Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 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.
Failure to Protect Two Residents from Resident-to-Resident Abuse: Two residents with intact cognition and histories including depression and other medical conditions became involved in a verbal dispute that escalated into a physical fight in a hallway near the smoking courtyard. Staff heard yelling and intervened, but both residents swung at each other, and one resident struck the other in the face. Interviews and the investigation confirmed the altercation, with staff describing an ongoing pattern of the two residents instigating each other.
The facility failed to ensure the DON did not serve as charge nurse when census exceeded 60 residents. The DON reportedly worked as charge nurse, provided direct care, covered the med cart, and administered meds while census ranged from the mid-80s to 90s, despite facility policy limiting DON charge nurse duties to an average daily occupancy of 60 or fewer residents.
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.
Unsafe and Dirty Flooring in Resident Room Entryways: The facility failed to maintain a safe, clean, and homelike environment when the entryway flooring in 7 sampled resident rooms was observed to be uneven, broken, missing transition strips, and dirty with grime and embedded debris. Staff interviews showed the condition had been present for an extended period, no related work orders were found, and leadership described the issue as cosmetic unless residents complained.
A resident with dementia and vision impairment received eye drops from a CMA even though no active physician order was in the chart, and the resident said she was getting them multiple times a day by reminding staff. Another resident with dementia, fractures, COPD, and insomnia had Lidocaine 4% patches documented as applied, but the MAR/TAR and clinical record did not show when the patches were removed. Staff and the pharmacist confirmed the patch removal documentation was missing, and the manufacturer’s directions reviewed during survey indicated the patch should be removed after no more than eight hours.
A cook was observed actively preparing lunch with a full beard and no beard net, while another dietary staff member was also working in the kitchen with hair restraints in place. The Dietary Mgr stated that all dietary staff were expected to wear hair restraints and that staff with facial hair were required to wear beard nets at all times while in the kitchen and when preparing food. Facility policy required the food service area to be maintained in a clean and sanitary manner and staff handling food to be trained in safe food handling practices.
Failure to disinfect shared therapy equipment between residents. A BP cuff was used on multiple residents and a therapy resistance band was shared among several residents without being cleaned between uses. Staff, including an LPN and the DON, stated that BP cuffs should be disinfected between residents and that shared therapy bands should be cleaned or dedicated to one resident, while the facility policy required reusable resident-care equipment to be disinfected between resident use.
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.
CMA Administered Eye Drops Without an Order: A resident with dementia and cognitive communication deficit received artificial tears from a CMA even though no active physician order was in the chart. The CMA said he gave the drops because the resident asked for them and he wanted to accommodate her, and he admitted he did not check for an order. The RN confirmed there was no order, and staff gave conflicting accounts about who was supervising the CMA during medication administration.
A resident with Parkinson's disease, epilepsy, neuropathy, bipolar disorder, pain, and later-documented moderate cognitive impairment was care planned to be supervised while smoking and to have smoking materials stored by staff between smoking times. However, observations showed the resident obtaining a lighter, going to the smoking patio, and smoking independently with no staff present, including while smoking with other residents. Staff interviews confirmed that residents deemed independent smoked alone, while those needing supervision were supposed to have a staff member stay with them the entire time, and the DON acknowledged the care plan wording was confusing.
A resident with COPD, chronic respiratory failure, and continuous oxygen use had an order for weekly oxygen tubing, humidifier bottle, and filter changes, but the record did not show the tubing was changed as ordered on two occasions. During observations, the nasal cannula tubing was brown-stained, had particles inside the prongs, and had no date on it or the humidifier. Staff gave inconsistent accounts of how often tubing should be changed and whether it should be dated, while the acting DON stated the facility policy did not require dating oxygen tubing.
Incomplete Pre- and Post-Dialysis Assessments: A resident with ESRD receiving hemodialysis 3x/week did not have complete pre- and post-dialysis assessments documented after returning from offsite dialysis. The record lacked post-dialysis vital signs and access site checks after multiple dialysis treatments, and staff interviews confirmed that these assessments were expected to include vitals, weight, pain, mood, and access site evaluation.
A resident with dementia, fractures, MDD, COPD, and insomnia had Lidocaine 4% patch orders documented on the MAR/TAR, but the record did not show when the patch was removed or how long it remained in place. The consulting pharmacist’s monthly MRR did not identify the missing removal documentation or the lack of an order addressing patch removal, even though staff stated the usual practice was to remove the patch after 12 hours and the package directions reviewed during survey said to remove it after no more than 8 hours.
