Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Payson Care Center during CMS and state inspections, most recent first.
A resident with multiple health conditions and high risk for skin breakdown did not receive consistent weekly skin assessments as required by facility policy. CNAs documented several new skin issues, including blisters and bruising, but there was no evidence that nurses performed further assessments, notified providers, or obtained new treatment orders. The DON confirmed that scheduled skin checks were missed and follow-up on new findings was not documented.
A facility failed to obtain informed consent from a resident before administering Duloxetine and Trazodone for depression. The resident's care plan included these medications, but the required consents were not completed, as confirmed by staff interviews. The facility's policy mandates obtaining consent before starting psychotropic medications, which was not adhered to in this case.
The facility failed to maintain an effective training program for five staff members, leading to incomplete training in dementia, infection prevention, resident rights, and abuse. Personnel files and interviews confirmed the lack of documentation for required training, despite multiple requests. The facility's policy mandates regular training, which was not adhered to, resulting in a deficiency.
The facility failed to ensure that five staff members received ongoing education on abuse, neglect, exploitation, and dementia care. Personnel files and interviews revealed that required annual training for 2024 and 2025 was not completed by a CNA, OT, LPN, another CNA, and an RN. Interviews with management highlighted the facility's expectations for training completion, but documentation was lacking. This deficiency could lead to a deficit in staff knowledge and skills, potentially affecting resident care.
Two residents with severe cognitive impairment were involved in an altercation, resulting in a deficiency due to the facility's failure to prevent abuse. The incident involved physical aggression, and the facility's investigation was incomplete, lacking documentation and assessments of harm. Staff interviews revealed both residents exhibited aggressive behaviors, but the facility did not adequately address the situation.
A facility failed to document and retain evidence of an investigation into an altercation between two residents with severe cognitive impairments. The incident involved physical aggression, but the facility did not complete a thorough investigation or retain necessary documentation. Staff interviews revealed that both residents exhibited aggressive behaviors, making altercations plausible. Despite understanding the importance of proper investigation, the facility did not meet its own expectations for documentation and evidence retention.
The facility failed to issue timely Medicare Non-Coverage notices to two residents. One resident with Alzheimer's was informed of the end of Medicare services on the same day, leaving no time for appeal. Another resident, cognitively intact, did not receive the required SNF ABN form. Staff interviews revealed confusion about determining the last covered day of service.
A resident with bilateral lower extremity amputations experienced a delay in receiving a left leg prosthetic due to missing documentation, despite measurements being completed. The resident was not included in the restorative therapy caseload, and the facility's records lacked a care plan for the amputation. This delay hindered the resident's ability to ambulate, contrary to the facility's Prosthesis Care and Management policy.
A resident admitted for orthopedic aftercare following a lower extremity amputation did not receive necessary restorative nursing services, despite recommendations from therapy discharge summaries. The resident was not on the facility's restorative therapy caseload, and there was no documentation of a Restorative Care Referral form. Interviews with staff confirmed the lack of evidence supporting the resident's participation in restorative therapy, which does not meet facility expectations.
A resident with moderate cognitive impairment and mobility issues experienced multiple falls, resulting in injuries, due to inadequate supervision and failure to implement fall prevention measures. Despite having a care plan, there was no evidence of specific interventions, and staff interviews revealed inconsistencies in communication and execution of fall checks. The facility's policy required updates to the care plan after falls, but this was not done, highlighting a deficiency in fall prevention.
A resident with a history of falls and moderate cognitive impairment experienced a fall due to inadequate supervision and failure to address behavioral changes. Despite signs of restlessness and confusion, the facility did not implement effective interventions, resulting in the resident being found on the floor with labored breathing. Incomplete documentation and lack of communication among staff contributed to the deficiency.
A resident with multiple health issues required continuous oxygen therapy, but the facility failed to provide a specific oxygen dose in the physician's order and did not consistently document the dose. Interviews with staff revealed that the facility's process for administering oxygen was not followed, as the order lacked necessary parameters and the care plan did not include oxygen use details.
A resident with a history of falls was found on the floor with labored breathing and twitching, but the facility failed to document the incident accurately. Despite staff observations and actions taken, the clinical record lacked evidence of the fall and necessary assessments, contrary to facility policies. Interviews revealed that the facility's process for handling falls was not followed, resulting in incomplete documentation.
