappropriated. On March 31, 2023, the facility became aware that a resident's petty cash box was missing $110.00, with the money disappearing between April 1, 2023, and April 14, 2023. The Administrator (Staff #38) confirmed that an internal investigation was conducted, which included reviewing account logs and interviewing staff with access to the funds. However, no staff members were placed on leave during the investigation, and no additional audits were conducted to check for other missing funds. Staff #100 admitted to improper accounting during an interview on April 19, 2023, and was subsequently terminated. Despite this, the incident was not reported to the applicable agencies as required by facility policy and state and federal regulations. Staff #38 admitted to only reporting the incident to his regional operations consultant, despite being familiar with the reporting requirements. Staff #63, who discovered the missing funds, confirmed that the only individuals with access to the petty cash were herself, Staff #32, and Staff #100. She stated that handling the funds was not a regular task for her and that she only did it when other staff members were unavailable. During the investigation, it was determined through a process of elimination that Staff #100 was responsible for the missing money. The facility's policy on abuse prevention, revised in September 2021, defines misappropriation of resident property and outlines the steps to be taken when such incidents occur, including placing suspected individuals on suspension and reporting the incident immediately to local authorities if the value exceeds $25.00. These steps were not followed in this case, leading to the deficiency.
Failure to Prevent Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that residents' property was not misappropriated. On March 31, 2023, the facility discovered that $110.00 was missing from the residents' petty cash box. The money went missing between April 1, 2023, and April 14, 2023. The Administrator (Staff #38) confirmed that only the Office Manager (Staff #63), Accounts Receivable (Staff #32), and the Receptionist at the time (Staff #100) had access to the funds. An internal investigation was conducted, including reviewing account logs and interviewing the staff with access to the funds. However, no individuals were placed on leave pending the investigation, and no additional audit was conducted to ensure other money was not missing. Staff #100 admitted to improper accounting during an interview on April 19, 2023, and was immediately terminated. The incident was not reported to the applicable agencies as required by facility policy and state and federal regulations. Staff #63, who discovered the missing funds, stated that the facility keeps $300.00 in petty cash for residents who need cash, and the funds are reconciled from the residents' accounts. She confirmed that she was interviewed by Staff #38 but was not placed on leave pending the investigation. The facility's policy on Abuse Prevention Program defines misappropriation of resident property and outlines the procedures for investigating and reporting such incidents. Despite this, the Administrator chose to report the incident only to his regional operations consultant and did not follow the policy's requirements for reporting to local authorities or suspending the accused individuals during the investigation.
Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident diagnosed with depressive episodes, type 2 diabetes, and hypertension. The resident exhibited behaviors such as talking loudly and being argumentative with staff, smearing feces on the curtain, bed, and himself, and refusing assistance with cleaning. Despite these behaviors being documented in nursing notes and care conference notes, the psychiatric reassessment did not address these issues. Interviews with staff revealed that the resident's inappropriate behaviors were known but not adequately managed or referred for an updated PASRR Level II assessment. The Director of Nursing confirmed that the PASRR was incomplete and did not address the resident's scatolia behaviors or other relevant symptoms. The facility's policy on behavior monitoring under the Abuse Prevention program stated that appropriate treatment and services should be provided to residents displaying mental or psychological adjustment difficulties. However, the psych provider notes did not indicate that the resident's behaviors were informed or reviewed, leading to a failure in addressing the resident's mental health needs adequately.
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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 Lake Havasu City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Haven Of Lake Havasu | 1.8 mi | — | 1 | 0 |
| Havasu Regional Medical Center | 4.9 mi | — | 0 | 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.