Havasu Nursing Center

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Meet other general requirements that are deficient.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Emergency Preparedness Deficiencies

Develop a communication plan.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Based on clinical record review, staff and family interviews, and facility documents and policy, the facility failed to ensure a resident's privacy was maintained during medication administration for one resident (resident #27). This deficient practice could result in further violations of resident privacy. Findings include: An observation was made on April 9, 2025 at 07:51 a.m. Licensed Practical Nurse (LPN) Staff #23 prepared medications for Resident #27. Staff #23 stepped away from the medication cart and went into Resident #27's room and gave the medications, however the computer screen was not closed or locked, displaying Resident #27's name, date of birth and medications. Staff #23 came back to screen and utilized the computer then turned around and went back into Resident #27's room again. The screen still had resident #27's name up with the screen unlocked. At 7:58 a.m. Staff #23 came back to the cart and was shown the screen and asked what could happen if the computer was left unlocked and unattended? Staff #23 stated somebody could come and mess with it. An interview was conducted on April 10, 2025 at 10:49 a.m. with Director of Nursing (DON) Staff #27 and revealed that the process for the medication pass and screen access is to either minimize or close the screen from any resident information display. Staff #27 state that if the screen was already left unlocked someone could see something that is HIPPAA (Health Insurance Portability and Accountability Act) protected. Asked how important is it to lock the screens and Staff #27 stated that it is absolutely important, everybody knows how important it is to protect the information. A review of the Resident Rights policy (revised February 2021), revealed that the Policy Statement reads: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: section t. Privacy and confidentiality. A review of the HIPAA Training Program policy (revision date April 2007) revealed that under the Policy Interpretation and Implementation part 1. To ensure the confidentiality of out resident's protected health information (PHI) and facility information, a HIPAA and data security training program will be provided for all employees and business associates who have access to protected health and facility information.

Based on observations, clinical record review, staff interviews and policies and procedures, the facility failed to ensure that a centered care plan with interventions was developed for one resident (#15) with oxygen orders. The deficient practice could result in a care plan that is not person centered. Findings include: Resident #15 was admitted on September 20, 2022, with diagnosis included hemiplegia and hemiparesis, Type 2 diabetes mellitus, hypothyroidism, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated February 11, 2025 revealed a Brief interview Mental Status (BIMS) of 08 which indicated the resident was cognitively impaired. Review of Initial Care plan dated September 20, 2022 revealed no focus area for oxygen. A review of the documented physician order revealed oxygen at 2 liter via nasal cannula to keep oxygen levels at 90 or above with start date of March 24, 2025. Review of a health status provider note dated March 30, 2025 revealed a verbalized understanding and discussed patient decline and use of oxygen as patient is needing the oxygen to keep oxygen saturations above 90%. A physician order dated April 10, 2025 revealed that resident #15 was on continuous supplemental oxygen at 2 liter per minute, via nasal cannula to maintain oxygen saturation above 90%. However, review of the compressive care plan revealed no focused area for oxygen. An interview was conducted on April 09, 2025 at 08:48AM with Certified Nurse Assistant (CNA/staff #18), who stated that staff know who is on oxygen through the nursing reports or when the resident is admitted. Staff #18 stated that the nursing report will provide information regarding how many liters as well as which machine is used for a resident. Staff #18 stated that she was aware of resident #15 being on oxygen. Staff #18 stated that the CNA, Registered nurse, social workers, and resident coordinators help in creating the care plans for the residents. The oxygen should be care planned for the resident; and that, the risks is that their oxygen saturation can drop. An interview was conducted on April 09, 2025 at 10:24AM with Licensed Practical Nurse (LPN/Staff #23), who described the facility process for oxygen administration who stated that it was importantant that oxygen is properly connected and resident is getting adequate amounts of oxygen liter. Staff #23 stated that resident #15 had been declining and was on oxygen at 2 liters and her oxygen saturations are monitored throughout the day. Staff #23 stated that the oxygen is care planned, but was unable to locate it on care plan. She confirmed that it should have been care planned. Staff #23 stated the MDS coordinator does the care planning; but that, all staff assigned to the resident are responsible for it. An interview was conducted on April 09, 2025 at 10:38AM with Minimum Data Set (MDS) Coordinator (Staff #43), who confirmed that she participates in the care planning and reviews doctors ' orders then creates car