An unidentified white pill was left on the floor in a hallway for about 36 minutes and was passed by multiple nurses, CNAs, residents, the RN, the chef, and the Administrator without being removed. A CNA even wheeled a resident directly over the pill. When an RN finally retrieved it, the pill was identified as loratadine, but its origin could not be determined. The RN stated meds are administered on the hall and residents may take them outside their room, and the facility policy required meds to be kept in a locked med cart inaccessible to residents or others passing by.
Inaccurate Smoking Care Plan Documentation: A resident with osteoarthritis, anxiety, PTSD, depression, insomnia, weakness, and a history of falls had smoking assessments documenting no impairments and ability to smoke independently, but the care plan also included interventions for staff supervision while smoking and storage of smoking materials. Staff interviews confirmed they relied on care plans and smoking assessments, and the DON acknowledged the conflicting documentation in the resident’s record.
Failure to document and administer ordered flu and pneumococcal vaccines: A resident with multiple chronic conditions consented to receive both vaccines, and provider orders were entered, but the vaccines were not given and there was no MAR documentation or chart explanation for the omission. The IP/DON confirmed the resident had agreed to vaccination, the record showed the vaccines were pending, and facility policy required both vaccines to be documented in the medical record.
Inaccurate daily nursing staffing postings were found after review of the facility assessment, PBJ staffing data, and weekend staff postings. The postings did not include the facility name, did not identify unit-specific assignments, and did not show whether behavior unit staff were licensed or unlicensed; one posting also listed 211.5 total hours when the accurate total was 268.5 hours. The administrator stated staffing was based on acuity and census, but also acknowledged the postings did not identify specific assignments or licensure designations and that CMA and LPN hours were not always counted correctly.
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 Protect Two Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from verbal and physical abuse during an altercation between them in the hallway near the smoking courtyard doors. Resident #1 was admitted with diagnoses including sepsis due to E. coli infection, pneumonia, urinary tract infection, and adult failure to thrive, and had a BIMS score of 15 with documented depression, trouble falling asleep, and little energy. Resident #2 was admitted with diagnoses including acute respiratory failure with hypoxia, sepsis, insomnia, depression, and cognitive communication deficit, and also had a BIMS score of 15. The record showed no prior behavioral concerns for Resident #2 before the incident. The behavior note and investigation report documented that the residents became involved in a verbal argument that escalated into a physical altercation. Staff heard yelling and intervened, but the residents began swinging their fists at each other. The report stated that Resident #1 attempted to hit Resident #2 first, and Resident #2 struck Resident #1 in the face. A witness statement from a nursing student described the residents arguing, cussing, and throwing punches, with the last punch from Resident #2 hitting Resident #1 in the jaw. Both residents were separated and assessed with no injuries. Interviews with both residents and staff confirmed the incident and the ongoing conflict between the two residents. Resident #2 stated that Resident #1 approached, yelled, and swore at him before trying to punch him, and that he then punched Resident #1 in the face. Resident #1 stated that Resident #2 was blocking the hallway, tried to push and swing at him, and later hit him in the cheek. A CNA stated that both residents liked to instigate each other and that staff now try to keep them apart. The Administrator stated that resident-to-resident abuse should be reported and investigated after residents are separated and safe. Facility policies stated that the facility strives to prevent abuse and that residents have the right to be free from abuse.
DON Worked as Charge Nurse Above Census Threshold
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not work as charge nurse when the facility census was more than 60 residents. The facility assessment, completed March 21, 2022, stated that the nursing staffing plan included licensed nurses, a full-time DON, at least 1 RN per 24-hour period, and CNA staffing based on resident care needs. The facility was licensed for 112 beds, and the average daily census ranged from 85 to 95 residents, with 20 to 30+ short-term stays and 40 to 50 admissions per month. During the survey, the census was 87 residents, and the Administrator reported that the DON had served as charge nurse and provided direct care in the last several months. In a written response, the Administrator identified multiple dates when the DON worked as charge nurse at census levels of 84, 87, 90, and 98 residents. The Administrator also stated that the DON worked on the medication cart and administered medications to residents, and that the DON would come in to cover shifts that could not be filled, including CNA positions. Facility policy stated that the DON may only serve as charge nurse when the average daily occupancy is 60 or fewer residents.
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.
