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 Haven Of Sedona during CMS and state inspections, most recent first.
The facility failed to provide required transfer/discharge notices to residents and to send copies of those notices to the State Long-Term Care Ombudsman. Several residents with conditions such as hemiplegia after stroke, COPD, atherosclerotic heart disease, hepatic encephalopathy, and cirrhosis were discharged to home, hospice, another SNF, or an acute hospital without documentation that the ombudsman received a copy of the discharge/transfer notification. In multiple cases, discharge summaries and forms documented the discharge destination, services, and follow-up appointments, but did not include ombudsman contact information or appeal rights, and there were no physician discharge orders for some residents. Staff, including the Resident Relations Manager, Business Office Manager, and ED, reported that the NOMNC was the only form used as a discharge/transfer notice, acknowledged that it lacked ombudsman and advocacy contact information, and confirmed that they did not send copies of discharge/transfer notifications to the ombudsman, instead emailing only a monthly list of discharged or transferred residents.
A resident with hemiplegia, psychiatric diagnoses, and dependence on staff for ADLs required assistance with toileting hygiene and bathing per the care plan and MDS, which documented bilateral extremity impairment and wheelchair use. CNA task logs for bowel/bladder and toilet use contained multiple blank shifts, leaving it unclear whether toileting and hygiene care was provided or refused, despite the EHR having specific codes for refusals and unavailability. Behavior and NP notes described the resident’s verbal aggression, sexually inappropriate comments, resistance to care, shower refusals, and repeated complaints that peri care was inadequate, while a nurse documented finding the peri area clean after one such complaint. A CNA and an LPN both stated that blank entries likely reflected a failure to chart and that all ADL care should be documented, consistent with facility policies requiring provision and documentation of ADL services. Surveyors concluded that the facility failed to ensure and document necessary ADL care, specifically toileting hygiene, for this resident.
A resident with intact cognition was not given advance written notice before receiving a new roommate, contrary to facility policy. Documentation showed that only the incoming resident was notified of the change, and the existing resident learned of the new roommate's arrival at the time it occurred, resulting in distress. Staff interviews and policy review confirmed that both parties should have been notified in advance, but this was not done.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft, as observed by surveyors and confirmed through documentation review. This lack of safeguards and staff guidance placed residents at risk for harm.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with PTSD and multiple medical conditions was hit and had utensils thrown at her by another cognitively impaired resident during a meal. The incident was witnessed and reported, but there was no documentation in the perpetrator's clinical record, no provider or family notification, and no care plan update to address behavioral risks, despite facility policy requiring protection from abuse and prompt investigation.
A resident with multiple health conditions experienced a change in skin status that was observed by staff but not properly documented in the medical record. Although a CNA and RN noticed and treated a red, swollen, and open area on the resident's arm, there was no corresponding nursing assessment or description in the clinical record, and a weekly skin assessment was completed after the resident was sent to the hospital, inaccurately indicating no new issues. Facility policy requires timely and accurate documentation of such changes, which was not followed in this case.
A resident with Parkinson's disease received the wrong dosage of Carbidopa-Levodopa due to a transcription error by hospice, which was not identified until the family raised concerns. The facility's process for verifying medication orders failed to catch the discrepancy between the handwritten order and the medication bottles. The resident experienced a fall and confusion, potentially related to the incorrect dosage.
The facility failed to prevent abuse among residents with cognitive impairments, resulting in multiple altercations. A resident with mild cognitive impairment was hit by another with severe impairment, and another incident involved a resident being hit in the chest. Despite staff training and care plans, these incidents highlight a deficiency in protecting residents from abuse.
A facility failed to maintain adequate staffing levels, resulting in insufficient care for a resident with a history of a femur fracture, COPD, and anxiety disorder. On a night shift, the facility was understaffed, leading to a situation where the staff could not be as attentive as needed. The resident reported rough handling by an RN, which caused hip pain and led to hospitalization. The resident did not return to the facility.
A resident with a fracture and other conditions experienced unnecessary pain due to the facility's failure to administer pain medications as ordered. Despite having physician's orders for specific pain levels, the resident was given incorrect medication, and there was a lack of documentation and access to the necessary medication supply. The Director of Nursing acknowledged the issue, noting that staff did not follow the facility's pain management policy.