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that the care plan was revised after each fall for one (#94) of four sampled residents. The deficient practice could result in resident not getting the individualized care that they need. Findings include: Resident #94 was admitted to the facility on March 26, 2025 with diagnoses that included type 2 diabetes mellitus, muscle weakness, unsteady on feet, abnormality of gait and mobility. An admission fall risk evaluation dated March 27, 2025 revealed that the resident had a history of 1-2 falls in the last 3 months. Further review of fall risk evaluation revealed that the resident was alert and oriented x 3. A care plan initiated on March 28, 2025 revealed that the resident had the high risk for falls. Interventions included to anticipate needs; ensure call light is within reach when in room; to participate in activities that promote exercise, physical activity for strengthening and improved mobility and ensure use of non-skid socks when ambulating or mobilizing in wheelchair. Further review of care plan revealed that the resident needed assistance with activity of daily living (ADL) tasks. An admission Minimum Data Set (MDS) assessment dated April 2, 2025 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident is cognitively intact. Further review of the MDS dated April 2, 2025, revealed that the resident had two falls in the last six months prior to admission. A progress note dated April 7, 2025 revealed that the resident was observed by staff sitting on floor next to her bed. According to the note the resident stated that she lost her balance, slid to floor and denied any head injuries. Doctor and family were notified. However, there was no evidence in the clinical record that the care plan had been revised regarding the fall on April 7, 2025; and that, a fall incident report had been initiated. A progress note dated April 8, 2025 revealed that Resident #94 was observed by the nurse lying on the floor in her room in front of the bathroom door. The note indicated that the resident had green/purple bruising on her right ankle/foot. The progress further revealed that the resident had a pain level of eight out of ten and was sent to emergency room (ER) for evaluation and treatment. A progress note dated April 8, 2025 at 2:59 p.m. by Licensed Practical Nurse (LPN/ staff # 13) regarding post fall revealed that the resident had an acute facture of the right 4th rib with 1-2-millimeter (mm) displacement with mild swelling around rib and the doctor and family were notified. A fall incident report dated April 8, 2025, revealed that the resident sustained a fall with contributing factors listed as wet floor, weakness/fainted, ambulating without assistance. The fall incident report revealed resident mental status as oriented to place. No other information was provided in this report. Further, review of the c

Based on observation, clinical record review, interview, and review of policy and procedures the facility failed to ensure Enhanced Barrier Protection (EBP) was in place for seven residents (#2, #19, #20, #343, #36, #195, #94) according to professional standards. This deficient practice could result in the increased risk of pathogen transmission. Findings include: -Resident #2 was admitted to the facility on January 1, 2025 with diagnoses that include Pyothorax without fistula and a breakdown (mechanical) of nephrostomy catheter among others. The MDS revealed the resident's BIMS score of 14 and also urinary incontinence and indwelling catheter care. The clinical record revealed a doctor's order for a nephrostomy tube output three times a day. -Resident #36 was admitted on March 3, 2025 with diagnosis including acute respiratory failure with hypoxia with a peripherally inserted central catheter (PICC line LUE location). -Resident #19 was admitted on January 01, 2025 with diagnosis of chronic obstructive pulmonary disease. This resident has a Physician order for Foley catheter care on January 1, 2025. There is no order for EBP measures, however, there was a Physician order to use the facility skin and wound protocol if indicated. -Resident #195 was admitted on April 4, 2025 with primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. The resident has a G- tube site cleansing order and a daily tracheostomy care ordered by the Physician on April 05, 2025. -Resident #343 was admitted on April 08, 2025 with a primary diagnosis of unspecified severe protein-calorie malnutrition. This resident also has a Foley catheter care and maintenance order by the Physician on April 9, 2025. -Resident #94 was admitted on March 26, 2025 with a primary diagnosis of pneumonia with plans to use long term use of antibiotics. The resident has a PICC line on her right upper extremity (RUE) with a weekly dressing order from the Physician on March 29, 2025. -Resident #20 was admitted on November 05, 2024 with a primary diagnosis of urinary tract infection. The resident is currently wearing a Foley catheter with a catheter care order placed on February 20, 2025. However, the Care Plan failed to reflect on Physician's order for EBP protocol and interventions for the seven residents (#2, #19, #20, #343, #36, #195, #94). There is also no evidence of any interdisciplinary communications to provide this vital universal precaution measure to protect the spread of infections within the facility; including signage outside resident's room visibly posted. An observation was conducted on April 10, 2025 at 2:00 p.m. It was observed that there was no signage identifying the residents' need for EBP. In addition, each of the residents that qualified for EBP did not have personal protective equipment readily accessible for staff use. Documentation failed to mention that any of the identified residents refused care plan regarding infect