Multiple residents with cognitive impairments engaged in physical altercations, resulting in injuries and a lack of timely care plan updates or skin assessments. Staff supervision was inconsistent, with periods where residents were left unsupervised despite known behavioral risks. Additionally, a CNA was reported by several residents and a family member for verbal and physical abuse, with evidence of neglect in care provision. The facility's documentation revealed failures to follow internal and federal reporting and investigation procedures for abuse incidents.
A resident with dementia and behavioral issues struck another resident and used inappropriate language, but the facility did not complete an incident report, conduct an investigation, or update the care plan. The DON was unaware of the event, and required abuse prevention and reporting procedures were not followed.
A resident with dementia struck another resident with a rolled-up newspaper and used inappropriate language, but the incident was not reported, assessed, or investigated by staff. The DON and Administrator were unaware of the event until the survey, and there was no evidence of timely reporting to the State Agency or mandated entities as required by policy and regulation.
A resident with dementia and ongoing behavioral issues struck another resident with a rolled-up newspaper and used inappropriate language, but the facility did not complete an incident report, conduct an investigation, or update the care plan. The DON and Administrator confirmed the event was not reported or managed according to policy, and no interventions were documented to ensure resident safety.
A resident with dementia and behavioral issues struck another resident and used inappropriate language, but staff failed to complete an incident report, conduct an assessment, or update the care plan. The DON was unaware of the event, and required documentation and investigation procedures were not followed.
Failure to Adequately Assess and Treat Resident Skin Conditions
Penalty
Summary
The facility failed to ensure that a resident's skin was adequately assessed and treated according to professional standards and facility policy. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, obesity, and recent orthopedic aftercare, was identified as high risk for skin breakdown. The care plan required weekly skin checks and treatment as ordered, but there was no evidence of a physician's order for weekly skin checks, and documentation of these assessments was inconsistent or missing. Multiple skin issues were documented by CNAs on shower sheets, including a popped blister on the sacral region, blisters on the chest, red spots on the abdomen, and bruising on the arm. Despite these findings, there was no evidence that nurses completed further skin assessments, notified providers, or obtained new treatment orders for the newly identified skin conditions. The clinical record lacked documentation of follow-up assessments or interventions for these issues, and scheduled skin assessments were missed without follow-up. Interviews with staff confirmed that the expected process was for CNAs to report new skin findings to nurses, who would then assess, notify providers, and document actions taken. The Director of Nursing acknowledged that the required weekly skin assessment was not completed and that there was no documentation or follow-up on new skin issues identified by CNAs. The facility's policy required comprehensive skin assessments on admission and weekly thereafter, but these procedures were not consistently followed for this resident.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from a resident before administering psychotropic medications, specifically Duloxetine and Trazodone. Resident #23, who was admitted with diagnoses including pneumonitis, respiratory failure, and chronic obstructive pulmonary disease, was prescribed Duloxetine for depression. However, the consent form for this medication was not signed by the resident or a representative, and it lacked information on non-drug approaches, the reason for the prescription, and expected benefits. The resident's care plan included the use of antidepressants, and the Medication Administration Records showed that Duloxetine and Trazodone were administered. Despite this, there was no evidence of a signed informed consent for Trazodone prior to March 5, 2025. Interviews with staff, including an LPN and the interim DON, confirmed that the required consents were not completed before administering these medications, which did not meet facility expectations. The facility's policy on psychotropic medication informed consent, reviewed in September 2024, mandates obtaining consent before starting such medications. The policy emphasizes that the resident or their representative must understand the benefits and risks associated with the medication. The lack of completed consents for Duloxetine and Trazodone before administration indicates a failure to adhere to this policy, potentially impacting the resident's ability to make informed decisions about their treatment.
