Primrose Post-acute
Inspection History Overview
Detailed Inspection Reports
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Fines and Penalties by Year
2022 2 penalties totaling $41,753
Fine
Payment Denial
2021 3 penalties totaling $173,593
Fine
Fine
Fine
2020 1 penalties totaling $7,100
Fine
Health Violations by Year
2025 16 violations
Reasonably accommodate the needs and preferences of each resident.
Respond appropriately to all alleged violations.
Ensure each resident receives an accurate assessment.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
PASARR screening for Mental disorders or Intellectual Disabilities
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Have a plan that describes the process for conducting QAPI and QAA activities.
Provide and implement an infection prevention and control program.
Implement a program that monitors antibiotic use.
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
2024 20 violations
Reasonably accommodate the needs and preferences of each resident.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Dispose of garbage and refuse properly.
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.
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Provide care and assistance to perform activities of daily living for any resident who is unable.
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.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide and implement an infection prevention and control program.
2023 5 violations
Provide and implement an infection prevention and control program.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide safe, appropriate pain management for a resident who requires such services.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure services provided by the nursing facility meet professional standards of quality.
2022 28 violations
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Plan the resident's discharge to meet the resident's goals and needs.
Provide and implement an infection prevention and control program.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
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.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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.
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.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Ensure each resident receives an accurate assessment.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Ensure services provided by the nursing facility meet professional standards of quality.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure medication error rates are not 5 percent or greater.
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.
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
2021 7 violations
Provide and implement an infection prevention and control program.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2020 3 violations
Provide and implement an infection prevention and control program.
Protect each resident from the wrongful use of the resident's belongings or money.
Provide and implement an infection prevention and control program.
2019 18 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide activities to meet all resident's needs.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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.
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.
Provide or obtain dental services for each resident.
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
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.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
2018 36 violations
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.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide activities to meet all resident's needs.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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.
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
2017 5 violations
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
Have a program that investigates, controls and keeps infection from spreading.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Protect each resident from all abuse, physical punishment, and involuntary separation from others.
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.