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 Rocky Mountain Care - Maple Dell during CMS and state inspections, most recent first.
A resident with cerebral infarction, dementia, and HTN was given a roommate’s full med pass after incorrect room assignments on the nursing report sheet and failure to verify identity against the MAR. The error included antihypertensives, antidiabetics, an anticoagulant, and other meds, and the resident developed hypoglycemia, severe hypotension, and decreased responsiveness, requiring hospitalization for toxic encephalopathy and accidental drug overdose.
The facility was found to have deficiencies in food storage, preparation, and sanitation. Observations revealed unlabeled and unsealed food items, improper dish machine temperatures, and staff handling food with bare hands. The kitchen was also noted to be unclean, with personal items in the food preparation area.
A resident with multiple health conditions did not receive their prescribed fentanyl patch for several days due to a pharmacy error and lack of follow-up by the nursing staff. The resident's dosage was changed from a single 37.5 mcg patch to two patches totaling 37 mcg, but the medication was not delivered, and the staff failed to verify its receipt.
The facility failed to meet the nutritional needs of residents, as observed in small portion sizes and resident complaints. During lunch service, residents received inadequate portions, such as chicken pieces the size of a silver dollar. One resident reported poor meal quality the previous day. The Registered Dietitian was unsure about test tray records, and the Dietary Manager noted a cook needed more training. Observations showed inconsistencies in portion sizes, indicating non-compliance with nutritional guidelines.
The facility failed to provide palatable and properly heated meals, leading to resident complaints about cold, flavorless food and inadequate portions. A test tray confirmed the food was below recommended temperatures and lacked seasoning. The new Dietary Manager acknowledged the issues, noting a need for better training for staff.
A registered nurse in an LTC facility failed to perform hand hygiene and used bare hands to handle medications during a medication pass. This breach in infection control protocol was observed during the administration of medications to two residents. Interviews with staff confirmed that hand hygiene was required and that medications should not be touched with bare hands.
The facility failed to maintain an effective pest control program, resulting in a significant presence of flies affecting multiple residents. Observations revealed flies on residents and in common areas, with staff acknowledging the issue and attributing it to frequently opened doors. Despite some measures, such as installing a fly light and residents purchasing their own fly swatters, the problem persisted, causing discomfort and dissatisfaction.
The facility failed to investigate allegations of neglect and abuse for five residents, leading to deficiencies in care. One resident experienced a fall resulting in a hip fracture, another sustained a laceration with unclear origins, and a third alleged neglect by a CNA. Two other residents had incidents involving falls and neglect allegations, but investigations were incomplete or inconclusive, highlighting systemic issues in the facility's response to such allegations.
The facility failed to implement effective policies for monitoring and addressing deficiencies, including abuse reporting, pain management, medication availability, and infection control. Recurring issues were noted in food quality and safety, with inadequate labeling and handling of medications. Despite regular QAPI meetings, the facility did not effectively address these ongoing issues.
A resident with chronic pain did not receive prescribed Fentanyl patches for several days due to a change in prescription and miscommunication with the pharmacy. Despite the resident's complaints of pain, the facility staff failed to ensure the availability of the medication, resulting in a deficiency in pain management.
The facility was found to have deficiencies in medication handling and storage, including leaving medication carts unlocked and unattended, using insulin pens past expiration, and improperly repackaging narcotics. Observations revealed that medication carts were left open with resident information visible, and insulin pens were used beyond the recommended 28-day period. Additionally, narcotics were taped back into medication cards, contrary to facility protocol, indicating a lack of staff understanding and adherence to proper procedures.
The facility did not employ a full-time Registered Dietitian (RD) or a clinically qualified nutrition professional as the director of nutrition services. The Dietary Manager (DM) lacked the required certification and was still in training. The RD visited weekly and was available for consultation, but the DM had only recently started and was not yet certified.
The facility failed to report alleged violations involving abuse, neglect, or mistreatment to the State Survey Agency within the required timeframe for two residents. A resident with multiple medical conditions experienced a fall while using a mechanical lift, which was not reported. Another resident had an unwitnessed fall resulting in a hip fracture, and the incident was not reported within the required two-hour window. The facility's reporting process was found to be deficient.
