Payson Care Center

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Administration Deficiencies

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Quality of Life and Care Deficiencies

Provide appropriate care/assistance for a resident with a prosthesis.

Quality of Life and Care Deficiencies

Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

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Violation cited

Based on observations, record review, interviews, and review of facility documentation and policy, the facility failed to ensure that written policies and procedures were developed and implemented to prohibit and prevent abuse for one resident (#1). Resident #1 was admitted to the facility on March 18, 2023, with diagnoses that included dementia, anemia, type 2 diabetes mellitus, and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated October 11, 2024, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) assessment score that was unable to be assessed due to the resident being rarely or never understood. A Behavior Note dated September 12, 2024, revealed a behavior summary for the last 6 months that Resident #1: removed decor from walls in the hallway, urinated in the hall, removed items from nurse carts, entered peers rooms and interfered with care, turned off peer's oxygen, and removed fire extinguishers from fire case. Additionally, "These behaviors have been numerous and consistent." A Health Status Note dated November 18, 2024, revealed that Resident #1 "hit another resident with a rolled up newspaper while passing her in the hallway. She is using inappropriate language while interacting with another resident." There was no evidence that an incident report or assessment was completed for Resident #1 after the incident on the date of November 18, 2024. Additionally, there was no evidence that the facility conducted a thorough investigation of the incident, or put interventions in place to ensure the residents' safety while the investigation took place. A care plan dated February 17, 2023, revealed a focus that the resident exhibits behavioral issues with foul language and abrasive with little concern for the feelings of others. There was no evidence that the care plan was updated after the incident on November 18, 2024. An interview was conducted with the Director of Nursing (DON / Staff #60) on January 14, 2025, at 12:49 PM. The DON stated that examples of physical abuse would be roughness when providing care from a staff member to a resident, or would be pinching, slapping, or swinging an object and making contact from a resident to another resident. At this time, the clinical record of Resident #1 was reviewed together, and specifically, the Health Status Note dated November 18, 2024, where Resident #1 was documented to strike another resident with a rolled-up newspaper. The DON stated that this was the first time she was aware of this incident, and that it was not reported to her, it was not investigated, and that it was not reported to the state agency. She stated that there was no way to tell if any injuries occurred because there was no incident report or investigation, she further stated that there was not a way to tell if the residents were separated for safety. She stated that this did not meet her expectation of how a resident to resident incident would be managed. The interview continued, and the D

Based on observations, record review, interviews, and review of facility documentation and policy, the facility failed to ensure that an allegation of abuse was thoroughly investigated, and that further potential abuse was prevented during an investigation of abuse for one resident (#1). Resident #1 was admitted to the facility on March 18, 2023, with diagnoses that included dementia, anemia, type 2 diabetes mellitus, and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated October 11, 2024, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) assessment score that was unable to be assessed due to the resident being rarely or never understood. A Behavior Note dated September 12, 2024, revealed a behavior summary for the last 6 months that Resident #1: removed decor from walls in the hallway, urinated in the hall, removed items from nurse carts, entered peers rooms and interfered with care, turned off peer's oxygen, and removed fire extinguishers from fire case. Additionally, "These behaviors have been numerous and consistent." A Health Status Note dated November 18, 2024, revealed that Resident #1 "hit another resident with a rolled up newspaper while passing her in the hallway. She is using inappropriate language while interacting with another resident." There was no evidence that an incident report or assessment was completed for Resident #1 after the incident on the date of November 18, 2024. Additionally, there was no evidence that the facility conducted a thorough investigation of the incident, or put interventions in place to ensure the residents' safety while the investigation took place. A care plan dated February 17, 2023, revealed a focus that the resident exhibits behavioral issues with foul language and abrasive with little concern for the feelings of others. There was no evidence that the care plan was updated after the incident on November 18, 2024. An interview was conducted with the Director of Nursing (DON / Staff #60) on January 14, 2025, at 12:49 PM. The DON stated that examples of physical abuse would be roughness when providing care from a staff member to a resident, or would be pinching, slapping, or swinging an object and making contact from a resident to another resident. At this time, the clinical record of Resident #1 was reviewed together, and specifically, the Health Status Note dated November 18, 2024, where Resident #1 was documented to strike another resident with a rolled-up newspaper. The DON stated that this was the first time she was aware of this incident, and that it was not reported to her, it was not investigated, and that it was not reported to the state agency. She stated that there was no way to tell if any injuries occurred because there was no incident report or investigation, she further stated that there was not a way to tell if the residents were separated for safety. She stated that this did not meet her expectation of how a resident to resident incident would be mana