Unsafe and Dirty Flooring in Resident Room Entryways
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike interior environment for 7 of 7 sampled resident rooms on the 100-Hall. During observations, the entryway flooring in each of the seven rooms was described as uneven, broken, missing the transition strip, and dirty with brownish/black grime. In several rooms, visible cracks were present, and in some areas the crack or gap between the room flooring and hallway flooring was embedded with dirt and debris. The same flooring conditions were observed during multiple walk-throughs. On the initial walk-through, the flooring problems were documented in two rooms on the 100-Hall. On later walk-throughs, the same conditions remained in all seven sampled rooms, including broken flooring, missing transition strips, visible cracks, and dirty surfaces. The final walk-through again showed the same issues, including grime on the white flooring and dirt/debris embedded in the gaps between the room and hallway flooring. The facility’s work order log for the prior 12 months did not show any active, open, pending, completed, or closed work orders related to the flooring in the seven rooms. The Maintenance Director stated that he had only noticed the flooring issue less than a month earlier, did not have an estimate for when it would be fixed, and said it was not a priority because it was cosmetic. The Executive Director stated that the issue was considered cosmetic and could take a backseat unless residents complained. Staff interviews reflected that the flooring had been present for an extended period, with one CNA stating it had been that way for over a year and a housekeeping staff member stating he had observed the gaps since October 2025. The facility policy stated that residents are to be provided with a safe, clean, comfortable environment and that staff and management should maximize a homelike setting that is clean, sanitary, and orderly.
Medication Administration Without Orders and Incomplete Patch Removal Documentation
Penalty
Summary
The facility failed to ensure that medications were administered with a physician order for one resident and failed to ensure accurate dispensing and administration of medications for another resident. One resident with diagnoses including unspecified dementia, adult failure to thrive, cognitive communication deficit, and vision impairment had eye drops in the medication cart even though the clinical record showed no active physician order for eye drops from March 10, 2023 through April 20, 2026. A CMA stated he gave the eye drops earlier in the day because the resident asked for them and he wanted to accommodate her, and he did so without checking for an order. The resident stated she received the eye drops about three times a day because she reminded staff she needed them. The record for that resident showed a prior order for Artificial Tears Solution 1% that had been discontinued on March 10, 2023. The MAR for April 2026 did not show an order for eye drops and did not document administration. The RN stated she knew the resident wanted the eye drops and believed they helped her vision, but confirmed there was no physician order in the record and that the drops should not have been administered. A new physician order for Artificial Tears Ophthalmic Solution was written shortly after the observation. For another resident with diagnoses including hip and spinal fractures, dementia, major depressive disorder, COPD, and insomnia, the record showed physician orders for Lidocaine 4% external patches and documentation that the patch was administered on multiple dates. However, there was no documentation showing when the patch was removed after application on those dates. Staff stated the normal protocol was for the patch to be on for 12 hours and then removed, and the manufacturer’s directions reviewed during the survey indicated the patch should be removed after no more than eight hours. The pharmacist stated there were no physician orders in the record regarding removal of the patch and that documentation of patch removal every 12 hours was important.
Failure to Use Required Hair and Beard Restraints During Food Preparation
Penalty
Summary
Sanitary conditions were not maintained in the kitchen when dietary staff were observed actively preparing lunch for residents without appropriate facial hair restraints. During the initial kitchen tour, two dietary staff members were seen wearing hair restraints on the top of their heads, but one cook had a full beard with long hair covering the sides of his face, chin, and upper lip and was preparing food without a beard restraint. Additional kitchen observations on later dates found staff properly wearing hair and beard restraints. During interview, the Dietary Manager stated that all dietary staff were expected to wear hair restraints while working in the kitchen and that staff with facial hair, including the cook observed earlier, were required to wear beard nets at all times while in the kitchen and when preparing food. Facility policy stated that the food service area shall be maintained in a clean and sanitary manner and that employees handling, preparing, or serving food must be trained in safe food handling practices and demonstrate competency before working with food or serving residents.
Failure to Disinfect Shared Therapy Equipment Between Residents
Penalty
Summary
The facility failed to maintain infection prevention and control during physical therapy services when the same blood pressure cuff was used on five residents without being disinfected between uses. During an observation of therapy services, staff placed the cuff on one resident, then passed the same cuff to another staff member who used it on additional residents, with no sanitizing before or after each resident's use. The cuff was also placed back on the basket on the BP machine after use without being disinfected. During group therapy, the same therapy resistance band was used by multiple residents without being wiped down between residents. One resident used the band, then it was passed to another resident, then to another, and then to a fourth resident for exercises. The band was not disinfected before or after each resident's use. Interviews confirmed that staff understood equipment such as BP cuffs should be disinfected between residents, and the acting IP/DON stated that BP cuffs should be sanitized between resident use and that therapy resistance bands should either be dedicated to one resident or cleaned between uses. The facility policy stated that reusable resident-care equipment, including BP cuffs, must be cleaned and disinfected between resident use according to manufacturer instructions, but the observed practice did not follow that policy.
