Haven of Sedona: Abuse Report Failures Cited - AZ
She was left alone in the shower room for thirty minutes. When the aide returned, the resident was screaming. Staff got her dressed and into her wheelchair. Then the resident told them she was going to report them.
She did it herself. She wheeled back to her room and sent an email.
What happened next at Haven of Sedona is the subject of a federal complaint inspection completed August 19, 2025, one that found the facility failed to report an allegation of abuse to state authorities within the required timeframe, and that the executive director let the reporting window close entirely because she didn't click a link in an email.
The resident's account, as documented by inspectors, begins with a shower that went wrong. A certified nursing assistant, identified in inspection records as Staff #46, left the shower room after the resident dropped something. Thirty minutes passed. When Staff #46 came back, the resident was screaming. Staff got her dressed and into her wheelchair. The resident then said she intended to report them.
She made good on it immediately. She wheeled herself to her room and sent an email. The charge nurse, upon learning what happened, texted the executive director, Staff #29, to report it right away.
That text went out the same night.
The executive director received the email notification at 10:16 p.m. She did not check her email that night. She saw it the next morning, around 10 a.m., nearly twelve hours after it arrived.
In an interview with inspectors, the executive director described what she did after reading it. She reviewed the situation. The facility conducted what she called "the initial 2 hours of making sure the resident was safe." One aide was sent home. The other was suspended. A skin assessment was performed. The executive director concluded the findings were "not substantial for abuse and neglect."
Then she tried to file the report with the state.
The verification link in the reporting email had expired.
"She did not click the verification link sent to her email to submit the report to the State Agency," inspection records state, "and when she attempted to click the link it expired."
The executive director told inspectors they would fix their reporting processes going forward.
The second aide, Staff #34, was not suspended until the following morning at 11:00 a.m. In her interview with inspectors, conducted at 1:30 p.m. on the day of the inspection, Staff #34 said she understood that allegations of abuse or neglect must be reported within two hours. She said she had reported the resident's allegations to the nurse immediately after they occurred, and that the nurse had notified the supervising nurse and the oncoming shift.
The charge nurse had texted the executive director the same night. The facility's own chain of notification had worked. The resident had reported herself. The nurse had escalated immediately. The text had gone to the top.
None of it produced a timely state report.
A registered nurse identified as Staff #58 told inspectors during a 2:24 p.m. interview that the facility's policy required reporting immediately to the administrator. If an allegation occurred outside of business hours, staff were supposed to leave a message, try to reach the Director of Nursing, and ensure the resident was safe.
The Director of Nursing and the executive director, interviewed together at 2:32 p.m., both stated the reporting timeframe was two hours. The executive director's account of the night in question did not explain why, having received a text from the charge nurse and an email notification, she did not check either until the following morning.
The facility's own written policy, a document titled "Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation — Reporting and Investigating," revised in January 2024, required that all reports of abuse, neglect, or exploitation be reported immediately, and no later than within two hours, to the state agency, the ombudsman, the resident's representative, Adult Protective Services, law enforcement, the physician, and the medical director.
The resident had reported her own aides. The charge nurse had texted the executive director within the hour. The executive director had a phone. She had email. She had a policy on her books that she had revised fourteen months before this incident occurred.
The state never got the report on time. The link expired.
What the inspection record does not resolve is what the resident experienced in that shower room during those thirty minutes. The inspection documents the screaming. It documents the skin assessment the executive director ordered, and her conclusion that the findings did not rise to the level of abuse or neglect. It does not document what the resident said she experienced, beyond the fact that she was determined enough to wheel herself back to her room and send an email about it the same night it happened.
She reported herself. She did the thing the facility was supposed to do, faster than the facility did it, and from a wheelchair.
The executive director told inspectors the facility would fix its reporting processes. The inspection was classified at a level of minimal harm or potential for actual harm, affecting few residents. The two aides were suspended. The skin assessment found nothing the executive director considered substantial.
The resident's email sat in an inbox until morning.
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.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
HAVEN OF SEDONA in SEDONA, AZ was cited for abuse-related violations during a health inspection on August 19, 2025.
She was left alone in the shower room for thirty minutes.
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.