Sedona Trace Health and Wellness Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's responsible party has the right to exercise the resident's rights for one (Resident #1) of seven residents reviewed for resident rights. The facility failed to ensure Resident #1's POA, FM A, notified when the resident was discharged from facility with FM B.This failure could place residents at risk of not having their preferred responsible party represent them in a medical, nursing care and safe discharge decisions.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 (Resident #1) of 3 residents reviewed for safe transfer or discharge. The facility failed to ensure the safety of Resident #1 when she was discharged on 04/26/26 with FM B. This failure could result in the safety of the residents who are discharged from the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 (100/200-Hall) medication room reviewed for pharmacy services. The facility failed to ensure expired medical supplies were removed from 100/200-hall medication storage room on 07/24/2025. This failure could place residents at risk of receiving medication using expired medical supplies, increased pain due to dull needles, and/or infection due to contamination of expired medical supplies.

Inspectors wroteBased on interview and record review, the facility failed to provide specialized habilitation services and failed to obtain specialized durable medical equipment for one (Resident #1) of three residents reviewed for PASRR (Preadmission Screening Resident Review) services. The facility failed to request a customized mattress within 20 business days after the IDT meeting for Resident #1. This failure could put resident at risk of not receiving the needed care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave for one (Resident #1) of three residents reviewed for discharges, in that: The facility failed to readmit Resident #1 and provide or document sufficient preparation for an orderly discharge when Resident #1 was sent to a behavioral health hospital on [DATE]. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge, injury, and rehospitalization. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to adequately equip to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member to a centralized staff work area for 2 (Resident #34 and 48) of 6 residents reviewed for call lights, in that: The facility failed to ensure Residents #34 and 48's bathroom and shower call lights operated on 06/11/24. An IJ was identified on 06/11/24. The IJ template was provided to the facility on [DATE] at 7:32 P.M. While the IJ was removed on 06/13/24, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy because of the facility need to evaluate the effectiveness of its corrective actions. This failure could place residents at risk for injury, accidents, not having needs met, and death.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart and ensure infection control measures during implementation of care, handling, cleaning, storage and disposal of equipment, supplies, biohazardous waste and including infection control practices for mechanical ventilation/tracheostomy care including the use of humidifiers were followed by staff for 3 (Residents #5, #36, and #77) of 7 residents reviewed for respiratory care, in that: The facility failed to ensure Resident #5, #36 and #77's nasal cannulas and tubing were properly stored when not in use. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for food storage and sanitation, in that: 1. The facility failed to ensure kitchen staff secured their hair in hairnets in the kitchen. 2. The facility failed to clean the inside of the one ice machine. 3. The facility failed to discard expired food and beverage items in the walk-in refrigerator. 4. The facility failed to ensure the freezer unit in the walk-in freezer was maintained in safe operating condition . These deficient practices could place residents at risk of foodborne illness.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the residents rights to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 2 of 3 residents (Resident #50 and Resident #71) reviewed for advanced directives. The facility failed to ensure Resident #50's out of hospital do-not-resuscitate (OOH-DNR) form included the resident's printed name and date signed. The facility failed to ensure Resident #71's Medical Power of Attorney (MPOA) included all pages and was signed, dated, and witnessed or notarized to confirm it was valid. These failures could place residents at-risk of having their wishes dishonored or delay necessary medical treatment or intervention due to confusion regarding authority to make medical decisions on behalf of the resident.

Inspectors wroteBased on interviews and record review, the facility failed to complete a comprehensive, accurate, and standardized reproducible assessment for 2 (Resident #86 and Resident #88) of 3 residents reviewed for comprehensive assessments. The facility failed to include Resident #86's cancer diagnosis in the comprehensive assessment. The facility failed to include Resident #88's depression diagnosis in the comprehensive assessment. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided.

Inspectors wroteBased on interviews and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness, developmental disability, or intellectual disability, were provided with a PASRR Level II assessment for 1 (Resident #86) of 3 residents reviewed. The facility failed to ensure Resident #86 received a PASRR level 2 evaluation. This failure could place residents at risk for not receiving necessary mental health services to reach their highest practicable level of well-being.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for three of eight residents (Resident # 20, Resident #39, and Resident #72) reviewed for quality of life. 1. The facility failed to ensure Resident #20 and Resident #39's nails were cleaned. 2. The facility failed to ensure Resident #72's nails were cleaned and did not have rough edges. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 6 of 10 residents reviewed for the usage of Blood Pressure Monitors (Resident #28, Resident #73, Resident #41, Resident #75, Resident #84, and Resident #198) as indicated by: The facility failed to ensure MA B, MA C and LVN A disinfected the blood pressure monitors between the residents. These failures could place the residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents had the right to a clean, comfortable, and homelike environment, which included housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior, for 1 of 4 residents (Resident #84) reviewed for a homelike environment. The facility failed to ensure the dents and scuffs on the interior wall of Resident #84's room were repaired and painted. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide food that accommodates resident's preferences for one (Resident #62) of four residents reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to provide Resident #62 with her food preferences with consistency, for breakfast and lunch during her entire stay at the facility from the day of admission [DATE]). Resident #64 requested not to have tomatoes, sausage, and eggs. This failure could affect the residents that are provided daily meals by the facility, by placing them at risk for adverse effect from food, frustration, not enjoying meals, and weight loss.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to have the results of the most recent survey of the facility posted in a place readily available to all residents, family members, and legal representatives for the facility reviewed for residents rights. The facility failed to post the facility's most recent inspection reports. This deficient practice prevented residents from exercising their rights and placed them at risk of having no awareness of the facility's inspection history and any plans of correction the facility should have in place.