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.
CMA Administered Eye Drops Without an Order
Penalty
Summary
The facility failed to ensure that medication administration was supervised and carried out in accordance with prescriber orders when a CMA administered Artificial Tears Ophthalmic Solution to a resident without a valid physician's order. Resident #4 had diagnoses including unspecified dementia, adult failure to thrive, and cognitive communication deficit. The resident's record showed an earlier order for Artificial Tears Solution 1% that had been discontinued, and the clinical record contained no physician order for eye drops from March 10, 2023 through April 20, 2026. There was also no documentation that eye drops had been administered to the resident on April 21, 2026. During interview, the CMA stated he gave the eye drops because the resident asked for them and he wanted to accommodate her, and he acknowledged that he did not check for an order before administering them. He also stated that he had given the eye drops to the resident previously and that he normally verifies a physician's order before administering medication. The resident stated that she received the eye drops about three times a day because she reminded staff she needed them and said she had received them earlier that morning. The CMA reported that he believed the resident was upset and that he administered the drops without checking for an order. The RN stated that no physician's order for the eye drops was found in the medical record and that the drops should not have been administered because there was no active order. She also stated that she had been under the impression that an order existed and later discarded the eye drop box after finding it in the medication cart. Interviews with nursing staff showed conflicting accounts about who was supervising the CMA during medication administration, and staff could not clearly identify who was responsible for supervising him at the time. Facility policy required medications to be administered in accordance with prescriber orders and stated that the DON supervises all personnel who administer medications.
Failure to Supervise a Resident During Smoking
Penalty
Summary
The facility failed to ensure supervision was provided to one resident who was care planned to need supervision while smoking. The resident was admitted with diagnoses including Parkinson's disease without dyskinesia, epilepsy, hereditary and idiopathic neuropathy, a wedge compression fracture of T3 vertebrae, bipolar disorder, and need for assistance with personal care. The admission note stated the resident was alert, oriented to person, place, time, and situation, required substantial to maximal assistance with chair and bed-to-chair transfers, and had frequent pain with limited participation in rehabilitation and daily activities because of pain. The resident's smoking-related documentation was inconsistent. The smoking care plan stated the resident would smoke safely and included an intervention that facility staff would supervise the resident while smoking at designated times and store smoking materials between designated times. The smoking assessment indicated the resident used tobacco and scored as able to smoke independently, yet the intervention section still included staff supervision and storage of smoking materials. A later care plan also identified the resident as having moderate cognitive impairment with a BIMS score of 8 and stated the resident needed supervision or assistance with all decision-making. Observations showed the resident smoking without staff present. On one occasion, the resident obtained a lighter from the nurse station, wheeled himself to the patio, lit his cigarette, and smoked independently with no staff present on the patio. On another occasion, the resident was observed smoking on the designated patio with three other residents and no staff present. Staff interviews stated that residents assessed as independent smoked alone on the patio, while residents requiring supervision were supposed to have a staff member stay with them the entire time. The acting DON stated the resident was assessed as independent with smoking and acknowledged the care plan wording could be confusing about whether the resident required supervision while smoking.
Failure to Change and Document Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure oxygen tubing was changed as ordered for a resident with quadriplegia, COPD, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. The resident was admitted with oxygen therapy ordered, including oxygen at 0-5 LPM as needed to keep oxygen saturation above 89% and an order to change the oxygen tubing, humidifier bottle, and clean the filter one time a day every Sunday. The baseline care plan included oxygen therapy, but it did not include interventions related to oxygen use care such as tubing changes. Review of the clinical record showed that the oxygen tubing/humidifier/filter change was documented on the TAR as code 9 on March 29, 2026 and April 19, 2026, but there was no documentation that the tubing was actually changed on those dates and no explanation for why it was not. Other TAR entries showed the task documented as completed on April 5 and April 12, 2026. Daily skilled evaluations during March and April documented that the resident was using oxygen. During observations on April 19 and April 20, 2026, the resident was seen using oxygen with the tubing connected to the concentrator; the nasal prongs were brown-stained and had a small brown substance/particles inside them, and there were no dates on the tubing or humidifier. The caregiver and resident did not know when the tubing had last been changed. Staff interviews reflected differing practices, with one LPN stating tubing was changed every night shift and dated, an RN stating it was changed weekly and dated, another LPN stating it was changed weekly every Sunday and dated, and the acting DON stating tubing is changed every seven days and as needed, but that the facility policy did not require dating oxygen tubing.