Deficient Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for five out of nine sampled staff members, which could lead to a deficit in staff knowledge and skills affecting resident care. The personnel files and training records revealed that several staff members did not complete required annual training for dementia, infection prevention and control, resident rights, and abuse for the years 2024 and 2025. Specifically, a CNA hired in 2010, an OT hired in 2024, an LPN hired in 2020, another CNA hired in 2021, and an RN hired in 2023 were all found to have incomplete training records. Interviews with the Business Office Manager and other staff members confirmed the lack of documentation for training completion. The Business Office Manager was unable to provide proof of training completion for several staff members, despite multiple document requests. The interim director of nursing and the regional director of clinical services acknowledged the facility's expectations for training completion and the risks associated with not maintaining proper training records. The facility's policy on education and training requirements mandates that training on topics such as abuse, dementia management, infection control, and resident rights should be completed prior to providing services independently, annually, and as needed based on the facility's assessment. The facility's assessment requires quarterly training for resident rights and abuse, including dementia care, and annual training for infection prevention and control. The failure to adhere to these requirements was identified as a deficiency in the facility's training program.
Deficiency in Staff Training on Abuse and Dementia Care
Penalty
Summary
The facility failed to ensure that five out of nine sampled staff members received ongoing education on abuse, neglect, exploitation, and dementia care. This deficiency was identified through a review of personnel files, staff interviews, and facility policy review. Specifically, the certified nursing assistant (CNA), occupational therapist (OT), licensed practical nurse (LPN), another CNA, and a registered nurse (RN) did not complete the required annual training for dementia and abuse for the years 2024 and 2025. The lack of training could lead to a deficit in staff knowledge and skills, potentially affecting resident care and leading to harm. Interviews with the Business Office Manager, interim director of nursing, regional director of clinical services, and the executive director revealed that the facility had expectations for training completion and maintaining documentation. However, they were unable to provide proof of training completion for several staff members. The facility's policy required that training on topics such as abuse and dementia management be completed prior to independently providing services, annually, and as necessary based on the facility's assessment. Despite these requirements, the facility did not maintain adequate records of training completion, which could result in incompetent care and services being provided.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by each other, resulting in a deficiency. Resident #104, who was readmitted with severe cognitive impairment and multiple diagnoses including PTSD and vascular dementia, was involved in an altercation with Resident #400. The incident occurred when Resident #400 punched Resident #104 and attempted to push them, which was witnessed by a CNA. Both residents had a BIMS score of 00, indicating severe cognitive impairment, and exhibited behaviors such as exit-seeking and aggression. The facility's documentation and investigation into the incident were incomplete. The report submitted to the Department of Health Services lacked supporting documentation of the facility's investigation, and there were no assessments of the residents' cognition or psychosocial and physical harm following the incident. Interviews with staff revealed that both residents were ambulatory and had a history of aggressive behaviors, making altercations plausible. However, the facility did not adequately document or investigate the incident to prevent further occurrences. Interviews with the interim director of nursing and the executive director highlighted an understanding of the importance of identifying, reporting, and investigating incidents. However, the facility's expectations for notifying the chain of command and completing investigations were not met. The facility's policy on abuse identification outlined risk factors and defined abuse, but the failure to execute these expectations led to the deficiency.
Failure to Document and Investigate Resident Altercation
Penalty
Summary
The facility failed to ensure proper documentation and evidence retention of an investigation into an alleged incident between two residents. Resident #104, who was readmitted with severe cognitive impairment and other behavioral disturbances, was involved in an altercation with Resident #400, who also had severe cognitive impairment. The incident involved Resident #400 allegedly punching and attempting to push Resident #104, which was witnessed by a CNA. However, the facility did not retain documentation of a thorough investigation or assessments of the residents' cognition or harm following the incident. The report indicates that the facility submitted an incomplete reportable event record to the Department of Health Services, lacking documentation supporting the investigation. Interviews with staff revealed that both residents exhibited exit-seeking behaviors and aggression, making altercations plausible. Despite this, the facility was unable to provide documentation of the investigation when requested, indicating a failure to complete a thorough investigation and retain necessary evidence. Interviews with the executive director and other staff members highlighted an understanding of the importance of identifying, reporting, and investigating alleged incidents. However, the facility did not meet its own expectations for notifying the chain of command and ensuring a complete investigation. The facility's policies on abuse and investigation require thorough evidence collection and review, which were not adhered to in this case.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required written notices of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to two residents within the mandated timeframe. One resident, who had Alzheimer's disease and other mobility-related diagnoses, was not issued the NOMNC and SNF ABN until the day Medicare services were set to end, which was February 3, 2025. The resident's power of attorney was verbally informed on the same day, which did not allow sufficient time for the resident to appeal the decision or prepare for discharge. The facility's policy requires these notices to be given at least two days before the end of Medicare Part A stay or when Part B therapies are ending. Another resident, who was cognitively intact and had undergone orthopedic aftercare, was not provided with the SNF ABN form at all, despite the end of Medicare services on December 20, 2024. Interviews with the Social Services Director and Business Office Manager revealed a lack of understanding of how to determine the last covered day of service and the necessity of issuing the SNF ABN form. The facility's policy states that the SNF ABN should be issued if the beneficiary intends to continue services that may not be covered by Medicare, informing them of potential financial liability.