Significant Medication Error Due to Incorrect Room Assignment and Failed Resident Identification
Penalty
Summary
Ensure that residents are free from significant medication errors was not met when a resident was inadvertently given a complete medication pass intended for the roommate. The resident had diagnoses including cerebral infarction, dementia, and hypertension. At about 9:00 AM, the resident received 13 medications meant for the roommate, including amlodipine, furosemide, clonidine, metformin, glimepiride, saxagliptin, apixaban, and Lyrica. The error occurred because the room assignments on the nursing report sheet were incorrect, and the agency nurse who administered the medications did not verify the resident’s identity against the MAR. After the medication error, the resident’s blood glucose decreased from 138 mg/dL to 87 mg/dL and blood pressure dropped to 67/48 mmHg. The resident was documented as sleepy and arousable only with painful stimuli. Hospital discharge summaries showed the resident required a three-day hospitalization for toxic encephalopathy and hypotension due to accidental drug overdose and hypoglycemia.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility was found to have several deficiencies in its food storage, preparation, and sanitation processes. During an initial walk-through of the kitchen, it was observed that food items in the walk-in freezer and refrigerator were not properly labeled or sealed, leaving them open to air. This included packages of a green substance, beef patties, cookie dough, and other items. Additionally, personal items belonging to kitchen staff were found in the food preparation area, which is against professional standards for food service safety. The dish machine used for cleaning dishware was not operating at the required temperatures necessary for proper sanitation. Multiple observations showed that the wash and rinse temperatures were consistently below the required levels, with the wash temperature often below 160 degrees Fahrenheit and the rinse temperature below 180 degrees Fahrenheit. The temperature logs for the month of August revealed numerous instances where the temperatures did not meet the necessary standards, and there were even days when no temperatures were documented at all. This failure to maintain proper sanitation temperatures poses a risk of foodborne bacteria. Furthermore, kitchen staff were observed handling food with bare hands, which is a violation of food safety protocols. One staff member was seen pulling apart dinner rolls and filling cups with brown sugar using her bare hands. The kitchen was also noted to be unclean, with food splatter on the stove, crumbs on the griddle, and greasy surfaces. Interviews with dietary aides and the dietary manager revealed a lack of awareness and adherence to the required temperature standards for the dish machine, as well as inadequate monitoring and maintenance of the equipment.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to provide routine and emergency pharmaceutical services to a resident, identified as Resident 16, who was not administered medications as ordered by the physician due to unavailability from the pharmacy. Resident 16, who had multiple diagnoses including type II diabetes mellitus, vascular dementia, and chronic pain, was observed questioning the RN about the absence of his fentanyl patch, which had been unavailable for a week. The RN confirmed the change in dosage from a single 37.5 mcg patch to two patches totaling 37 mcg, but was unsure of the reason for the change. The resident's medical records indicated that the fentanyl patch was not administered from 8/21/24 to 8/26/24 due to the drug being unavailable or waiting for the correct dosage patches. Interviews with the RN and the Director of Nursing (DON) revealed a communication error with the pharmacy, which led to the resident not receiving his medication. The pharmacy could no longer provide the 37.5 mcg dose and instead offered a combination of two patches to equal 37 mcg. However, the pharmacy did not send the medication, and the nurses continued to order it without verifying its receipt. The DON acknowledged that the resident should not have gone without his pain medication and recognized the need for clarification and follow-through in the medication ordering process to prevent such occurrences.
Deficiency in Nutritional Menu Compliance
Penalty
Summary
The facility failed to provide menus that met the nutritional needs of residents, as evidenced by observations and resident complaints about portion sizes. Specifically, four residents were affected by this deficiency. During a lunch service observation, residents were served portions that were smaller than expected, with pieces of chicken described as being the size of a silver dollar. Residents expressed dissatisfaction with the portion sizes, stating that the food was inadequate and not satisfactory. Additionally, one resident reported that meals served the previous day were of poor quality, with insufficient meat in the beef stroganoff and watery gravy. The facility's dietary practices were further scrutinized through interviews and record reviews. The Registered Dietitian admitted to conducting weekly food quality audits but was unsure if records of test trays were maintained. The Dietary Manager acknowledged that one of the cooks required additional training, particularly in food presentation and adherence to menus and spreadsheets. Observations of the tray line revealed inconsistencies in portion sizes, with the meat portions not appearing to meet the specified 3 oz size. These findings indicate a failure to adhere to established nutritional guidelines and menu specifications, resulting in resident dissatisfaction and complaints.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at an appetizing temperature, as evidenced by multiple resident complaints and a test tray evaluation. Residents reported that the food was often cold, lacked flavor, and did not match the menu. Specific instances included residents receiving cold meals, meals that were not as described, and portions that were inadequate. A test tray evaluation revealed that the food was served at temperatures below the recommended levels, lacked seasoning, and some menu items were missing. Interviews with residents and family members highlighted dissatisfaction with the food quality, which had reportedly declined after a change in dietary management. The new Dietary Manager acknowledged the issues and noted that one of the cooks required additional training. The Registered Dietitian also identified palatability issues during her audits but did not maintain records of these audits. The facility's failure to maintain food quality and temperature standards led to widespread resident dissatisfaction and complaints.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of a registered nurse (RN) during a medication pass. On the morning of August 27, 2024, RN 2 was observed administering medications to residents without performing hand hygiene before or after the medication pass. Specifically, RN 2 was seen pushing medications through a medication pack into the palm of his hand and then placing them into a medication cup using bare fingers. This occurred multiple times, including when administering medications to resident 14 and another resident. Interviews conducted with RN 2, RN 3, and the Director of Nursing (DON) confirmed that the facility's protocol requires hand hygiene to be performed before and after each medication pass, and that medications should not be touched with bare hands. RN 2 acknowledged that hand hygiene should have been performed and that touching medications with bare hands was not appropriate. RN 3 and the DON reiterated the importance of hand hygiene and the expectation that gloves should be used if necessary, ensuring they are clean and used for one patient at a time.
