Primrose Post-Acute

Inspectors wroteBased on interview and record review, the facility failed to act upon recommendations from the Pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes), for two of five sampled residents (Resident 4 and Resident 7). This deficient practice placed Residents 4 and 7 at risk for receiving unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of five sampled residents (Resident 4) prior to administering psychotherapeutic medications (psychotropic, a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior). This deficient practice violated Resident 4's and their resident representative's (RR) right to make an informed decision regarding the use of psychotherapeutic medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the physician for one of five sampled residents (Resident 1), after Resident 1 had a change in condition and developed diarrhea on 6/26/26. This deficient practice had the potential to result in a delay in care, treatment and worsening of the resident's symptom.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was completed accurately for two of 16 sampled residents (Resident 4 and Resident 7), who were coded for a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Residents 4 and 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was a one-to-one (1:1) feeder (a caregiver who was assigned to assist a resident with feeding for the duration of a meal) for one of five sampled residents (Resident 13) during meals. This deficient practice placed Resident 13 at risk for poor nutritional intake during meals.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of five sampled residents (Resident 24) hair was washed and the resident's nails were trimmed during activity of daily living ([ADL]- activities such as bathing, dressing, and toileting a person performs daily) care. This deficient practice placed Resident 24 at risk for poor personal hygiene, skin irritation, and discomfort.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of five sampled residents (Resident 13) Low Air Loss Mattress ([LALM]- a specialized medical bed used to prevent and treat pressure ulcers) was maintained in the correct setting. This deficient practice had the potential to place Resident 13 at risk for pressure ulcers (localized damage to the skin and /or underlying tissue usually over a bony prominence).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:1. Three Hoyer lifts (a mechanical device used to transfer non-ambulatory individuals between surfaces from a bed to a wheelchair and vice versa without manual lifting) were not blocking a fire alarm in the facility's hallway.2. One of five sampled residents (Resident 39) had a physician order for going out on pass (OOP, temporary permission to leave a confined facility) and was signed out before going OOPThis deficient practice had the potential to result in safety hazards for residents, staff members, and visitors and placed Resident 39 at risk for medical complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of five sampled residents (Resident 11) received continuous oxygen (O2) at two liters per minute ([L/min]- a metric unit of volume used to measure liquids and gases) according to the physician's order. This deficient practice had the potential for Resident 11 not to receive adequate O2 and cause respiratory distress (difficulty breathing) to the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 48) was evaluated by the physician at least every 60 days and documented in the resident's clinical records. This deficient practice had the potential for a delay in the assessment of Resident 48's medical condition and receiving necessary care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the responsible party, for one of five sampled resident's (Resident 4), prior to administering psychotropic medications (drugs that changes brain function and results in alterations in perception, mood, consciousness or behavior) to the resident. This deficient practice had the potential to result in the use of unnecessary psychotropic medication that could cause harm to Resident 4.

Inspectors wroteDuring observation, interview and record review, the facility failed to ensure staff (Physical Therapist [PT] 1) performed hand hygiene (washing hands or using an alcohol-based hand sanitizer) after PT 1 picked up gloves from the floor, prior to obtaining clean gloves from the glove dispenser, donning (putting on) new gloves and providing care to one of five sampled residents (Resident 37). This deficient practice had the potential to lead to cross contamination (the physical transfer of harmful bacteria or viruses from one person or object to another) and the spread of infection to Resident 37, other residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the recent California Department of Public Health (CDPH, state licensing and certification agency) annual survey results for 2024 and 2025 in the areas of the facility that are prominent and accessible to the residents, resident representatives, family members, and visitors. This deficient practice placed the residents, family members, and visitors at risk of not knowing the status of the facility's non-compliance outcome results and past performance history.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the updated daily nurse staffing information that included the facility name, current date, total number and the actual hours worked by nursing staff directly responsible for resident care per shift along with the resident census, at the beginning of each day. This deficient practice had the potential to affect the care of the residents in the facility and for residents needs to go unmet.

Inspectors wroteBased on interview and record review, the facility failed to update the care plan for one out of one sampled resident (Resident 2). This failure had the potential to result in Resident 2 not receiving relevant care based on the changes in their medical conditions, in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility followed- up with the Medical Doctor (MD 1) of one of three residents (Resident 1), regarding the resident and Resident 1's Responsible Party's (RP 1) request to talk to MD 1. This failure violated Resident 1 and RP 1's right to communicate with and access to persons and services inside and outside the facility.

Inspectors wroteBased on interview and record review, the facility failed to conduct a readmission Interdisciplinary Team ([IDT] group of healthcare professionals, including physician, nurses, resident/ resident representative, working together to develop a plan of care for the residents) meeting, for one of four residents (Resident 1), and her Responsible Party (RP), to allow participation in planning resident's care. This failure resulted in the resident and her RP not aware of the plan of care, and the potential for lack of coordinated or inadequate care plan and lack of opportunities to improve care.