Failure to Provide Timely Prosthetic Care
Penalty
Summary
The facility failed to provide appropriate care and assistance for a resident with a prosthetic device, specifically in preparing the left prosthetic device for use. The resident, who was readmitted following an amputation of the left lower extremity, had a history of Type 2 Diabetes Mellitus, bilateral lower extremity amputations, muscle weakness, and limited activity due to disability. Despite the resident's eagerness to receive the left leg prosthetic and the completion of measurements, there was a significant delay in obtaining the prosthetic device, which was attributed to the need for additional documentation from the provider. The clinical records did not reflect a care plan for the left lower extremity amputation or an order for prosthetic follow-up. The resident expressed frustration and concern over the delay, fearing muscle weakness due to the prolonged wait. Interviews with staff revealed that the resident was not on the restorative therapy caseload, despite the existence of a special treatment plan for residents with prosthetic needs. The delay was further compounded by the lack of a signed and dated letter of medical necessity, which was only drafted on March 6, 2025. The facility's Prosthesis Care and Management policy mandates that residents with prosthetic devices receive the necessary care and assistance to use their prostheses. However, the resident's inability to ambulate due to the delay in receiving the prosthetic device highlights a failure to meet this policy. The resident attended prosthetic fitting appointments, but the lack of a timely follow-up and the absence of a comprehensive care plan contributed to the deficiency identified by the surveyors.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to ensure that a resident received the necessary restorative nursing services to attain their highest level of health and well-being. The resident, who was admitted for orthopedic aftercare following a lower extremity amputation, did not receive the recommended restorative nursing services, including training and skill practice in amputation/prostheses care. Despite recommendations from both Occupational and Physical Therapy discharge summaries, the resident did not participate in the restorative nursing program during the assessment period, and there was no documentation to support the initiation or completion of a Restorative Care Referral form. Interviews with the resident and staff revealed that the resident was not on the facility's restorative therapy program caseload, and the resident did not recall being offered participation in the program. The Rehabilitation Director and the RNA confirmed the lack of evidence supporting the resident's participation in restorative therapy, which does not meet facility expectations. The facility's policies on Activities of Daily Living and Restorative Nursing were not adhered to, as the resident's needs for restorative care were not addressed, despite being identified as a fall risk with decreased mobility and functional task participation.