Ineffective Pest Control Leads to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant presence of flies within the premises. Multiple residents, including those identified as 2, 5, 6, 24, 37, and 40, reported and were observed to have flies around and on them. Resident 24, for instance, was seen with flies in her room and on her knee, expressing frustration over the persistent issue. Similarly, resident 2 had flies on her feet and face during an interview, indicating a need for pest control measures. Resident 37 corroborated these observations by mentioning that she could hear her roommate, resident 2, yelling at the flies. Resident 6 also had a fly swatter within reach and complained about the pervasive presence of flies. The problem extended to common areas, as observed in the dining area near the 400 hall, where flies were seen landing on dining tables. Staff members, including a CNA and the Maintenance Director, acknowledged the issue, attributing the increase in flies to the frequent opening of doors by smokers. The CNA mentioned that fly swatters were even given as bingo prizes, and efforts were made to keep doors and windows closed. The Maintenance Director noted that residents had resorted to purchasing their own fly swatters and lights, and a fly light was installed over the fridge in the long-term care area. Despite these efforts, the fly problem persisted, causing discomfort and dissatisfaction among residents.
Failure to Investigate Allegations of Neglect and Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for five residents, leading to deficiencies in care. Resident 156 experienced an unwitnessed fall resulting in a right hip fracture and subsequent surgical intervention. Despite the severity of the incident, the Director of Nursing acknowledged that the fall should have been investigated for possible neglect, but no comprehensive investigation documentation was provided. Resident 158 sustained a laceration to the shin from an unknown origin, which led to hospitalization. The initial report indicated uncertainty about the injury's source, and while some staff interviews were conducted, the investigation was incomplete, lacking detailed documentation and timely submission. Similarly, Resident 15 alleged neglect by a CNA, but no investigation or documentation was found in the facility's records, and the current administrator was unable to locate any investigation related to the incident. Resident 53 experienced a fall resulting in injury, but the investigation was deemed inconclusive, with insufficient documentation to verify the cause. Resident 161 was reported to Adult Protective Services by a local hospital for neglect, but the facility's investigation lacked comprehensive documentation. The administrator admitted to discussing the incidents with staff but failed to provide adequate investigative notes, indicating a systemic issue in the facility's response to allegations of neglect and abuse.
