Haven of Show Low: Abuse Protection Failure - AZ
The October 26 incident at Haven of Show Low involved Resident #4, described as confused, who approached Resident #2 from behind while she sat in her wheelchair in the hallway. According to the facility's Director of Nursing, Resident #4 placed his hands on the back of Resident #2's wheelchair, prompting her to yell at him to stop.
The DON told federal inspectors that Resident #4's hand then "contacted" Resident #2's head.
Administrator Staff #50 provided more specific details during an October 28 interview with inspectors. He described how Resident #4 "went like this" and demonstrated the motion by raising his hand and gesturing downward with an open palm onto the top of someone's head.
"Resident #4 popped me on top of the head," Resident #2 told the administrator during his investigation of the incident.
Staff #19, who witnessed the encounter, described it to the administrator as Resident #2 being "bopped on the head" by Resident #4.
The administrator confirmed to inspectors that "the contact did happen; that Resident #4 did contact Resident #2's head."
Despite this confirmation and witness accounts, facility leadership struggled to classify the incident definitively. When inspectors asked the DON directly whether the head contact constituted physical abuse, she declined to give a clear answer.
The DON said determining abuse "would depend on if the act was intentional." She explained that "if a resident was intentionally trying to hurt the other resident then that would be considered abuse."
The administrator echoed this reasoning, telling inspectors that "abuse is generally an intentional harm or action against another resident."
This interpretation conflicts with federal requirements for nursing homes to report incidents regardless of intent when resident-on-resident contact occurs. The facility's own policies, dated January 1, 2024, state that "all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management."
The policy guarantees residents "the right to a dignified existence, be treated with respect, kindness, and dignity, and be free from abuse, neglect, misappropriation of property, and exploitation."
Federal inspectors found no evidence that Haven of Show Low reported the head-striking incident to authorities despite the administrator's own investigation confirming it occurred.
The administrator told inspectors he expects staff to "report it to the Administrator or DON immediately" when they witness potential abuse. He said staff should "separate the residents and make sure they are safe, assess the residents, and then report the incident" when physical contact occurs between residents.
The facility followed some of these internal protocols. Staff #19 reported the incident up the chain of command to the DON, who then notified the administrator. The administrator conducted interviews with both the victim and the witness.
But the critical final step — reporting to outside agencies — never happened.
The incident began when Resident #4, moving through the hallway, encountered Resident #2 in her wheelchair. The administrator's account suggests Resident #4 first pushed or moved Resident #2's wheelchair from behind, which caused her to object verbally.
When Resident #2 told Resident #4 to stop, he responded by striking her on top of the head with his open hand.
The facility's failure to report extends beyond a simple oversight. Both the DON and administrator demonstrated awareness of their reporting obligations during inspector interviews. The administrator specifically outlined the proper response protocol when "an act of physical abuse were to happen in front of floor staff."
Yet when presented with a concrete incident involving verified physical contact between residents — one that left the victim describing being "popped" on the head — facility leadership chose not to classify it as reportable abuse.
This decision appears to hinge on their assessment of Resident #4's mental state and intentions. The administrator and DON both emphasized that Resident #4 was "confused," seemingly using his cognitive condition to justify not reporting the head strike.
Federal regulations, however, do not provide exceptions for reporting requirements based on the perpetrator's mental capacity. Nursing homes must report incidents of resident-on-resident contact that could constitute abuse, allowing external investigators to make determinations about intent and appropriate responses.
The inspection occurred following a complaint, though the report does not specify whether the complaint related to this specific incident or other concerns at the facility.
Haven of Show Low's handling of the October 26 incident reveals a pattern of selective interpretation of federal requirements. Despite having clear policies mandating reports to "local, state and federal agencies," facility leadership applied their own criteria to determine what constitutes reportable abuse.
The administrator's demonstration of the head-striking motion to inspectors — raising his hand and gesturing downward with an open palm — provided vivid confirmation that significant physical contact occurred between the residents.
Resident #2's own words to investigators — "Resident #4 popped me on top of the head" — leave little ambiguity about the nature and impact of the contact.
Staff #19's witness account describing Resident #2 being "bopped on the head" corroborates both the victim's account and the administrator's understanding of what happened.
The facility's 2024 policies explicitly state that residents have the right to "be free from abuse" and guarantee thorough investigation and reporting of all incidents. The October 26 head-striking incident tested these commitments.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. But the failure to report represents a systemic problem that could affect any resident who experiences similar incidents.
Resident #4 remains at the facility, as does Resident #2. The administrator's investigation confirmed physical contact occurred between them, but no external agencies were notified to conduct independent assessments or implement protective measures.
The DON's reluctance to classify the incident as abuse, combined with the administrator's focus on intent rather than impact, suggests a facility culture that prioritizes internal management over regulatory compliance and resident protection.
Resident #2 continues living in the same environment where she was struck on the head by another resident, with facility leadership having decided the incident didn't warrant outside scrutiny or intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Haven of Show Low from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
HAVEN OF SHOW LOW in SHOW LOW, AZ was cited for abuse-related violations during a health inspection on November 20, 2025.
According to the facility's Director of Nursing, Resident #4 placed his hands on the back of Resident #2's wheelchair, prompting her to yell at him to stop.
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.