Failure to Provide Required Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required transfer/discharge notices to residents and to send copies of those notices to the Office of the State Long-Term Care Ombudsman for multiple residents. Surveyors found that the facility relied on the Notice of Medicare Non-Coverage (NOMNC) as its only discharge/transfer notice and did not use any separate form that met regulatory content requirements. The NOMNC used by the facility did not include the effective date of transfer/discharge, the location to which the resident would be transferred or discharged, the name, address, and telephone number of the State Long-Term Care Ombudsman, or contact information for protection and advocacy agencies for individuals with developmental disabilities or mental disorders. Staff interviews confirmed that the Resident Relations Manager and Business Office Manager considered the NOMNC to be the facility’s discharge/transfer notice and that they did not provide ombudsman information to residents or send copies of discharge/transfer notifications to the ombudsman. For Resident #107, who had hemiplegia and hemiparesis following cerebral infarction, systolic congestive heart failure, muscle issues, and gait and mobility abnormalities, the physician documented that the resident would transfer to another SNF at the family’s request, and a subsequent note showed the resident was discharged via transport van. The discharge MDS documented an unplanned discharge to a SNF. However, review of the clinical record revealed no evidence that a discharge notification was sent to the State Long-Term Ombudsman. The facility’s Admissions, Transfers and Discharges policy referenced reporting information in accordance with facility policy and professional standards but did not include requirements for notifying the ombudsman. For Resident #8, admitted with COPD, palliative care, and paroxysmal atrial fibrillation, the care plan included goals for pre-discharge planning. A discharge order and a discharge-transfer note/summary documented discharge home with oxygen equipment, home health services, narcotic medications, and a scheduled PCP appointment, and this summary was signed by the resident’s family. The documentation given to the family did not include the ombudsman’s contact information or an explanation of appeal rights. The discharge MDS showed an unplanned discharge home with return not anticipated, and there was no evidence in the clinical record that the ombudsman was notified of the discharge. An email sent about 19 days after discharge contained only a list of residents who were discharged, deceased, or transferred, and for this resident it listed a discharge/transfer to another hospital without the reason for discharge or the same information provided to the family. For Resident #12, admitted with atherosclerotic heart disease, the discharge MDS documented an unplanned discharge to hospice at home. A discharge/transfer/LOA form indicated discharge to the community with hospice services at a private home/apartment, initiated by the resident or representative, and a discharge summary and progress note documented discharge home with belongings, medications, and paperwork. There was no physician order for discharge in the order summary report, and the clinical record did not show that a copy of the discharge notification was sent to the ombudsman. In an interview, the Resident Relations Manager stated that a copy of the notification is not sent to the ombudsman and that ombudsman information is not provided to residents. For Resident #100, admitted with COPD, an order directed transfer to the ED for shortness of breath, and a discharge summary documented respiratory distress and transport via ambulance to an acute care hospital. A social services note stated that the resident or representative was provided written notice of transfer, bed-hold notice, readmission policy, ombudsman and appeals information. However, the clinical record contained no evidence that a copy of the transfer notice was sent to the State Long-Term Care Ombudsman. For Resident #102, admitted and later readmitted with hepatic encephalopathy, influenza, and cirrhosis, clinical documentation showed an anticipated discharge to the community, an NP note indicating discharge to prior living arrangements, and an unplanned discharge home/community on the MDS. A discharge/transfer/LOA form and discharge summary documented discharge to a private home/apartment without hospice, initiated by the resident or representative, and a social services note recorded that the family picked the resident up and took him back to the reservation. There was no physician discharge order, and no indication in the record that a copy of the discharge notification was sent to the ombudsman. Interviews with the ombudsman and facility staff further described the deficient practice. The ombudsman reported that their office previously received a list of discharged/transferred residents but had not received anything for recent months and that they were sent only a list, not copies of discharge/transfer notifications. The Resident Relations Manager and Business Office Manager stated that Resident Relations is responsible for presenting the notice of proposed discharge/transfer, that the notice is presented up to 72 hours prior to discharge, and that a copy of the notification is not sent to the ombudsman. They also stated they were unsure if any policy or guidance outlined what information must be included in the notice and confirmed that the NOMNC was the only form used as a discharge/transfer notice, even though it lacked ombudsman and advocacy contact information. The acting DON reported being unfamiliar with discharge/transfer notification requirements, and the Executive Director stated that the facility used only the NOMNC, believed no paper notice was required beyond that, and understood the facility’s obligation as sending a monthly list of discharged/transferred residents to the ombudsman, not copies of the actual transfer/discharge notifications.