Facility Fails to Address Recurring Deficiencies in Care and Safety
Penalty
Summary
The facility failed to establish and implement written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. This deficiency was noted during the recertification survey, where several deficiencies cited in the previous survey were found again. These included issues related to abuse reporting, pain management, medication availability, drug labeling, food quality, food safety, and infection control. Specifically, the facility did not report alleged violations involving abuse or neglect to the State Survey Agency within the required timeframe, and pain management was not provided to a resident who required it. The facility also failed to provide routine and emergency drugs as ordered by the physician due to unavailability from the pharmacy. Medications were not labeled according to professional standards, with medication carts left unlocked and insulin pens used past their expiration date. Additionally, the quality of food served was found lacking in flavor and appearance, and food safety standards were not adhered to, with issues such as unlabeled food items and improper handling by kitchen staff. Infection control measures were inadequate, as evidenced by a staff member touching resident medications with bare hands. The facility's Quality Assessment and Performance Improvement (QAPI) meetings were held regularly, but the documentation and follow-up actions were insufficient to address these ongoing issues. The facility's failure to address these deficiencies indicates a lack of effective monitoring and corrective action implementation.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for Resident 16, who was admitted with multiple diagnoses including chronic pain and opioid dependence. The resident's care plan indicated a need for pain management, including the use of Fentanyl patches. However, there was a disruption in the supply of these patches due to a change in the prescription from a 37.5 mcg patch to a combination of two patches totaling 37 mcg, reportedly due to insurance issues. This change led to a period where the resident did not receive the prescribed Fentanyl patches from 8/20/24 to 8/26/24, as they were unavailable. During this period, the resident expressed concerns about not receiving the Fentanyl patches and reported experiencing pain. The nursing staff, including RN 3 and the ADON, were aware of the issue but did not resolve it effectively. The pharmacy was supposed to deliver the medications multiple times a day, but there was a miscommunication, and the patches were not delivered. The facility's medication administration record (MAR) indicated that the patches were not administered due to being unavailable, and the staff did not verify the availability of the patches in the facility's supply. The Director of Nursing (DON) acknowledged the issue, stating that the pharmacy believed they had already sent the medication, leading to a failure in delivery. The DON also noted that the resident's pain did not increase significantly during this period due to adjustments in other medications. However, the facility did not take adequate steps to ensure the resident received the necessary pain management, highlighting a deficiency in the facility's process for managing medication supply and communication with the pharmacy.
Medication Handling and Storage Deficiencies
Penalty
Summary
The facility was found to have several deficiencies related to the handling and storage of medications. During observations, it was noted that medication carts were left unlocked and unattended, with computer screens displaying resident information in view of others. This occurred on multiple occasions with different registered nurses, compromising both the security of the medications and the privacy of resident information. Additionally, insulin pens were found to be used past their expiration date. Insulin pens labeled with open dates were observed in the medication carts, indicating they were available for use beyond the recommended 28-day period after opening. Interviews with nursing staff revealed a lack of knowledge regarding the proper duration for insulin use after opening, contributing to the improper handling of these medications. Furthermore, the facility was found to be improperly handling narcotics. Medications were observed to be repackaged and taped back into medication cards, which is against the facility's protocol. This practice was acknowledged by some staff as acceptable under certain conditions, while others recognized it as inappropriate. The Director of Nursing confirmed that narcotics should be wasted with another nurse and not retaped, highlighting a discrepancy in staff understanding and adherence to medication handling procedures.
Deficiency in Nutrition Services Staffing
Penalty
Summary
The facility was found to have a deficiency in employing a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. The Dietary Manager (DM) did not meet the necessary certification requirements for the position. During an interview, the DM admitted to not having completed the required certification and mentioned that the Registered Dietitian (RD) visited the facility once a week and was available for consultation by phone. The RD confirmed that the DM was still undergoing training and had only recently started in the position, and that efforts were being made to provide the DM with information on approved training programs.
Failure to Timely Report Suspected Abuse and Neglect
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment to the State Survey Agency within the required timeframe for two residents. Resident 28, who had multiple medical conditions including a wedge compression fracture and type II diabetes, experienced a fall while using a mechanical lift. The incident was not reported to the State Survey Agency, and the facility's Administrator was unaware of the fall. Interviews revealed that the CNA assisting Resident 28 did not report the incident due to uncertainty about the reporting process, and the Director of Nursing was unaware of the frequency of such falls. Resident 156, with diagnoses including a fracture of the right femur neck and major depressive disorder, had an unwitnessed fall resulting in a right hip fracture. The fall was not reported to the State Survey Agency within the required two-hour window. The Director of Nursing acknowledged that unwitnessed falls should be investigated for possible neglect and admitted that the facility could have reported the incident more promptly. The delay in reporting these incidents indicates a deficiency in the facility's process for handling and reporting suspected abuse or neglect.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 66 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — 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
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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) |
|---|---|---|---|---|
| Mervyn Sharp Bennion Central Utah Veterans Home | 1.3 mi | ★★★★★ | 1 | 0 |
| Advanced Health Care Of Salem | 2.8 mi | ★★★★★ | 1 | 0 |
| Spanish Fork Rehabilitation And Nursing | 5.6 mi | ★★★★★ | 10 | 0 |
| Stonehenge Of Springville | 8.7 mi | ★★★★★ | 0 | 0 |
| Provo Rehabilitation And Nursing | 14.2 mi | ★★★★★ | 8 | 1 |
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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.