Haven of Sedona: Resident Left Alone in Shower - AZ
The August incident at Haven of Sedona exposed both the original abandonment and a cascade of reporting failures that followed, as administrators missed deadlines, ignored required notifications, and let a crucial abuse report expire without submission to state regulators.
Resident 11 was supposed to get her shower earlier in the day, but the certified nursing assistant assigned to help her left work early. By evening, staff realized she still needed her shower and decided to set her up for one.
Staff member 46, one of the CNAs involved, told inspectors they left the resident in the shower room for 30 minutes. At some point during that half hour, the CNA thought a nurse entered the shower room because the resident had dropped something.
But after 30 minutes, staff returned to find the resident screaming.
They dressed her and got her into her wheelchair. The resident immediately told them she was going to report them for what had happened.
She wheeled herself back to her room and sent an email reporting the incident. The charge nurse then texted the executive director to report it immediately.
The other CNA involved, staff member 34, knew the facility's policy required reporting allegations of abuse or neglect within two hours. She said she reported the resident's allegations to the nurse immediately, who then notified the supervising nurse and the oncoming shift.
But staff member 34 wasn't suspended until the following day at 11:00 a.m.
When inspectors interviewed registered nurse staff member 58, she said facility policy required immediate reporting to the administrator. If an allegation came outside business hours, staff should leave a message, try to reach the Director of Nursing, and make sure residents were safe.
The Director of Nursing and executive director both confirmed the two-hour reporting timeframe when inspectors interviewed them together.
The executive director said she was notified by email at 10:16 p.m. the night of the incident. She didn't check her email immediately and didn't see the message until around 10 a.m. the next day.
After reading and reviewing the email, the executive director said the facility completed the initial two hours of ensuring the resident's safety before sending one aide home and suspending the other.
Staff conducted a skin assessment and concluded the incident didn't rise to the level of substantial abuse and neglect.
But the executive director admitted she never clicked the verification link sent to her email to submit the required report to the state agency. When she finally tried to click the link, it had expired.
The facility's own policy, revised in January 2024, required all reports of abuse, neglect, or exploitation to be thoroughly investigated by facility management. The policy mandated immediate reporting, but within two hours, to multiple entities: the state agency, ombudsman, resident's representative, Adult Protective Services, law enforcement, the physician, and the medical director.
The executive director told inspectors they would fix their reporting processes moving forward.
The inspection revealed a facility where basic care coordination failed spectacularly. A resident's shower was forgotten until evening. When staff finally attempted to provide that care, they left her alone for 30 minutes until her screaming brought them back.
The resident's immediate response was telling. She didn't wait for staff to check on her or ask what happened. She wheeled herself away and filed her own complaint.
What followed was a series of missed steps and delayed responses that violated the facility's own policies. The executive director, notified by 10:16 p.m., didn't read the report until nearly 12 hours later. The required state notification was never completed because she failed to click a verification link before it expired.
Staff member 34 understood the two-hour reporting requirement but wasn't suspended until the next morning. The registered nurse described immediate reporting requirements, but the executive director's 12-hour delay in even reading the initial report made immediate compliance impossible.
The facility's skin assessment concluded no substantial abuse occurred, but federal inspectors found the incident significant enough to cite the facility for failing to protect residents from abuse and neglect.
The policy requiring reports to seven different entities within two hours exists because incidents like this can escalate quickly without proper oversight. When a resident is left screaming alone in a shower room, multiple safeguards should activate immediately.
Instead, Haven of Sedona's response revealed a facility where policies exist on paper but fall apart under basic operational pressure. A forgotten shower became a 30-minute abandonment. A clear reporting requirement became a missed deadline and expired link.
The resident who wheeled herself back to her room to file her own complaint understood something the facility's leadership apparently didn't: when care fails this fundamentally, immediate action is required.
The executive director's promise to fix reporting processes moving forward came only after inspectors documented how thoroughly those processes had broken down. The resident's screaming in an empty shower room had already provided all the evidence needed about what happens when basic care coordination fails.
Her email complaint, sent immediately after the incident, demonstrated more urgency about reporting abuse allegations than the facility's own administrators showed in the crucial hours that followed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Haven of Sedona from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
HAVEN OF SEDONA in SEDONA, AZ was cited for violations during a health inspection on August 19, 2025.
Resident 11 was supposed to get her shower earlier in the day, but the certified nursing assistant assigned to help her left work early.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.