Haven of Lake Havasu

Inspectors wroteBased on clinical record reviews, staff and resident interviews, review of facility documentation, and review of policy and procedures, the facility failed to protect the rights of two residents (#1 and #2) to be free from physical abuse by another resident. The sample size was 4. The deficient practice could result in the resident being in an unsafe environment. Findings Include: -Regarding Resident #1 Resident #1 was admitted on [DATE] with a diagnoses that included attention and concentration deficit, dysphagia, acute respiratory failure, muscle weakness, abnormalities of gait and mobility, and symbolic dysfunctions. A quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 05, indicating severe cognitive impairment. [...]

Inspectors wroteBased on clinical record review, facility documentation, and staff interviews, the facility failed to ensure two residents (#36 and #40) were provided adequate supervision to prevent resident abuse. The deficient practice could result in residents being at risk for abuse.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that two residents (#9, #228) were adequately supervised in order to prevent accidental falls; and, failed to ensure items in the environment that could be utilized unsafely were stored away from one resident (#31). The deficient practice resulted in two residents being physically harmed.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure advance directives were completed and maintained for one resident (#31). The deficient practice could result in residents not receiving proper care according to their preferences or potential harm to the resident's life.

Inspectors wrote-Resident #25 was admitted to the facility on [DATE], with diagnoses that include acute and chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure. The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview Mental Status (BIMS) 15 which indicated the resident was cognitively intact. A review of the documented Self Medication Evaluation revealed, that a self-administration evaluation was conducted on January 7, 2025 at 4:00 pm. The resident #25 wanted to self-administer medications. A review of physician orders included the self-administering of medications: [...]

Inspectors wroteBased on record review, resident and staff interviews and observations, the facility failed to ensure proper nail care for one resident (#31) was performed. This deficient practice could result in resident grooming and hygiene needs not being met.

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to ensure that medications were not left at the bedside for two resident. (#25, #283). The facility census was 85 and the sample was 3 residents. The deficient practice could result in harm to the residents, staff and/or visitors who have access to medications.

Inspectors wroteBased on observations, interviews, and review of policy, the facility failed to ensure food was stored in accordance with appropriate guidelines. The facility census was 85. The deficient practice could increase the risk for foodborne illness.

Inspectors wroteBased on observation, staff interviews, and policy and procedures, the facility failed to ensure that refuse was disposed of appropriately. The deficient practice could result in an unsanitary condition and the harborage of pests and insects.

Inspectors wroteBased on clinical record review, interviews, review of policies, the facility failed to ensure resident # 1 did not sustain repeated fall accident and injury. This may result in residents sustaining injuries due to repeated falls.

Inspectors wroteBased on clinical record reviews, staff interviews, and policy review, the facility failed to ensure one resident (#135) was free from self-harm following an encounter of self-reported suicidal ideation. The deficient practice could result in further neglect, harm or possible death of residents.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure discharge planning included developing a discharge care plan for one sampled resident (#80). The deficient practice resulted in an ineffective transition to post-discharge care, and increases the risk factors leading to preventable readmission.

Inspectors wroteBased on record review, interviews and facility documentation and policy, the facility failed to ensure one resident (#1) was free from abuse from a staff member. The deficient practice could lead to further abuse of residents.

Inspectors wroteBased on documention, staff interviews, and the facility policy and procedures, the facility failed to provide supervision as directed by the nursing board for one staff (#33). The deficient practice could result in residents being physically and/or emotionally harmed.

Inspectors wroteBased on clinical review, staff interviews, and facility policy and procedures, the facility failed to ensure that medication administration for one resident (#18) met professional standards of practice, failed to ensure physicians orders for one resident (#8) were complete and failed to notify the physician of a change in condition (#65). The deficient practice could result in residents not receiving care that meets professional standards.

Inspectors wroteBased on clinical record, staff interviews, and the facility policy and procedures, the facility failed to assist one resident (#60) with repositioning. The deficient practice could result in a skin breakdown.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to provide an ongoing program of activities designated to meet the needs of one resident (#18). The deficient practice could impact the psychosocial needs of the residents.

Inspectors wroteReview of the employee file, staff interviews, and the policy and procedures revealed that the facility failed to ensure staff #57 had the educational requirements and experience for the position of Activity Manager. The deficient practice could result in activity assessments and the implementation of an appropriate activity program not being met for residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#46) was provided pain management services consistent with professional standards of practice. The deficient practice could result in unmanaged pain for residents. The census was 58, the sample was 16 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to revise the comprehensive care plan to include assessed goals and needs for one resident (#8). The deficient practice has the potential to cause resident's specific nutritional care needs not being met.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure the necessary treatment and services were provided for one resident (#65) as ordered by the physician regarding daily weights, and notficiation of changes in condition. The facility census was 58, and the sample was 16 residents. The deficient practice could result in the physician not being aware of changes in condition.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure a registered nurse was scheduled for 8 consecutive hours on September 18, 2022. The deficient practice could impact the quality of care provided to residents.

Inspectors wroteBased on clinical record review, staff interviews, review of policies and procedures, the facility failed to ensure one resident (#20) consistently received care and services to assess, treat, and identify pressure ulcers. The sample size was 2. The deficient practice could result in delayed identification of pressure ulcers and worsening of pressure ulcers.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure the resident environment remained free of accident hazards for three residents (#15, #24, and #17), by failing to ensure safe water temperatures were maintained. The deficient practice could result in residents sustaining burns related to hot water temperatures.

Inspectors wroteBased on clinical record reviews, staff interviews, policy review, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of two residents (#8 and #20). The sample size was 18 residents. The deficient practice could result in assessments not being accurate and in data that is not accurate for quality monitoring.

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure that professional standards were followed for one resident (#20) by not following the physician order regarding blood sugars. The sample size was 5. The deficient practice could result in an adverse outcome to residents.

Inspectors wroteBased on resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that one sampled resident (#18) was assisted with making a vision appointment. The deficient practice could result in decreased vision abilities.