Primrose Post-Acute

In the surveyor’s words

From the most serious findings on record at Primrose Post-Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF880Feb 15, 2022

  Based on observation, interview, and record review, the facility failed to implement infection control interventions to prevent the spread of corona virus ([COVID-19] a very deadly virus that easily spreads from person to person) in accordance with local Public Health guidelines, the facility's infection control policies and procedures (P/P), and mitigation plan ([MP] a plan to reduce the spread of infection) for 30 of 60 sampled residents by failing to ensure: 1. Treatment Nurse (TX) did not return to work with COVID-19 symptoms including cough and shortness of breath, on 1/26/2022, after he tested positive for COVID-19 on 1/21/2022. 2. […]

• Immediate jeopardy, patternF880Sep 8, 2021

  Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program for 6 out of 10 residents (Residents 1, 2, 3, 4, 5, and 9) and 3 of 3 staff (Staff 1, 2 and 3) with scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate your skin by intense itching, inflammation, and red patches) or suspicious rash by failing to: 1. Ensure skin rashes of six Residents (Residents 1, 2, 3, 4, 5, and 9) were assessed, identified, documented, implemented and/or had a plan of care initiated to ensure the residents received an effective treatment plan. 2. […]

• Immediate jeopardy, isolatedF678May 10, 2024

  Based on interview and record review, the facility failed to implement its policy and procedures (P/P) titled Emergency Procedures for Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) by not calling 911 (an emergency alert system) when one of one sampled resident (Resident 65), who had full code status (when a medical personal does everything possible to save a person's life in a medical emergency), was observed unresponsive in bed, on [DATE]. This deficient practice resulted in Resident 65's death and placed 54 other residents, who had Full Code statuses, at risk of not receiving timely life saving measures. […]

• Actual harm, isolatedF686Sep 7, 2021

  Based on observation, interview, and record review, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These deficient practices resulted in Resident 1's left first metatarsal (bones in the foot) and left hip scabs to worsen into an arterial wound (open, painful injuries found on the lower extremities due to poor circulation) on the left foot metatarsals and left hip to worsen into a Stage IV (full-thickness skin and tissue loss in which actual depth of the ulcer is completely obscured by slough [death tissue] and/or eschar [death tissue that falls off from the skin] in the wound bed) pressure ulcer (injury to the skin and/or underlying tissue over a bony prominence as a result of pressure or pressure in combination with shear-layers, and or… […]

• Actual harm, isolatedF686Jun 28, 2021

  Based on interview and record review, the facility failed to ensure for two of three sampled residents (Resident 1 and Resident 2) received all the necessary care and services to prevent pressure ulcer/pressure injury ([PU/PI] injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development. The facility failed to: 1. Adhere to Resident 2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Ensure Residents 1 and 2 were turned every two hours to prevent pressure ulcers, as per the resident's plan of care. 3. […]