Failure to Ensure and Document Toileting Hygiene Assistance for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident dependent on staff for ADLs, including toileting hygiene, consistently received and had documented assistance with these needs. The resident was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the left, non-dominant side, along with schizophrenia and major depressive disorder. The care plan identified the resident as being at risk for functional self-care deficits and functional mobility limitations and specified that he required assistance with toileting hygiene and bathing/showering, including washing, rinsing, and drying, with baths/showers to be provided per his schedule and preferences. The admission MDS documented that the resident was cognitively intact, had bilateral upper and lower extremity impairment interfering with daily function, used a wheelchair, and was dependent on staff for toileting hygiene, shower/bathing, oral and personal hygiene, dressing, and footwear. Review of the December CNA task logs for bowel and bladder and toilet use showed multiple shifts left unmarked/undocumented, meaning it was unclear whether toileting and bowel/bladder care were provided or refused on those shifts. The bowel and bladder task log had blank entries on several specific dates and shifts, and the toilet use task log also contained numerous blank entries across day, evening, and night shifts. A CNA explained that CNA care is documented in the EHR using specific codes, including codes for refusal and resident unavailability, and that if a task is left blank it likely means the CNA did not chart, making it questionable whether the care was provided. The CNA stated that blank areas mean one would not know if care was provided, and that everything should be charted so that care conferences and assessments have accurate data. An LPN similarly stated that blanks on the bowel and bladder task log made her think that either someone did not chart or the resident did not have a bowel movement, and that whoever was on shift should have charted appropriately so that others could determine whether care was provided. The resident’s record also contained multiple behavior and NP notes describing ongoing verbal aggression, sexually inappropriate comments, resistance to care, and specific complaints about how peri care and showers were provided. Notes documented that the resident sometimes refused showers, stated he only needed one shower a week, and complained that staff did not clean his peri area adequately after bowel movements, including an incident where he alleged staff did not clean under his penis despite a nurse finding his peri area and brief clean and dry. Another note described the resident demonstrating that he could clean his own peri area and then verbally abusing staff. Additional documentation described the resident’s frequent agitation, oppositional behavior, verbal aggression, and disruptive behavior during care interactions, including cursing at staff, making derogatory comments, and repeatedly activating the call light. Despite these behaviors and complaints, the facility’s own policies required that residents unable to carry out ADLs independently receive appropriate support and assistance with toileting and personal hygiene, and that all services provided, refusals, and care-specific details be documented in the medical record. The combination of the resident’s dependence on staff for toileting hygiene and the numerous undocumented shifts on CNA task logs led surveyors to determine that the facility failed to ensure ADL care such as toileting hygiene was provided and properly documented for this resident. Facility staff interviews reinforced the importance of ADL care and documentation and highlighted the gap between expectations and practice. The CNA familiar with the resident described him as a two-person assist due to behaviors, using briefs rather than the toilet, being very sexual, refusing care from male staff, and demanding extra wiping and frequent changes, which led staff to implement cares-in-pairs and show him wipes after each wipe to prove cleanliness. The CNA acknowledged that blank documentation entries likely meant CNAs did not chart and that this created uncertainty about whether care was provided. The LPN stated that residents should be rounded on at least every two hours for ADL care, emphasized that ADL care is important for dignity and to prevent skin breakdown, and confirmed that uncharted tasks prevent others from concluding whether care was provided. These findings, combined with the facility’s policies requiring provision and documentation of ADL services, formed the basis for the deficiency that the facility failed to ensure ADL care, specifically toileting hygiene, was provided and documented for this resident.
