Havasu Nursing Center: Ombudsman Notification Failures - AZ
Inspectors arrived at the facility on September 4, 2025, responding to a complaint. What they found was a gap that stretched across at least three months: June, July, and August of 2025. During that period, residents had signed themselves out against their doctors' wishes, and the state's designated advocate for nursing home residents had not been told.
The ombudsman program exists specifically for moments like these. When a resident walks out against medical advice, they are, by definition, leaving a care setting their physician believes they still need. The ombudsman is meant to be a check on that process, an outside set of eyes to ensure the resident understood their options and wasn't leaving because of something the facility failed to provide.
Havasu Nursing Center's own policy, revised as recently as March 2025, lays out what a discharge against medical advice is supposed to look like. A separate policy on transfers and discharges states that residents have the right to remain in the facility, and that any transfer or discharge requires notification, orientation, and documentation in the medical record. The ombudsman notification is part of that chain.
At 1:47 in the afternoon on September 4, inspectors submitted a written request to the facility asking for documentation of ombudsman notifications for the three-month period. At 4:00 that same afternoon, they sat down with the administrator, identified in the report as Staff #23, and the Director of Nursing.
The administrator explained how the system was supposed to work. Social services was responsible for notifying the ombudsman of all resident discharges, including those against medical advice. When a resident left AMA, staff would try to understand why, make sure the resident was safe, and notify all responsible parties. That was the process.
Then he acknowledged there was no documentation that it had actually happened.
The social worker had left without warning. Administration had split her duties across staff members. The administrator said he had taken on the ombudsman notification responsibility himself. He could not produce a single record showing he had followed through.
One resident's departure is documented in the inspection report. Resident #6 signed an Against Medical Advice Discharge Form on August 14, 2025. The form carries two signatures: the resident's and that of a Licensed Practical Nurse identified as Staff #62. There is no corresponding record of the ombudsman being contacted.
The violation was cited at the minimal harm level, meaning inspectors did not find evidence that residents were physically injured as a direct result of the lapse. But the harm a missed ombudsman notification causes is harder to see than a fall or a medication error. It is the absence of something: a phone call that wasn't made, an advocate who never knew to show up, a resident who left a nursing home in August without anyone outside the building checking to see if they needed help.
The inspector's request for three months of ombudsman records went unanswered because there were no records to provide.
The administrator knew the obligation was his. He said so. He just hadn't met it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Havasu Nursing Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 24, 2026 · Our methodology
Havasu Nursing Center in LAKE HAVASU CITY, AZ was cited for violations during a health inspection on September 4, 2025.
Inspectors arrived at the facility on September 4, 2025, responding to a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.