Based on clinical record review, staff and family interviews, and facility documents and policy, the facility failed to ensure a resident's privacy was maintained during medication administration for one resident (resident #27). Findings include: An observation was made on April 9, 2025 at 07:51 a.m. Licensed Practical Nurse (LPN) Staff #23 prepared medications for Resident #27. Staff #23 stepped away from the medication cart and went into Resident #27's room and gave the medications, however the computer screen was not closed or locked, displaying Resident #27's name, date of birth and medications. Staff #23 came back to screen and utilized the computer then turned around and went back into Resident #27's room again. The screen still had resident #27's name up with the screen unlocked. At 7:58 a.m. Staff #23 came back to the cart and was shown the screen and asked what could happen if the computer was left unlocked and unattended? Staff #23 stated somebody could come and mess with it. An interview was conducted on April 10, 2025 at 10:49 a.m. with Director of Nursing (DON) Staff #27 and revealed that the process for the medication pass and screen access is to either minimize or close the screen from any resident information display. Staff #27 state that if the screen was already left unlocked someone could see something that is HIPPAA (Health Insurance Portability and Accountability Act) protected. Asked how important is it to lock the screens and Staff #27 stated that it is absolutely important, everybody knows how important it is to protect the information. A review of the Resident Rights policy (revised February 2021), revealed that the Policy Statement reads: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: section t. Privacy and confidentiality. A review of the HIPAA Training Program policy (revision date April 2007) revealed that under the Policy Interpretation and Implementation part 1. To ensure the confidentiality of out resident's protected health information (PHI) and facility information, a HIPAA and data security training program will be provided for all employees and business associates who have access to protected health and facility information.

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that the care plan was revised after each fall for one (#94) of four sampled residents. Findings include: Resident #94 was admitted to the facility on March 26, 2025 with diagnoses that included type 2 diabetes mellitus, muscle weakness, unsteady on feet, abnormality of gait and mobility. An admission fall risk evaluation dated March 27, 2025 revealed that the resident had a history of 1-2 falls in the last 3 months. Further review of fall risk evaluation revealed that the resident was alert and oriented x 3. A care plan initiated on March 28, 2025 revealed that the resident had the high risk for falls. Interventions included to anticipate needs; ensure call light is within reach when in room; to participate in activities that promote exercise, physical activity for strengthening and improved mobility and ensure use of non-skid socks when ambulating or mobilizing in wheelchair. Further review of care plan revealed that the resident needed assistance with activity of daily living (ADL) tasks. An admission Minimum Data Set (MDS) assessment dated April 2, 2025 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident is cognitively intact. Further review of the MDS dated April 2, 2025, revealed that the resident had two falls in the last six months prior to admission. A progress note dated April 7, 2025 revealed that the resident was observed by staff sitting on floor next to her bed. According to the note the resident stated that she lost her balance, slid to floor and denied any head injuries. Doctor and family were notified. However, there was no evidence in the clinical record that the care plan had been revised regarding the fall on April 7, 2025; and that, a fall incident report had been initiated. A progress note dated April 8, 2025 revealed that Resident #94 was observed by the nurse lying on the floor in her room in front of the bathroom door. The note indicated that the resident had green/purple bruising on her right ankle/foot. The progress further revealed that the resident had a pain level of eight out of ten and was sent to emergency room (ER) for evaluation and treatment. A progress note dated April 8, 2025 at 2:59 p.m. by Licensed Practical Nurse (LPN/ staff # 13) regarding post fall revealed that the resident had an acute facture of the right 4th rib with 1-2-millimeter (mm) displacement with mild swelling around rib and the doctor and family were notified. A fall incident report dated April 8, 2025, revealed that the resident sustained a fall with contributing factors listed as wet floor, weakness/fainted, ambulating without assistance. The fall incident report revealed resident mental status as oriented to place. No other information was provided in this report. Further, review of the care plan revealed no evidence that the care plan had been revised regarding the fall on April 8, 202