Inspectors wroteBased on interview and record review, the facility failed to implement intervention in one of three residents' (Resident 1), care plan titled, Resident 1 has indwelling foley catheter (catheter that drains urine from bladder into a bag outside the body), which indicated to monitor and document Resident 1's urine output. This failure had the potential to delay identification of changes and signs of complications (low urine output, signs of urinary tract infections) in the resident's urinary status, causing delay in care and interventions, that can lead to serious infections and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality, by failing to ensure Medical Doctor's (MD 1) progress notes on 9/22/2025 and 10/6/2025, for one of three residents (Resident 1), indicating a plan for urology consultation, were clarified, ordered and scheduled. This failure resulted in Resident 1 being not seen by a urologist timely and placed the resident at risk for delayed necessary interventions to provide quality care when needed.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate documentation for one of three residents (Resident 1), when the Interdisciplinary Team ([IDT] group of healthcare professionals, including physician, nurses, resident/ resident representative, working together to develop a plan of care for the residents) meeting was rescheduled. This failure resulted in Resident 1's medical record being inaccurate and incomplete.

Inspectors wroteBased on observation, interviews and record review, the facility failed to protect resident-identifiable, personal and/or medical information for 3 of 3 sampled residents (Residents 1, 2 and 3). This deficient practice violated Resident 1, 2 and 3's right to privacy and had the potential to result in the public obtaining access to confidential (private) information and for their identity to be compromised or stolen.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure the emergency dry food storage room had the correct thermometer for accurate temperatures. This deficient practice resulted in inadequate monitoring of food being stored in the room.

Inspectors wroteBased on interview and record, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for three of 17 sampled residents (Residents 13, 120, and 42) by failing to: 1. Ensure Resident 13's Gabapentin (medication used to treat seizure and nerve pain medication) was encoded as anticonvulsant medication under MDS section N (N0415 High-Risk Drug Classes). 2. Ensure Resident 120's Pressure Ulcer stage 2 ([PU] Partial-thickness loss of skin, presenting as a shallow open sore or wound) was encoded under MDS section M0300 (Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage) discharge assessment. 3. Ensure Resident 42 had accurate documentation in the Minimum Data Set ([MDS]- a resident assessment tool) to reflect her use of Eliquis ([anti-coagulant]- medication used to thin the blood). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide meeting minutes and evidence of sufficient governing oversight to demonstrate the maintenance of an effective Quality Assurance and Performance Improvement (QAPI - a data driven proactive approach to improvement used to ensure services are meeting quality standards) Program for the last recertification survey of 2024. This deficient practice resulted in repeat deficiencies in the areas of Resident Assessments and Food and Nutrition Services that could affect the residents' health.

Inspectors wroteBased on observation, interviews, record review, the facility failed to ensure the call light was within reach for one of four sampled residents (Resident 7). This failure had the potential for increased risk of falls, delayed response to emergencies, and unmet basic needs for Resident 7.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Implement its abuse prevention and reporting policy by failing to submit the results of the investigation of an allegation of financial abuse to the state agency (California Department of Public Health) within five working days of the incident for one of one sampled resident (Resident 52). This deficient practice delayed the investigation by the CDPH and placed Resident 52 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Complete and re-submit the Preadmission Screening and Resident Review ([PASARR - a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability, or related condition) Level one (I) screening and refer one of two sampled residents (Resident 45) who had a diagnosis of major depressive disorder ([MDD] - a mood disorder that causes a persistent feelings of sadness and loss of interest) to the appropriate state-designated authority for PASARR Level two (II) evaluation and determination. This deficient practice had the potential to result in Resident 45 to not receive the appropriate medical treatments for mental illness diagnosis.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 39) received a Pre-admission Screening and Resident Review ([PASRR] - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) level II assessment. This deficient practice had the potential to result in Resident 39 not receiving the required services for his mental health condition.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 63) had the battery changed in her Life Vest (device that monitors the heart to correct dangerous rhythms) per physician's order. This deficient practice had the potential to result in the battery running out which would prevent monitoring of the resident's heart rhythm.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident who was admitted to the facility with intact skin did not develop a pressure ulcer ([PU] - injury to skin and underlying tissue resulting from prolonged pressure on the skin or bony prominences) for one of four sampled residents (Resident 120) by failing to: 1. Ensure nursing staff implemented Resident 120's care plan titled Resident is at risk for skin breakdown to apply barrier cream and to check resident's skin daily. This deficient practice resulted in Resident 120 acquiring a PU stage 2 (Partial-thickness loss of skin, presenting as a shallow open sore or wound) on sacral (a triangular-shaped bone located at the base of the spine) area.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's bed was in the low position for one of four sampled residents (Resident 6). This failure had the potential for an increased risk of falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensur e an inventory of personal belongings was completed upon transfer to General Acute Care Hospital (GACH) for one of one sampled resident (Resident 120). This deficient practice had the potential for not having proper accountability of Resident 120's personal belongings.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 42) food was at an appetizing temperature for consumption. This deficient practice resulted in Resident 42 not being able to eat the hard-boiled eggs she requested for breakfast.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 65) preferences to accommodate her lactose intolerance (digestive issue that results in difficulty digesting the sugar in milk) was honored. This deficient practice resulted in Resident 65 not being able to enjoy milk with her meals. This practice also had the potential to result in Resident 65 experiencing diarrhea, belly pain, or nausea if she consumed the milk that was provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Follow enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms) for one of four sampled residents (Resident 6). 2. Ensure Certified Nursing Assistant 1 (CNA 1) performed hand hygiene (the act of cleaning one's hands with soap and water or using an alcohol-based hand sanitizer to remove germs, dirt, and other unwanted substances) before and after performing care for one of four sampled residents (Resident 16). This failure had the potential for an increased risk of developing and spreading life threatening infections to Resident 6, Resident 16, as well as other residents and staff in the facility.