Inadequate Supervision and Fall Prevention for Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident with moderate cognitive impairment and a history of falls. The resident, who was admitted with diagnoses including osteoporosis and mobility issues, experienced multiple falls within a short period. Despite having a care plan, there was no evidence of specific interventions related to falls before or after each incident. The resident's clinical record documented falls on several occasions, resulting in injuries such as rib fractures and a T1 compression fracture. Interviews with staff revealed inconsistencies in the communication and implementation of fall interventions. A CNA mentioned being informed of fall interventions through nurses or fall packets, while an LPN noted the resident was on a restorative program and had an active order for 15-minute checks. However, another CNA was unaware of any 15-minute checks being conducted, and there was no documentation to support that these checks were performed. The health information management director confirmed the absence of 15-minute check forms for the resident, indicating a lapse in the facility's monitoring process. The facility's policy on fall management required assessment and intervention updates following a fall event, but the care plan was not revised accordingly. The Director of Nursing acknowledged the importance of 15-minute checks to prevent further falls and injuries, yet the lack of documentation and execution of these checks highlighted a deficiency in the facility's fall prevention measures. The failure to implement and document appropriate interventions placed the resident at risk of additional harm.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident with a history of falls and moderate cognitive impairment. The resident, who was admitted with diagnoses including spinal stenosis and chronic kidney disease, experienced a significant change in behavior, including hallucinations and agitation, which was not promptly addressed by the staff. Despite the resident's increased restlessness and confusion, the facility did not implement effective interventions to prevent a fall. On the morning of the incident, the resident was found on the floor by a CNA, exhibiting labored breathing and twitching. The resident had been restless and pulling off his oxygen cannula earlier, but the staff did not adequately monitor or intervene to prevent the fall. The facility's documentation was incomplete, with missing progress notes, fall assessments, and neurochecks, indicating a lack of proper follow-up and communication regarding the resident's condition. Interviews with staff revealed inconsistencies in the reporting and handling of the resident's condition. The DON was unaware of the resident's hallucinations and confusion prior to the fall, and the facility's policies on incident management and change in condition were not followed. The failure to recognize and address the resident's behavioral changes and the lack of documentation and communication contributed to the deficiency in providing a safe environment for the resident.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory services according to professional standards for a resident who required continuous oxygen therapy. The resident, who had a history of spinal stenosis, chronic kidney disease, polyneuropathy, and falls, was admitted with a physician's order for continuous oxygen via nasal cannula. However, the order lacked specific instructions or information regarding the oxygen dose. The care plan for the resident did not include any details about oxygen use, and the O2 Sats Summary log showed inconsistencies in documenting the oxygen dose, with only one entry specifying a dose of 3 liters. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed that the facility's process for administering oxygen was not followed. The RN stated that every resident on oxygen should have a physician's order specifying the dose, which was not the case for this resident. The DON confirmed that the oxygen order lacked parameters for the dose and that the dose was not consistently charted, which did not meet the facility's expectations for providing respiratory care. The facility's policy on oxygen administration required a specific liter flow to be indicated in the order, which was not adhered to in this instance.
Incomplete Documentation of Resident Fall Incident
Penalty
Summary
The facility failed to ensure that the medical record for a resident was complete and accurate, which could lead to interdisciplinary team members not being aware of the resident's status and potentially result in a gap in care. The resident, who was admitted with diagnoses including spinal stenosis, chronic kidney disease, polyneuropathy, and a history of falling, experienced an incident on January 19, 2025. The resident was found on the floor by a CNA, exhibiting labored breathing and twitching, and was subsequently sent to the hospital. However, the clinical record lacked documentation of any falls or incidents where the resident was found on the ground, and the fall assessments and neurocheck documents were incomplete and unsigned. The report details that on the morning of the incident, the resident was restless and anxious, removing his nasal cannula and attempting to climb out of bed. Despite these observations, there was no evidence in the clinical record of a fall event or the necessary documentation following such an incident. A witness statement from a CNA indicated that the resident was found face down on the floor with labored breathing, and the nurse on duty assessed the resident and called for emergency services. However, the facility's documentation did not reflect these events accurately, as required by their policies. Interviews with staff, including the DON, revealed that the facility's process for handling falls was not followed. The DON acknowledged the absence of documentation regarding the falls, post-fall assessments, neurochecks, and skin or pain assessments. The facility's policies require that any change in a resident's condition, such as a fall, be documented thoroughly, including assessments and notifications to relevant parties. The lack of complete and accurate documentation in this case did not meet the facility's expectations and standards.
Failure to Prevent and Address Resident and Staff Abuse
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving both resident-to-resident and staff-to-resident abuse. In several cases, residents with significant cognitive impairments and behavioral disturbances engaged in physical altercations with each other. For example, one resident with dementia and a history of behavioral issues struck another resident with a rolled-up newspaper and later with a book, causing a skin tear. There was no evidence that the care plan was updated after these incidents, nor that a skin assessment was completed following the injury. Additionally, there was no documentation of room changes or increased staff monitoring to ensure resident safety after these altercations. Another incident involved two residents, both with severe cognitive impairments, where one resident sat on another who was sleeping, resulting in the latter striking the former in the face. Although the residents were separated and placed on 15-minute checks, the documentation and interviews revealed that staff supervision was inconsistent, and staff were not always present or able to effectively monitor and redirect residents exhibiting aggressive behaviors. Staff interviews confirmed that staffing levels were sometimes insufficient to provide adequate supervision, and that staff had to leave residents unsupervised while attending to other duties. The facility also failed to prevent and address staff-to-resident abuse. One resident, who was cognitively intact but physically dependent, reported that a CNA was rude, rough, and failed to provide necessary care, such as changing and responding to call lights. Additional complaints from other residents and a family member corroborated these allegations, indicating a pattern of neglect and verbal abuse by the same staff member. The facility's policies required prompt investigation and separation of alleged abusers, but the report identified discrepancies between facility policy and federal guidelines regarding the timeliness of reporting abuse. The documentation showed that the facility did not always follow its own procedures for reporting, investigating, and updating care plans in response to abuse allegations.
