Haven of Sedona: Resident Left Naked in Shower - AZ
The incident unfolded on a day when the certified nursing assistant regularly assigned to Resident #11 had left her shift early. The resident was not part of another aide's shower group, but she asked twice for help. Staff #34 later told inspectors she had been hesitant to assist because she was finishing her last rounds at the end of her shift. Eventually, she and a second CNA, Staff #46, decided to help the resident shower rather than leave her upset any further.
The resident was crying on the way to the shower room.
Once inside, the two aides left her alone. They did not return for about 30 minutes. When they heard her screaming, they came back. The resident immediately yelled, "Get me the f*** out of here," and told them she had been left in the shower for over an hour. Staff #34 told inspectors she asked the resident to calm down. The resident became louder and used profanity. Staff #34 and Staff #46 told the resident to calm down again so they could assist her, and then left her alone and naked in the shower room a second time, this time to go notify the nurse.
The nurse was unavailable. The two aides returned on their own.
Staff #46 gave inspectors a somewhat different account of the washcloth. Staff #34 said she gently placed it on the shower chair's armrest. Staff #46's account of the general sequence did not materially differ from Staff #34's. Both confirmed the two extended periods of abandonment, the screaming, and what happened next: after the aides finally helped the resident get dressed and into her wheelchair, the resident told them she was going to report them to the state. She wheeled herself back to her room and sent an email.
Before the resident reached her room, the two aides were already at the nurses' station discussing whether to record her, Staff #34 told inspectors, for their own protection. Staff #46 was uncomfortable with the idea. They decided against it.
The charge nurse texted the executive director, Staff #29, to report the incident that same night. The text went out. An email notification also reached the executive director at 10:16 p.m.
The executive director did not check her email that night. She saw it around 10 a.m. the following morning. By then, the two-hour window the facility's own policy required for reporting to the Arizona Department of Health Services, the ombudsman, the resident's representative, Adult Protective Services, law enforcement, the physician, and the medical director had long since closed.
The executive director told inspectors she read the email, reviewed the situation, and said the facility had done the initial two hours of making sure the resident was safe before sending one aide home and suspending the other. She said they conducted a skin assessment and concluded the incident did not rise to the level of substantial abuse and neglect. Then she described what happened with the state report: she did not click the verification link sent to her email to submit it to the Arizona Department of Health Services. When she eventually tried, the link had expired. "They would fix their reporting processes moving forward," she told inspectors.
Staff #34 said she was not suspended until 11 a.m. the day after the incident.
The facility's own written policy, revised in January 2024, required reports of abuse, neglect, or exploitation to go out immediately, and no later than two hours, to a list of parties that included the state agency, the ombudsman, the resident's representative, Adult Protective Services, law enforcement, the physician, and the medical director. The registered nurse on staff told inspectors the policy also required immediate notification to the administrator, and that if an allegation came in outside of business hours, staff were expected to leave a message, try to reach the Director of Nursing, and confirm the resident was safe.
The Director of Nursing and the executive director both told inspectors the reporting window was two hours. Neither disputed that the report to the state did not go out within that window. The expired link was the executive director's explanation for why the submission never completed.
Inspectors attempted a phone interview with the licensed practical nurse who had entered the shower to assist the resident. There was no response.
What the inspection record captures most plainly is the sequence: a resident who asked twice for help and was made to wait, who cried on the way to the shower, who was left alone for half an hour, who screamed, who was told to calm down, who was left alone again, who sent an email from her room the moment she got back to it, and whose report to the state then sat unsubmitted because a verification link in an executive director's inbox went unclicked until it expired.
The resident had told the aides she was going to report them to the state before she ever reached her room. She did exactly that. What happened to her report after it left her hands is its own story.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: October 18, 2026 · Our methodology
HAVEN OF SEDONA in SEDONA, AZ was cited for violations during a health inspection on August 19, 2025.
The incident unfolded on a day when the certified nursing assistant regularly assigned to Resident #11 had left her shift 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.