Inspectors wroteBased on interview and record review. The facility failed to: 1. Complete the McGeer Criteria (minimum set of signs and symptoms which when met, indicated that a resident likely has an infection and that an antibiotic (a drug used to treat infections caused by bacteria) might be needed) for Infection Screening Evaluation for one of two sampled residents (Resident 13). This deficient practice had the potential to result in the development of multi-drug-resistant organisms ([MDRO] - microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) from inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet ([sq. ft.] unit of measurement) per resident in multiple resident bedrooms for six out of 30 resident rooms. The insufficient space had the potential to result in and lead to inadequate nursing care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Implement its Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy and procedure (P&P) by not reporting within two (2) hours of an allegation of physical abuse, for one of three sampled residents (Resident 1) to the California Department of Public Health ([CDPH] - state licensing and certification agency) and the Ombudsman (an agency who investigates, reports on, and helps settle complaints against the facility), after Resident 2 allegedly hit Resident 1 on 12/5/2024. This deficient practice resulted in the delay of investigation by the CDPH and had the potential to place Resident 1 for further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to install floor mats (a cushioned floor pad designed to help prevent injury should a resident falls) for one of three residents (Resident 1) who was a high risk for fall, as indicated on the resident ' s Care Plan. This failure had the potential to result in Resident 1 sustaining injuries such as fractures (broken bones) and brain hemorrhage (bleeding in the brain) from a fall.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Report an allegation of abuse to the State agency (Department of Public Health) within 24 hours for one of 3 sampled residents (Resident 1). This deficient practice had the potential to result in further abuse for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Implement its abuse Policy and Procedure (P&P) titled, Abuse Investigation and Reporting which indicated an allegation of abuse would be reported immediately to the State Licensing/Certification Agency immediately, but no later than two hours. This deficient practice had the potential for a delay in the investigation of the state agency and placed Resident 1 and other residents at risk for further abuse.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to revise and provide an updated accurate resident census in the Facility's Assessment. This deficient practice had the potential to place residents at risk for lack or delay of care and treatment services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate space to access the room's restroom for two out of 7 sampled residents (Resident 28 and Resident 39). This deficient practice resulted in psychological harm from the shame of possibly soiling themselves while sitting in their wheelchairs.

Inspectors wroteBased on interview and record review the facility failed to develop a care plan (the process of identifying a patient's needs and facilitating care and ensures collaboration among nurses, patients, and other healthcare providers) for three of 18 sampled residents (Residents 44, 16, and 53). This deficient practice had the potential for Resident 44, Resident 16, and Resident 53 to not receive the care and services needed.

