SEDONA, AZ. Resident #11 got a new roommate without advance notice, and nobody at Haven of Sedona documented the change in their medical record.
Federal inspectors responding to a complaint found the facility violated resident rights regulations by failing to provide written notification before changing roommate assignments. The violation affected few residents but represented a breakdown in basic documentation requirements that nursing homes must follow.
The facility's own policy, revised in January 2024, required advance written notice before any roommate change. That notice must explain why the change was being made. Staff also must document room changes in the resident's medical record.
None of that happened for Resident #11.
During interviews on August 19, the facility's Resident Rights Manager reviewed the clinical record and confirmed there was no documentation of a roommate change notification. The manager acknowledged staff should have completed the notification but failed to do so.
The Director of Nursing told inspectors that best practice required nursing staff to document room changes as progress notes in clinical records. She expected social services to complete their documentation for roommate changes and upload completed forms into resident files.
Haven of Sedona's written policy states that room or roommate assignments may change if the facility deems it necessary, but resident preferences must be taken into account. The policy requires advance written notice before any change occurs.
The inspection report notes that residents have the right to choose or decline a roommate, and the notification form includes that option. Without proper notification, residents cannot exercise this fundamental right.
Federal regulations protect nursing home residents' rights to participate in decisions affecting their living arrangements. Roommate assignments directly impact residents' daily quality of life, privacy, and comfort. When facilities fail to provide required notifications, residents lose their ability to voice preferences or concerns about living arrangements.
The violation occurred despite clear facility policies outlining proper procedures. Staff knew the requirements but failed to follow them, leaving Resident #11 without the advance notice guaranteed under federal law.
The Resident Rights Manager's admission that staff "should have completed the notification but failed to do so" highlights a gap between written policies and actual practice at the facility. Documentation failures prevent residents from understanding changes to their living situations and exercising their rights to object or request alternatives.
Haven of Sedona operates at 505 Jacks Canyon Road in Sedona. The complaint inspection was completed August 19, 2025, with inspectors finding the facility failed to meet federal standards for resident rights and documentation requirements.
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.