Signature Healthcare of Primacy

In the surveyor’s words

From the most serious findings on record at Signature Healthcare of Primacy, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF640Dec 1, 2021

  Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete discharge assessments, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 16 of 42 sampled residents (Resident #4, #5, #8, #9, #11, #14, #16, #17, #18, #19, #20, #24, #25, #27, #32, and #73) reviewed for completion of the MDS. The findings include: Review of the MDS 3.0 RAI Manual v (version) 1.17.1 October 2019, page 2-37 revealed .Discharge Assessment .Must be completed when a resident is discharged .Must be completed (item Z0500B) within 14 days after the discharge date . […]

• No harm, potential for more than minimal, isolatedF686Mar 3, 2026

  Based on policy review, medical record review, hospital record review, observation, and interview, the facility failed to ensure residents received treatment and services to promote healing, provide skin assessments, initiate wound treatments, and administer wound treatments for 5 of 96 (Residents #4, #10, #74, #79, and #90) sampled residents for pressure injuries/ulcers. The findings include: 1. Review of the facility policy titled, Skin Integrity, dated 1/2025, revealed .The facility will ensure that based on the comprehensive assessment of a resident.A resident receives care, consistent with professional standards of practice, to prevent avoidable skin integrity issues .unless the individual's clinical condition demonstrates that they were unavoidable.A resident with impaired skin… […]

• No harm, potential for more than minimal, isolatedF689Mar 3, 2026

  Based on policy review, medical record review, observation, and interview, the facility failed to ensure the residents' environment was free from accident hazards for 2 of 3 (Resident #1 and #126) residents reviewed for accident hazards. The findings include: 1. Review of the facility policy titled, Oxygen Storage, dated 1/2025, revealed .The facility acknowledges the special hazards associated with the storage and use of compressed oxygen cylinders and the use of cryogenic (low temperature liquid) oxygen and has established procedures for the safe storage, use and transfer of oxygen in the facility.E-tanks [a 3-foot tall aluminum container filled with compressed medical-grade oxygen gas] will be stored in an approved O2 [oxygen] tank holding device or in an approved storage rack at all… […]

• No harm, potential for more than minimal, isolatedF761Mar 3, 2026

  Based on policy review, medical record review, observation, and interview, the facility failed to ensure that medications were properly stored for self- administration when medications were found unsecured in 1 of 55 (Resident #40) resident rooms during initial tour. The findings include: 1. Review of the facility policy titled, Medication Storage Bedside Medication Storage, dated 1/2024, revealed .The manner of storage prevents access by other residents. Lockable drawers or cabinets are required .The nurse will oversee storage security and accountability of bedside medications . Review of the facility policy titled, Medication Storage .of Medication, dated 1/2025, revealed .medication supplies should remain locked when not in use or attended to by persons with authorized access . 2. […]

• No harm, potential for more than minimal, isolatedF638Dec 1, 2021

  Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete quarterly assessments, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 5 of 42 sampled residents (Resident #3, #22, #23, #28, and #76) reviewed for completion of the MDS. The findings include: Review of the MDS 3.0 RAI Manual v (version) 1.17.1 October 2019, page 2-33 revealed, .The Quarterly assessment must be completed at least every 92 days following the previous OBRA [Omnibus Budget Reconciliation Act] assessment of any type .The ARD [Assessment Reference Date] (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type .The… […]