Failure to Provide Advance Notice of Roommate Change
Penalty
Summary
The facility failed to provide advance written notice to a resident prior to a roommate change, as required by policy and resident rights. One resident, who was alert, oriented, and had intact cognition, was not informed in advance that a new roommate would be moving into her room. Documentation confirmed that while the incoming resident received notice of the room change, there was no evidence that the existing resident was notified. The resident only became aware of the change at the time of the new roommate's arrival, when staff inquired if she had been notified. This lack of notification was acknowledged by the Director of Nursing, who stated that the process had 'slipped through the cracks.' The affected resident reported that the new roommate was disruptive, which caused her significant distress, including a panic attack. Staff interviews confirmed that facility policy requires both the resident being moved and the resident receiving a new roommate to receive advance written notice, except in the case of new admissions. Review of the clinical record and facility policy further substantiated that the required notification and documentation were not completed for the resident who received the new roommate.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. This deficiency was identified through surveyor observations and review of facility documentation, which revealed that the required safeguards and protocols were not in place or not consistently followed. As a result, the facility did not ensure adequate protection of residents from potential harm related to abuse, neglect, or theft. Surveyors found that the absence of comprehensive and enforced policies contributed to an environment where residents were at risk, as staff were not provided with clear guidance or training on how to prevent, identify, and report such incidents.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident. One resident, who had a history of alcoholic cirrhosis, hepatic encephalopathy, diabetes, and PTSD, reported being hit in the arm and having a fork and knife thrown at her by another resident during lunch in the bistro area. The incident was witnessed by another resident and reported to staff, but there was no evidence of injury or pain upon assessment. The affected resident expressed feeling triggered due to a history of past abuse and reported ongoing distress following the incident. The resident who committed the act had severe cognitive impairment, as indicated by a BIMS score of 3, and a diagnosis of dementia. The care plan for this resident addressed cognitive impairment but did not include interventions related to behavioral issues or interactions with other residents. There was no documentation in the clinical record of the incident, nor evidence that the provider or family had been notified. Additionally, there was no follow-up or revision of the care plan to address the behavioral incident. Interviews with staff confirmed that the incident occurred and that the residents were separated afterward. However, the facility's documentation and response were incomplete, as there was no record of the incident in the perpetrator's clinical file, no notification to the provider or family, and no update to the care plan to address the behavioral risk. The facility's policy required protection from abuse and prompt investigation and reporting of such incidents, but these steps were not fully implemented in this case.
Incomplete Documentation of Resident Skin Condition
Penalty
Summary
The facility failed to ensure that the medical record for one resident was accurate and complete, specifically regarding the assessment and documentation of a skin condition. The resident, who had multiple diagnoses including dementia and diabetes, was admitted with orders for weekly skin checks. On the day the resident was found on the floor and subsequently sent to the hospital for evaluation of a possible infection and cellulitis on the left arm, there was no nursing assessment or description of the skin condition documented in the clinical record. Interviews with staff revealed that a CNA observed an inflamed and purple area on the resident's arm but did not report it to a nurse, assuming everyone was already aware. A registered nurse recalled noticing a red, swollen, and open area on the resident's arm the day before the hospital transfer, and stated that the area worsened by the following day, prompting treatment and wrapping of the arm. However, this assessment and treatment were not documented in the resident's medical record. A unit manager and LPN stated that the weekly skin assessment was completed after the resident had already been sent to the hospital, and that the assessment inaccurately indicated no new or ongoing skin issues. The facility's policies require that all changes in a resident's condition, including skin abnormalities, be documented in the medical record with specific details. The Director of Nursing confirmed that assessments should be completed timely and documented accurately, and that it would be inappropriate to document an assessment that was not actually performed.