Failure to Implement Abuse Prevention and Investigation Procedures
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, as evidenced by the handling of an incident involving a resident with dementia and other medical conditions. The resident, who was rarely or never understood according to the MDS assessment, exhibited ongoing behavioral issues, including removing items from nurse carts, interfering with care, and entering peers' rooms. On one occasion, the resident struck another resident with a rolled-up newspaper and used inappropriate language, but there was no evidence that an incident report or assessment was completed following this event. Additionally, the facility did not conduct a thorough investigation of the incident, nor were interventions put in place to ensure resident safety during the investigation. The care plan for the resident was not updated after the incident, and the DON was unaware of the event until it was brought to her attention during the survey. Facility policy required prompt investigation, reporting, and implementation of safety interventions in cases of alleged abuse, but these procedures were not followed in this instance.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported immediately, but not later than two hours, to the State Agency and mandated entities. Specifically, a resident with dementia and other medical conditions struck another resident with a rolled-up newspaper and used inappropriate language during an interaction. Documentation showed that no incident report or assessment was completed following this event, and there was no evidence that the incident was reported to the appropriate authorities as required. Interviews with the DON and Administrator revealed that neither was aware of the incident until it was brought to their attention during the survey. The DON confirmed that the event was not reported, investigated, or communicated to the state agency, which did not meet her expectations for handling resident-to-resident incidents. Review of facility policies and federal regulations highlighted a discrepancy in reporting timeframes, but the facility's failure was in not reporting the incident at all within the required period.
Failure to Investigate and Prevent Further Abuse Following Resident-to-Resident Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse and did not implement measures to prevent further potential abuse during the investigation of an incident involving a resident. Specifically, after a resident with dementia and a history of behavioral issues struck another resident with a rolled-up newspaper and used inappropriate language, there was no evidence that an incident report or assessment was completed. The clinical record did not show that the incident was reported to the Director of Nursing (DON) or the state agency, nor was there documentation of an internal investigation or any interventions to ensure resident safety during the period following the incident. Additionally, the resident's care plan, which already noted behavioral issues, was not updated after the incident. Interviews with the DON and Administrator confirmed that the incident was not reported or investigated according to facility policy, which requires prompt reporting, investigation, and implementation of safety interventions. Facility policies reviewed also mandate separation of residents and assessment for injury in such cases, but there was no evidence these steps were taken.
Failure to Document and Investigate Resident-to-Resident Incident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with multiple diagnoses, including dementia, anemia, type 2 diabetes mellitus, and dysphagia. The resident had a history of behavioral issues, as documented in both the quarterly MDS assessment and behavior notes, which included actions such as removing items from walls and nurse carts, urinating in the hallway, interfering with peers' care, and tampering with safety equipment. On a specific date, a health status note documented that the resident struck another resident with a rolled-up newspaper and used inappropriate language, but there was no evidence that an incident report or assessment was completed following this event. Further review revealed that the facility did not conduct a thorough investigation of the incident, nor were interventions implemented to ensure resident safety during the period following the event. The resident's care plan, which previously addressed behavioral issues, was not updated to reflect the new incident. The Director of Nursing confirmed during an interview that she was unaware of the incident and acknowledged that the expected procedures for managing and documenting resident-to-resident incidents were not followed. Facility policies require comprehensive documentation and investigation of such events, but these standards were not met in this case.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 2 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Payson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rim Country Health & Retirement Community | 0.8 mi | ★★★★★ | 2 | 0 |
| Haven Of Camp Verde | 38.1 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.