Based on observations, clinical record review, staff interviews and policies and procedures, the facility failed to ensure that a centered care plan with interventions was developed for one resident (#15) with oxygen orders. Findings include: Resident #15 was admitted on September 20, 2022, with diagnosis included hemiplegia and hemiparesis, Type 2 diabetes mellitus, hypothyroidism, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated February 11, 2025 revealed a Brief interview Mental Status (BIMS) of 08 which indicated the resident was cognitively impaired. Review of Initial Care plan dated September 20, 2022 revealed no focus area for oxygen. A review of the documented physician order revealed oxygen at 2 liter via nasal cannula to keep oxygen levels at 90 or above with start date of March 24, 2025. Review of a health status provider note dated March 30, 2025 revealed a verbalized understanding and discussed patient decline and use of oxygen as patient is needing the oxygen to keep oxygen saturations above 90%. A physician order dated April 10, 2025 revealed that resident #15 was on continuous supplemental oxygen at 2 liter per minute, via nasal cannula to maintain oxygen saturation above 90%. However, review of the compressive care plan revealed no focused area for oxygen. An interview was conducted on April 09, 2025 at 08:48AM with Certified Nurse Assistant (CNA/staff #18), who stated that staff know who is on oxygen through the nursing reports or when the resident is admitted. Staff #18 stated that the nursing report will provide information regarding how many liters as well as which machine is used for a resident. Staff #18 stated that she was aware of resident #15 being on oxygen. Staff #18 stated that the CNA, Registered nurse, social workers, and resident coordinators help in creating the care plans for the residents. The oxygen should be care planned for the resident; and that, the risks is that their oxygen saturation can drop. An interview was conducted on April 09, 2025 at 10:24AM with Licensed Practical Nurse (LPN/Staff #23), who described the facility process for oxygen administration who stated that it was importantant that oxygen is properly connected and resident is getting adequate amounts of oxygen liter. Staff #23 stated that resident #15 had been declining and was on oxygen at 2 liters and her oxygen saturations are monitored throughout the day. Staff #23 stated that the oxygen is care planned, but was unable to locate it on care plan. She confirmed that it should have been care planned. Staff #23 stated the MDS coordinator does the care planning; but that, all staff assigned to the resident are responsible for it. An interview was conducted on April 09, 2025 at 10:38AM with Minimum Data Set (MDS) Coordinator (Staff #43), who confirmed that she participates in the care planning and reviews doctors ' orders then creates care plans. Staff #43 stated that if doctor had oxygen order she would add it to th

Based on observation, clinical record review, interview, and review of policy and procedures the facility failed to ensure Enhanced Barrier Protection (EBP) was in place for seven residents (#2, #19, #20, #343, #36, #195, #94) according to professional standards. Findings include: -Resident #2 was admitted to the facility on January 1, 2025 with diagnoses that include Pyothorax without fistula and a breakdown (mechanical) of nephrostomy catheter among others. The MDS revealed the resident's BIMS score of 14 and also urinary incontinence and indwelling catheter care. The clinical record revealed a doctor's order for a nephrostomy tube output three times a day. -Resident #36 was admitted on March 3, 2025 with diagnosis including acute respiratory failure with hypoxia with a peripherally inserted central catheter (PICC line LUE location). -Resident #19 was admitted on January 01, 2025 with diagnosis of chronic obstructive pulmonary disease. This resident has a Physician order for Foley catheter care on January 1, 2025. There is no order for EBP measures, however, there was a Physician order to use the facility skin and wound protocol if indicated. -Resident #195 was admitted on April 4, 2025 with primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. The resident has a G- tube site cleansing order and a daily tracheostomy care ordered by the Physician on April 05, 2025. -Resident #343 was admitted on April 08, 2025 with a primary diagnosis of unspecified severe protein-calorie malnutrition. This resident also has a Foley catheter care and maintenance order by the Physician on April 9, 2025. -Resident #94 was admitted on March 26, 2025 with a primary diagnosis of pneumonia with plans to use long term use of antibiotics. The resident has a PICC line on her right upper extremity (RUE) with a weekly dressing order from the Physician on March 29, 2025. -Resident #20 was admitted on November 05, 2024 with a primary diagnosis of urinary tract infection. The resident is currently wearing a Foley catheter with a catheter care order placed on February 20, 2025. However, the Care Plan failed to reflect on Physician's order for EBP protocol and interventions for the seven residents (#2, #19, #20, #343, #36, #195, #94). There is also no evidence of any interdisciplinary communications to provide this vital universal precaution measure to protect the spread of infections within the facility; including signage outside resident's room visibly posted. An observation was conducted on April 10, 2025 at 2:00 p.m. It was observed that there was no signage identifying the residents' need for EBP. In addition, each of the residents that qualified for EBP did not have personal protective equipment readily accessible for staff use. Documentation failed to mention that any of the identified residents refused care plan regarding infection control. An interview with a CNA staff #32 conducted on April 10, 2025 regarding