Haven of Sedona

Inspectors wroteBased on staff interviews, review of clinical record and policy review, the facility failed to protect the rights of 2 of 3 residents sampled (#1, #2) to be free from physical and verbal abuse between residents. The deficient practice could result in resident injury, psychological, or behavioral harm as well as continued resident to resident abuse.

Inspectors wroteBased on review of facility documentation, staff interviews, and facility policy, the facility failed to ensure that the Director of Nursing did not work as Charge nurse when facility census was more than 60 residents. The census was 87. This deficient practice could result in potential harm to residents due to insufficient staffing to adequately meet resident needs.

Inspectors wroteBased on observations, resident and staff interviews, and policy reviews, the facility failed to ensure maintenance, clean, safe and comfortable interior for 7 out of 7 rooms sampled. The census was 87. The deficient practice could result in resident rooms not having a safe, clean, and homelike environment.

Inspectors wroteBased on closed record review, staff interviews, and the review of facility process and policy, the facility failed to ensure that a copy of the transfer/discharge notification was sent to the ombudsman for five of five sampled residents (#12, #100, #102, #8, and #107) for discharge. The census was 87. The deficient practice could leave residents without protection against inappropriate transfers or discharges and without access to an advocate to explain their rights and options.

Inspectors wroteBased on observation, staff and resident interview, and review of the clinical record and facility policy, the facility failed to ensure that medications were administered with a physician order for one (Resident #4); and, and failed to ensure the accurate dispensing and administration of medications for one resident (#72) of 25 sampled residents for medications. The universe was 87. The deficient practice could result in residents needs not met and inaccurate and unsafe provision of medications.

Inspectors wroteBased on observation, staff interviews, and review of facility policy, the facility failed to ensure sanitary conditions were maintained in the kitchen by requiring dietary staff to utilize appropriate hair restraints, including beard coverings, during food preparation. The deficient practice had the risk of physical contamination of food served to residents. The census was 87, and the sample was 85 residents.

Inspectors wroteBased on observations, staff interviews, facility documentation and policy and procedures, the facility failed to maintain infection prevention and control pertaining to sanitizing medical equipment for five out of five sampled residents (#1, #82, #24 #35 & #23). The census was 87. The deficient practice could result in transmission of disease and infection to residents.

Inspectors wroteBased on observation, interviews, clinical record review, and facility policy review, the facility failed to ensure that care and services were provided in accordance with accepted standards of quality by failing to provide appropriate staff supervision during medication administration for one (#4) of 25 sampled residents. The facility census was 87 residents. The deficient practice resulted in unsupervised staff administering medication to the resident without a physician's order.

Inspectors wroteBased on clinical record reviews, staff interviews and facility policies and procedures, the facility failed to ensure was ADL (activities of daily living) care such as toileting hygiene was provided for 1 of 2 residents (#55) sampled for ADLs. The census was 87. The deficient practice could result in residents' hygiene needs not being met.

Inspectors wroteBased on observation, clinical record review, staff interviews and facility policy review the facility failed to ensure supervision was provided to one of 2 sampled resident (#93) for smoking, who was care planned to need supervision while smoking. The deficient practice could result resident needing supervision may not be able to manage their smoking in a way that minimizes harm.

Inspectors wroteBased on observations, clinical record review, interviews and facility polity, the facility failed to ensure staff changed oxygen tubing as ordered by the physician for 1 of 1 sampled resident (#2) for respiratory care. This deficient practice could lead to contaminated tubing and increase the risk of respiratory infections. Resident #2 was admitted on [DATE] with diagnoses of quadriplegia, COPD (chronic obstructive pulmonary disease), chronic respiratory failure with hypoxia and dependence on supplemental oxygen. A health status note dated March 25, 2026 included that the resident was alert and oriented x 4, answered all questions appropriately and had a caregiver at bedside upon admission. The baseline care plan dated March 25, 2026 included the resident was on oxygen therapy related to COPD. Intervention included oxygen per physician order. [...]

Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to ensure pre and post dialysis assessment was completed for 1 of 1 sampled resident (#3) for dialysis. The deficient practice could result in resident not consistently monitored after returning from receiving offsite dialysis.

Inspectors wroteBased on observation, staff interviews, and review of the clinical record and facility policy, the facility failed to ensure consulting pharmacy services identified and reported medication irregularities for one of 5 sampled residents (#72) for medications. The census was 87. The deficient practice could result in inaccurate administration of prescribed medications, incomplete documentation, and potential adverse medication reactions including toxicity, skin irritation, and drowsiness.

Inspectors wroteThe facility failed to ensure proper control and accountability of medications, as evidenced by an unidentified medication left unattended on the floor for approximately 36 minutes, accessible to staff and residents, and not promptly addressed by multiple staff passing by. Additionally, the facility could not account for the origin of the medication. Census was 87.