Incomplete Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure pre- and post-dialysis assessments were completed for a resident with ESRD who received hemodialysis three times per week. The resident was admitted with diagnoses including hypertensive CHD and ESRD, was alert and oriented x4 on admission, and had orders for dialysis site care, observation of the access site every shift, and dialysis on Monday, Wednesday, and Friday. The care plan identified the resident as requiring hemodialysis related to ESRD, with interventions to obtain vital signs and weight per protocol and report significant changes in pulse, respirations, and BP immediately. Clinical record review showed that after offsite dialysis on April 3, April 8, and April 17, 2026, the facility did not document complete post-dialysis assessments. For April 3, there was no evidence that the facility documented pre- and post-dialysis assessments, including vital signs or assessment of the dialysis access site for bruits, thrills, bleeding, or infection. For April 8 and April 17, the record included pre-dialysis vital signs, but no post-dialysis vital signs were documented after the resident returned from dialysis, and there was no documentation explaining why the post-dialysis vital signs were not taken. Staff interviews reflected that pre- and post-dialysis assessments were expected to include vital signs, weight, pain level, mood, and access site checks, including assessment for infection, bleeding, bruit, thrill, and secure dressing with pressure applied after return from dialysis. The acting DON stated that if the vital signs section was missing, the assessment was considered incomplete. The facility policy on care of residents with ESRD stated that residents would be cared for according to currently recognized standards of care.
Consulting Pharmacist Failed to Identify Lidocaine Patch Documentation Irregularities
Penalty
Summary
The facility failed to ensure the consulting pharmacist identified and reported medication irregularities during the monthly medication regimen review for a resident with hip and spinal fractures, dementia, major depressive disorder, COPD, and insomnia. The resident had a BIMS score of 5, indicating severe cognitive impairment. A physician order for Lidocaine 4% external patch was entered with a discontinued date, then later re-entered, and the medication was documented as administered on multiple dates in March and April 2026. The clinical record showed repeated documentation that the Lidocaine patch was administered, but it did not show when the patch was removed or how long it remained on the resident after application. On several dates in April, the resident refused the patch, but the record still did not indicate whether a previously applied patch had been removed. The MAR/TAR also did not include documentation of patch removal or duration of wear, despite the patch being transcribed and administered across multiple shifts. The pharmacist’s medication regimen reviews dated March 17 and April 14, 2026 did not identify concerns related to the external Lidocaine patch, did not identify the absence of an order addressing removal of the patch after application, and did not identify the lack of documentation showing how long the patch remained in place. Staff interviews confirmed the normal practice was to apply Lidocaine patches for 12 hours and remove them after 12 hours, while the manufacturer’s directions reviewed during the survey stated the patch should be removed after no more than eight hours. The facility policy required the consulting pharmacist to review each resident’s medical record at least monthly, document findings, and communicate medication-related problems to the responsible physician.
Unidentified pill left unattended in hallway
Penalty
Summary
The facility failed to ensure proper control and accountability of medications when an unidentified white pill was observed on the floor in the 100 hall in front of a resident room and remained there for approximately 36 minutes. During that time, multiple staff members and residents passed by the pill without identifying or removing it, including nurses, CNAs, an RN, the facility chef, and the Administrator. A CNA wheeled a resident directly over the pill, and other residents in wheelchairs also passed by it while it remained unattended on the floor. At 10:34 AM, after being directed by the surveyor, an RN retrieved the pill and identified it as loratadine, but could not determine its origin and stated it did not belong to either resident in the room. The RN later stated that medications are administered on the hall using medication cups and spoons as needed and that she remains with residents until medications are taken. She also stated the resident in the room chooses which medications to take and may take them outside of her room. The resident identified by the RN as receiving loratadine stated she was certain she received her medication the prior day and that a student nurse administered it; she had a BIMS score of 15 and stated she knows her medications. The facility medication administration policy stated medications must be kept in the locked medication cart and the cart must be inaccessible to residents or others passing by.