Violation cited

Based on observations, record review, interviews, and review of facility documentation and policy, the facility failed to ensure residents were not abused by other residents, for 4 of 5 sampled residents (#1, #2, #3, and #4) and one resident (#5) was not abused by a staff member for 1 of 5 sampled residents. -Regarding Resident #1 and Resident #2: Resident #1 was admitted to the facility on March 18, 2023, with diagnoses that included dementia, anemia, type 2 diabetes mellitus, and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated October 11, 2024, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) assessment score that was unable to be assessed due to the resident being rarely or never understood. A Behavior Note dated September 12, 2024, revealed a behavior summary for the last 6 months that Resident #1: removed decor from walls in the hallway, urinated in the hall, removed items from nurse carts, entered peers rooms and interfered with care, turned off peer's oxygen, and removed fire extinguishers from fire case. Additionally, "These behaviors have been numerous and consistent." A Health Status Note dated November 18, 2024, revealed that Resident #1 "hit another resident with a rolled up newspaper while passing her in the hallway. She is using inappropriate language while interacting with another resident." An Event Note dated January 6, 2025, revealed that Resident #1 "was having a verbal dispute with another resident. During the verbal dispute this resident was hit with a book on her left arm causing a skin tear. Dressing applied at this time". There was no evidence that a room change occurred to separate the residents or that additional staff were placed to monitor the safety of the residents. There was no evidence that a skin assessment was completed for Resident #1 after the incident on the date of January 6, 2025. A physician order dated January 8, 2025, indicated treatment for a skin tear to the right forearm to cleanse with wound wash, cover with xeroform and dry dressing. A care plan dated February 17, 2023, revealed a focus that the resident exhibits behavioral issues with foul language and abrasive with little concern for the feelings of others. There was no evidence that the care plan was updated after the incidents on November 18, 2024, and January 6, 2025. Resident #2 was admitted to the facility on May 14, 2024, with diagnoses that included unspecified dementia with other behavioral disturbance, atrial fibrillation, and hyperlipidemia. A quarterly MDS assessment dated November 1, 2024, revealed that Resident #2 had a BIMS assessment score that was unable to be assessed due to the resident being rarely or never understood. Review of the progress notes revealed no notes dated January 6, 2025, regarding the incident between Resident #1 and Resident #2. Additionally, there was no evidence that the facility provided a room change to separate the residents or that additional staff were placed to mo

Based on observations, record review, interviews, and review of facility documentation and policy, the facility failed to ensure that the medical record was complete and accurately documented for one resident (#1). Resident #1 was admitted to the facility on March 18, 2023, with diagnoses that included dementia, anemia, type 2 diabetes mellitus, and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated October 11, 2024, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) assessment score that was unable to be assessed due to the resident being rarely or never understood. A Behavior Note dated September 12, 2024, revealed a behavior summary for the last 6 months that Resident #1: removed decor from walls in the hallway, urinated in the hall, removed items from nurse carts, entered peers rooms and interfered with care, turned off peer's oxygen, and removed fire extinguishers from fire case. Additionally, "These behaviors have been numerous and consistent." A Health Status Note dated November 18, 2024, revealed that Resident #1 "hit another resident with a rolled up newspaper while passing her in the hallway. She is using inappropriate language while interacting with another resident." There was no evidence that an incident report or assessment was completed for Resident #1 after the incident on the date of November 18, 2024. Additionally, there was no evidence that the facility conducted a thorough investigation of the incident, or put interventions in place to ensure the residents' safety while the investigation took place. A care plan dated February 17, 2023, revealed a focus that the resident exhibits behavioral issues with foul language and abrasive with little concern for the feelings of others. There was no evidence that the care plan was updated after the incident on November 18, 2024. An interview was conducted with the Director of Nursing (DON / Staff #60) on January 14, 2025, at 12:49 PM. The clinical record of Resident #1 was reviewed together, and specifically, the Health Status Note dated November 18, 2024, where Resident #1 was documented to strike another resident with a rolled-up newspaper. The DON stated that this was the first time she was aware of this incident. She stated that there was no way to tell if any injuries occurred because there was no incident report, assessment, or investigation, she further stated that there was not a way to tell if the residents were separated for safety. She stated that this did not meet her expectation of how a resident to resident incident would be managed or documented. Review of the facility's policy titled Nursing Documentation, reviewed September 5, 2024, revealed that the facility will ensure nursing documentation is consistent with professional standards of practice, the state nurse practice act, and any state laws governing the scope of nursing practice. Additionally, the medical record shall reflect a resident's progress and maintenance of their clinical,