Medication Error in Parkinson's Treatment
Penalty
Summary
The facility failed to ensure that a resident with Parkinson's disease was free from significant medication errors, resulting in the resident receiving the wrong dosage of Carbidopa-Levodopa. The resident was admitted for respite care with a prescription for Carbidopa-Levodopa 25-100mg to be administered four times a day. However, due to a transcription error by a hospice nurse, the resident received only one tablet instead of the prescribed two tablets per dose. This error was not identified until the resident's family raised concerns, prompting a medication reconciliation by hospice. The error was compounded by the facility's process for transcribing and verifying medication orders. The orders were received via fax and entered into the system by medical records, but the verification process failed to catch the discrepancy between the handwritten order and the medication bottles, which had the correct dosage. Interviews with facility staff revealed that there was confusion and a lack of clarity regarding the responsibility for verifying medication orders, especially for respite residents whose medications were managed by hospice. The resident experienced a fall and exhibited confusion and agitation, which may have been related to the incorrect dosage of Carbidopa-Levodopa. The facility's policy required staff to check the medication label against the MAR, but this step was not effectively implemented. The Director of Nursing acknowledged that the discrepancy could have been caught sooner if the staff had compared the medication labels with the MAR. The hospice's Associate Medical Director emphasized the importance of administering the correct dosage to manage Parkinson's symptoms and prevent withdrawal effects.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse by other residents, as evidenced by incidents involving residents with cognitive impairments. Resident #5, who was mildly cognitively impaired, was involved in an altercation with resident #3, who was severely cognitively impaired. On August 26, 2023, resident #5 was hit by resident #3, although no injuries were noted. Prior to this incident, resident #5 had been noted to be in a bad mood, calling others names, and had a psychiatric consult recommending continuation of medication and further medical evaluation. Resident #3, with severe cognitive impairment, was involved in multiple incidents, including hitting resident #5 and being hit by resident #4. On August 24, 2023, resident #3 experienced confusion after a room change and attempted to elope. The following day, resident #3 was awake most of the night and later involved in an altercation with resident #5. On September 7, 2023, resident #3 was hit in the chest by resident #4, who claimed resident #3 would not leave them alone. Despite these incidents, no injuries were reported. Resident #4, also severely cognitively impaired, was involved in an incident on September 7, 2023, where they hit resident #3 after being provoked. The facility's staff, including CNAs and LPNs, reported being trained to handle resident-to-resident abuse by redirecting and monitoring residents. However, the facility's interventions, such as care plans and psychiatric consultations, did not prevent these incidents, indicating a deficiency in ensuring residents' safety from abuse by others.
Staffing Deficiency Leads to Resident Distress and Hospitalization
Penalty
Summary
The facility failed to ensure sufficient staffing to provide quality resident care, as evidenced by the staffing levels on May 2 and May 3, 2024. On May 2, the night shift was understaffed with only one CNA and one RN, despite the facility's assessment indicating a need for 3-4 CNAs on the night shift. The Director of Nursing (DON) stated that a second CNA had called off, and the DON ended up working the shift, resulting in a total of three staff members. This staffing shortage led to a situation where the staff could not be as attentive as needed, causing distress to a resident who was cognitively intact and required moderate assistance for certain activities. The resident, who had a history of a left femur fracture, COPD, and anxiety disorder, expressed dissatisfaction with the care received on the night of May 2. The resident reported that an RN had been rough while moving them, leading to hip pain and subsequent hospitalization. The resident did not return to the facility after being sent to the hospital. The incident highlights the facility's failure to maintain adequate staffing levels, which directly impacted the quality of care provided to the resident.
Failure to Administer Pain Medications as Ordered
Penalty
Summary
The facility failed to administer pain medications as ordered for a resident, resulting in unnecessary pain. The resident, who was cognitively intact, was admitted with a fracture of the left femur, COPD, and an anxiety disorder. Physician's orders specified Hydrocodone-Acetaminophen for severe pain and Acetaminophen for mild to moderate pain. However, on two occasions, the resident experienced severe pain but was only given Acetaminophen, contrary to the physician's orders. Additionally, there was a lack of documentation regarding the resident's pain levels in the progress notes, and discrepancies were found between the MAR and progress notes. The Director of Nursing acknowledged the issue, stating that staff did not have access to the necessary medication supply cart, which led to the failure in administering the correct medication. Despite having a flyer outlining steps to take if medications are unavailable, the staff did not follow the protocol. The facility's policy on pain management was not adhered to, as the resident's pain was not appropriately treated on the specified dates.
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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 Sedona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Haven Of Cottonwood | 16.2 mi | — | 0 | 0 |
| Haven Of Camp Verde | 16.7 mi | — | 2 | 0 |
| Haven Of Flagstaff | 28.4 mi | — | 1 | 0 |
| Aspire Transitional Care | 30.3 mi | — | 0 | 0 |
| The Peaks Health & Rehabilitation | 31.8 mi | — | 0 | 0 |
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