Inaccurate Smoking Care Plan Documentation
Penalty
Summary
The facility failed to ensure that Resident #6’s care plan reflected accurate current assessment information. Resident #6 was admitted with diagnoses including unilateral primary osteoarthritis of the left knee, anxiety disorder, need for assistance with personal care, muscle weakness, PTSD, history of falls on the same level, depression, and insomnia. A Nursing Smoking Evaluation dated February 3, 2026 documented that the resident had no impairments and was able to smoke independently, and the smoking focus in the care plan was initiated the same day with a goal that the resident would smoke safely during the review period. The interventions included staff supervision while smoking at designated times, storage of smoking materials between those times, and an additional intervention stating that the resident was evaluated to smoke independently. A second Nursing Smoking Evaluation dated February 12, 2026 again documented that the resident had no impairments and was able to smoke independently. During interviews on April 22, 2026, a CNA stated staff were trained to use care plans to understand resident needs and report discrepancies, and an LPN stated nurses referenced care plans and smoking assessments to determine whether supervision was needed while smoking. The acting DON reviewed the record and acknowledged the conflicting information in the care plan, stating it did not meet facility expectations and could potentially result in a loss of the resident’s independence. The facility policy on documentation stated that all services provided and progress toward care plan goals must be documented completely and accurately.
Failure to Document and Administer Ordered Flu and Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal vaccinations were administered in accordance with professional standards for one sampled resident. Resident #87 was admitted with diagnoses including primary adrenocortical insufficiency, ulcerative colitis, immunodeficiency due to drugs, and adult failure to thrive. The resident’s immunization record showed both the influenza vaccine and pneumococcal vaccine were pending, and informed consent dated January 13, 2026 documented that the resident consented to receive both vaccines. The physician orders also dated January 13, 2026 included prescriptions for both vaccines, and the admission MDS showed a BIMS score of 14 and indicated the resident was not up to date on influenza or pneumococcal vaccination. During an interview on April 22, 2026, Resident #87 stated she had consented to receive both vaccinations but had not received them, and that the facility had not explained why. The acting Infection Preventionist/DON stated the process included verifying allergies, consent, and timing, then entering the order, obtaining the vaccine from the pharmacy, administering it, and documenting it in the MAR. She confirmed there was nothing in the chart explaining why the vaccines were not given, that the resident had consented, that the record showed the vaccines were pending, and that there was no MAR documentation of administration. A signed document also stated the facility had no documentation of the resident’s vaccinations. Facility policy required influenza vaccination to be offered between October 1 and March 31 and documented in the medical record, and pneumococcal vaccination to be administered per physician-approved protocols and documented in the medical record.
Inaccurate Daily Nursing Staffing Postings
Penalty
Summary
The facility failed to accurately post required daily nursing staffing information for all residents and visitors. Review of the facility assessment showed the facility was licensed for 112 residents, with an average daily census of 85-95 and 20-30+ short-term stays, and staffing plans that included RNs, LPNs, CNAs, a full-time DON, and at least 1 RN per 24-hour period. The Payroll-Based Journal Staffing Data Report showed excessively low weekend staffing for July through December 2025, and review of weekend Daily Staff Postings from that period showed the postings did not include the facility name, did not identify which staff were assigned to specific units, and did not indicate whether staff working in the behavior unit were licensed or unlicensed. The Daily Staff Posting for September 28, 2025 listed 211.5 total hours, but the accurate total was 268.5 hours. During interviews, the administrator and HR stated staffing was based on the facility assessment, acuity, and staff availability, and that the facility was always appropriately staffed. The administrator later stated the staffing team reviewed residents with catheters, wounds, IV antibiotics, behavioral concerns, or transfer needs, and that the Behavior Unit had 20 beds and the LTC Unit had 36 beds. She also stated the postings did not identify specific staff assignments or licensure designations, and acknowledged she was not aware that when a CMA provided incontinence care instead of passing medications, those hours should be counted as CNA hours, or that when an LPN covered a CNA shift, those hours should be counted as CNA hours rather than LPN hours.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 1 | 0 |
| Haven Of Camp Verde | 16.7 mi | ★★★★★ | 10 | 0 |
| Haven Of Flagstaff | 28.4 mi | ★★★★★ | 1 | 0 |
| Aspire Transitional Care | 30.3 mi | ★★★★★ | 2 | 0 |
| The Peaks Health & Rehabilitation | 31.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.