A list of the most recent deficiencies for Primrose Post-Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-11 | 2024-02-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-11 | 2024-02-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-11 | 2024-02-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-26 | 2023-11-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-06 | 2023-09-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-28 | 2023-07-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-28 | 2023-07-31 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-05 | 2023-04-06 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-20 | 2022-07-01 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-05-20 | 2022-07-01 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-03-22 | 2022-04-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-11 | 2022-03-16 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-02-11 | 2022-03-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-02-11 | 2022-03-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-02-11 | 2022-03-16 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-02-11 | 2022-03-16 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-02-11 | 2022-03-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-11 | 2022-03-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-11 | 2022-03-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-11 | 2022-03-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-11 | 2022-03-16 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-02-11 | 2022-03-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-11 | 2022-03-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-11 | 2022-03-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-11 | 2022-03-16 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-02-11 | 2022-03-16 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-02-11 | 2022-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-11 | 2022-03-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-11 | 2022-03-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-11 | 2022-03-16 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-02-11 | 2022-03-16 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-02-11 | 2022-03-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-11 | 2022-03-16 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-17 | 2022-03-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-17 | 2022-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-15 | 2022-03-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-10 | 2022-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-24 | 2022-02-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-08 | 2021-10-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-07 | 2021-09-21 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-07 | 2021-09-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-03 | 2021-09-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-28 | 2021-08-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-28 | 2021-08-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-01 | 2021-06-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-23 | 2020-02-24 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-12-23 | 2020-02-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-23 | 2020-02-24 | N |
| Respond appropriately to all alleged violations. | Health | 2019-12-23 | 2020-02-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-23 | 2020-02-24 | N |
| Provide activities to meet all resident's needs. | Health | 2019-12-23 | 2020-02-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-23 | 2020-02-24 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-12-23 | 2020-02-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-23 | 2020-02-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-23 | 2020-02-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-12-23 | 2020-02-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-12-23 | 2020-02-24 | N |
| Provide or obtain dental services for each resident. | Health | 2019-12-23 | 2020-02-24 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-12-23 | 2020-02-24 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-12-23 | 2020-02-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-12-23 | 2020-02-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-23 | 2020-02-24 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-12-23 | 2020-02-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-12-19 | 2020-01-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-19 | 2020-01-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-12-30 | 2019-02-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-12-30 | 2019-02-15 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-12-30 | 2019-02-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-12-30 | 2019-02-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-30 | 2019-02-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-12-30 | 2019-02-15 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-12-30 | 2019-02-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-12-30 | 2019-02-15 | N |
| Provide activities to meet all resident's needs. | Health | 2018-12-30 | 2019-02-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-30 | 2019-02-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-12-30 | 2019-02-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-12-30 | 2019-02-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-30 | 2019-02-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-12-30 | 2019-02-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-30 | 2019-02-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-12-30 | 2019-02-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-12-30 | 2019-02-15 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-12-30 | 2019-02-15 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-12-30 | 2019-02-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-12-30 | 2019-02-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-30 | 2019-02-15 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-12-30 | 2019-02-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-30 | 2019-02-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-30 | 2019-02-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-12-30 | 2019-02-15 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-12-30 | 2019-02-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-12-30 | 2019-02-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-29 | 2019-02-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-29 | 2019-02-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-12-29 | 2019-02-04 | N |