Inspectors wroteBased on clinical record review, interviews and and review of facility policies and procedures, the facility failed to ensure the care plan reflected accurate documentation of the current assessment information for one (#6) of 25 sampled residents for care plan reviews. The census was 87. The deficient practice could result in staff relying on inaccurate or conflicting information, potentially impacting the resident's safety and/or level of independence.

Inspectors wroteBased on staff and resident interviews, and review of the clinical record and facility policy, the facility failed to ensure that vaccinations were administered in accordance with professional standards for one of five sampled residents (#87). The universe was 87. The deficient practice could result in the acquisition, transmission, or complications from influenza or pneumococcal disease.

Inspectors wroteBased on review of facility staffing documentation, and staff interviews, the facility failed to accurately post required daily information impacting all residents and visitors of the facility. The universe is 87. The deficient practice could result in residents and visitors being provided with inaccurate nursing staffing information.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#11) was given an advance notice prior to a roommate change. The deficient practice could result in resident's preference to choose her roommate was not considered. -Resident #41 was admitted on [DATE] with diagnoses of metabolic encephalopathy, dementia and need for assistance with personal care. The NP (nurse practitioner note dated July 24, 2025 included that the resident had a BIMS score of 12 which was consistent with moderate cognitive impairment. The room/roommate change notice signed by resident #41 and social services and dated August 11, 2025 revealed that resident #41 was provided the notice that she was moving to the room of resident #11 and this change was effective August 12, 2025. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews, facility documentation and policy review and the State Agency complaint tracking system, the facility failed to follow their abuse reporting policy following an allegation of abuse for one resident (#11). The deficient practice could result in continued abuse and neglect to residents.

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one resident (#11) was reported to the State Agency (SA) within the required timeframe. The deficient practice could result in resident not protected from continued abuse.

Inspectors wroteBased on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an allegation of abuse for one resident (#5) was thoroughly investigated. The deficient practice could result in the appropriate State Agencies not being notified and allegations of abuse not being thoroughly investigated.

Inspectors wroteThe facility failed to ensure an allegation of resident (#5) abuse was reported to all applicable state agencies. Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an allegation of resident (#5) abuse was reported to all applicable state agencies. The deficient practice could result in further allegations of abuse not being reported and investigated by the appropriate state agencies.

Inspectors wroteThe facility failed to ensure an allegation of resident (#5) abuse was investigated. Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an allegation of resident (#5) abuse was investigated. The deficient practice could result in residents being abused.

Inspectors wroteBased on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident (#10) was not abused by another resident (#15). The deficient practice could lead to psychosocial or physical harm of a resident. -Regarding Resident #10 (alleged victim): Resident #10 was admitted to the facility June 5, 2025, with diagnoses that included alcoholic cirrhosis of liver, hepatic encephalopathy, type 2 diabetes mellitus, portal hypertension, acidosis, hypertension, unspecified head injury, and alcohol dependence. An admission minimum data set (MDS) assessment was still in progress. An Alert Note dated June 15, 2025, revealed a therapist came to the nurse after Resident #10 reported another resident hit her while having lunch in the bistro area on the rehab unit. This writer separated both residents, and ensured everyone was safe. [...]

Inspectors wroteBased on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure the medical record was accurate and complete for one resident (#2). The deficient practice could lead to care team members not being aware of a resident's status and lead to a delay in care or missed treatment. Findings Include: Resident #2 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia, pulmonary fibrosis, type 2 diabetes mellitus, insomnia, anxiety disorder, and depression. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 8, indicating moderate cognitive impairment. A physician order dated February 21, 2025, indicated to complete a skin check weekly. [...]

Inspectors wroteBased on resident and staff interviews, facility documentation and policy review, the facility failed to ensure ensure staffing information submitted was accurate. The deficient practice could result in residents receiving inadequate care due to potential lack of staffing.

Inspectors wroteBased on review of resident council minutes, resident and staff interviews, and policy and procedures, the facility was unable to demonstrate their response and rationale to grievances and recommendations voiced during resident council meetings. The facility census was 82. The deficient practice could result in residents' concerns, views, grievances or recommendations not being considered or acted upon by facility staff.

Inspectors wroteBased on observations, clinical record review, staff interview, facility documentation and policy review, the facility failed to protect the rights of five residents (#132, #23, #283, #187 and #483) to be free from physical abuse by another resident. The deficient practice could result in further resident abuse.

Inspectors wroteBased on clinical record review, staff interview, and policy and procedure, the facility failed to ensure that 2 residents (#29 and #37) out of 18 sampled, that were newly admitted , had a level I pre-screening to determine if the residents may have had an MI (mental illness) or ID (intellectual disability). The deficient practice could result in residents not receiving the necessary specialized services required.

Inspectors wroteBased on clinical record review, interviews, observations, and policy review, the facility failed to ensure that two residents (#190 and #79) received treatment and care in accordance with professional standards of practice by failing to follow physician's orders for resident care.

Inspectors wroteBased on observations, clinical record reviews, staff and resident interviews and review of policies and procedures, the facility failed to ensure that one resident (resident #21) was assessed for self administration for medications. The deficient practice could result in an adverse event for the resident. -Regarding Resident #21 Resident #21 was admitted on [DATE] with diagnosis including heart disease, atrial fibrillation, nonrheumatic mitral valve insufficiency, presence of a prosthetic heart valve, symptomatic epilepsy and epileptic syndromes with complex partial seizures, malignant neoplasm of the brain, repeated falls, insomnia, osteoporosis, anxiety disorder, and depression. A review of the quarterly MDS (minimum data set) dated November 26, 2024 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident was cognitively intact. [...]

Inspectors wroteBased on resident and staff interviews, facility documentation and policy review, the facility failed to ensure there was sufficient staff to meet the needs of the residents. The deficient practice could result in residents not receiving appropriate care and treatment that they need.

Inspectors wroteBased on observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#52) was treated with dignity regarding privacy of a foley catheter bag. The deficient practice could lead to a resident having psychosocial harm from lack of dignity.

Inspectors wroteBased on closed record review, staff interviews, review of facility documentation and policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure a safe and appropriate transfer of one resident (#182). The deficient practice could result in residents not receiving appropriate care and services during the transition of care.

Inspectors wroteBased on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment was accurate for one resident (#80). The deficient practice could result in incorrect discharge tracking information and data that is not accurate for quality monitoring.

Inspectors wroteBased on review of clinical records, staff interviews and review of facility policy and procedure, the facility failed to ensure that a Pre- admission Screening and Resident Review (PASRR) Level 2 referral was completed for one resident (#28). The sample size was 18. The deficient practice could lead to residents not receiving needed care and services.

Inspectors wroteBased on observations, clinical record reviews, resident and staff interviews, facility documentation and policy and procedures, the facility failed to ensure showers were provided for one resident (#36).

Inspectors wroteBased on observations, clinical record reviews, staff and resident interviews and review of policies and procedures, the facility failed to ensure physician orders, for hydration, were followed for resident #383. The deficient practice could result in fluid overload, electrolyte imbalance and a detrimental impact on kidney function.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure pain medications were administered following the physician-ordered parameter of two residents (#3 and #133). The deficient practice could result in residents' pain not adequately managed.

Inspectors wroteBased on observation, record review and interviews, the facility failed to assist one resident (#40) in obtaining routine dental services. The deficient practice could result in the delay of dental services.

Inspectors wroteBased on interviews, facility documentation and policy review, the facility failed to educate and offer an influenza vaccine that the resident was eligible to receive in accordance with the current Centers for Disease Control and Prevention (CDC) guidelines for one resident (#42) out of 5 reviewed for immunizations. The deficient practice posed the risk of the resident contracting influenza and its associated complications.

Inspectors wroteBased on clinical record review, interviews, and review of policies, the facility failed to ensure one resident (#4), was free from significant medication errors, related to the resident receiving the wrong dosage of Parkinson's disease medication. The deficient practice could result in complications and adverse medication side effects.

Inspectors wroteBased off of clinical record review, staff interviews, observation of current practice, and review of the facility's policies, the facility failed to ensure residents #3, #4, and #5, were free from abuse from other residents. The deficient practice could result in residents experiencing emotional and mental trauma from the abuse. Related to resident #5 Resident #5 was admitted to the facility on [DATE] with diagnoses that included Dementia, a history of strokes, and stage 3 Kidney disease. A review of a Quarterly MDS, dated [DATE] revealed resident #5 had a BIMS assessment completed. Resident #5 scored a 08 which indicated they were mildly cognitively impaired. A review of the care plan reveals it was revised on January 16, 2023 to include behavior issues as an area of focus. The care plan goals included that resident #5 would not harm themselves or others. [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure there was sufficient staffing to provide quality resident care. The deficient practice could result in residents' care needs not being met.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#1) was administered pain medications as ordered. The deficient practice resulted in a resident experiencing unnecessary pain.

Inspectors wroteBased on clinical documentation, staff interviews, and facility policy and procedures, the facility failed to implement non-pharmacological interventions for continued use of psychotropic medication for two residents (#6 and #11). The census was 57. The deficient practice could result in resident receiving unnecessary psychotropic medications.

Inspectors wroteBased on clinical documentation, staff interviews, and facility policy and procedures, the facility failed to ensure that one resident (#11) did not receive unnecessary pain medication. The census was 57. The deficient practice could result in residents being overmedicated.

Inspectors wroteBased on clinical record review, staff interviews, policy and procedures the facility failed to ensure services met professional standards by failing to provide bowel care for one resident receiving opioid therapy (resident #47). This deficient practice could result in residents having complications from constipation including fecal impaction, bowel obstruction or death.

Inspectors wroteBased on clinical record review, staff interviews, policy and procedures review, the facility failed to ensure that medications were properly secured for one resident (resident #2). The deficient practice could result in the inappropriate use of medications by residents.