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to ensure expired and discontinued medications were discarded and disposed in accordance with the regulatory requirement: 1. The facility failed to label medications in accordance with the facility's medication disposition policy for one of three residents (Resident 53) who was discharged from the facility 2. The facility failed to label multi-dose medications with an open date for two of two residents (Residents 1 and 17). This failure had the potential to result in the loss of medication potency and for residents to receive ineffective medication dosages.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Several food items were not dated and labeled in the dry storage area, reach in Refrigerator 1, Freezer 1, Freezer 2, and Freezer 3. 2. Dietary Aide 1 (DA 1) did not perform handwashing or wear gloves when cleaning the stainless-steel table. 3. [NAME] 1 did not perform handwashing or wear gloves when handling the scooper. 4. DA 2 did not perform handwashing after picking up a dirty towel on the kitchen floor. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 59 out of 64 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner when one out of one garbage bin was overfilled with the lid open. This deficient practice had the potential for harboring mice and other pest.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure a change of condition was formulated and responsible party notified for one of 18 sampled residents (Residents 55). This deficient practice violated the responsible party's right to be informed of the care services provided, violated the resident's rights of notification to the resident's representative (family member) and hand the potential to result in lack of proper care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set ([MDS] assessment and care screening tool), regarding functional limitation in range of motion, was conducted for one of 18 sampled residents (Resident 47). This deficient practice had the potential to result inaccurate care and services for Resident 47 due to inappropriate MDS care screening and tool assessment practices.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure g-tube residuals were checked for one of one sampled residents (Resident 8). 2. Ensure a clean stirring utensil was used when diluting the medications for one of one sampled residents (Resident 8). 3. Ensure physician orders were followed to place floor mats for one of 18 sampled residents (Residents 44). This deficient practice had the potential for the affected resident not to receive the care and services needed and the provision of a poor-quality care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure respiratory care was consistent with professional standards of practice when there was no physician order to administer oxygen for one of 7 sampled residents (Resident 16). This deficient practice had the potential to result in unsafe use of oxygen equipment, respiratory infection, unable to breathe comfortably, and/or hospitalization for Resident 16.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who received hemodialysis ([HD]) process of removing waste products and excess fluids from the body) received treatments in accordance with standards of practice for one of three sampled residents (Resident 216) by failing to communicate to physician and implement the fluid restrictions (certain amount of liquid each day) as recommended by hemodialysis. This deficient practice placed Resident 216 at risk for fluid overload, swelling, shortness of breath and discomfort.

Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to provide emergency care for one of 8 sampled residents (Resident 65) by: 1. Failing to call 911 after initiating CPR. This deficient practice resulted in Resident 65's death. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to document quality control checks for two of two medication carts in Nursing Station 1. This deficient practice had the potential to result in inaccurate blood sugar measurements for residents requiring blood sugar checks and can lead to uncontrolled blood sugar.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory test of Comprehensive Metabolic Panel ([CMP] a test that measures different substances in the blood and provides important information of the body's chemical balance and how it uses food and energy) results for one of 18 sampled residents (Resident 216) was reported to the physician in a timely manner. This deficient practice had the potential to result in Resident 216 experiencing preventable complications from abnormal lab values and possibly leading to medical complications requiring hospitalization.

Inspectors wroteBased on observation and record review, the facility failed to meet the required 80 square feet for each resident in rooms 1, 2, 3, 5, 22, and 31. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for residents in room [ROOM NUMBER], 2, 3, 5, 22 and 31 and resulted in psychosocial harm for two out of 21 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four residents (Resident 2 and Resident 3) were assisted with Activities of Daily Living ([ADL's] activities related to personal care) in a timely manner. This deficient practice resulted in Resident 2 feeling upset, Resident 3 feeling frustrated and ignored, and had the potential to result in skin breakdown and falls for Residents 2 and 3.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean and safe environment for residents by failing to ensure the activity room and hallway near the exit door (#3) were free of clutter. This deficient practice had the potential to result in accidents, fall and injuries for residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for one of one sampled resident (Resident 2) by failing to contact the physician and obtain orders for blood glucose (BG blood sugar level) checks for Resident 2 who had a history of Diabetes Mellitus ([DM] a chronic condition that affected the way the body processes blood glucose). This deficient practice increased the risk of Resident 2 having adverse effects (unwanted effects) related to hyperglycemia (high BG) or hypoglycemia (low BG) which could result in medical complications including hospitalization or death.

Inspectors wroteBased on interview, and record review, the facility staff failed to follow its infection control policy and procedure (P&P) for one of five sampled residents (Resident 5) by failing to use the appropriate measures to rinse and clean the resident ' s bedpan (shallow vessel used for urination or defecation) after use. This deficient practice had the potential to for cross contamination (transfer of harmful bacteria from one place to another), transmit infectious microorganisms and increase the risk of infection for Resident 5.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow it's Infection prevention and Control Policy and Procedure (P&P) during wound care for three of 3 of 4 sampled residents (Residents 2, 3 and 4) by failing to ensure facility staff performed hand hygiene (cleaning hands by handwashing or using an alcohol-based hand sanitizer) after removing soiled dressing, doffing (removing) soiled gloves and donning (putting on) clean gloves. This deficient practice had the potential to result in cross contamination (transfer of harmful bacteria from one place to another), infection and delay in the wound healing process for Residents 2, 3 and 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled narcotic drugs (strong pain medicine) for two of three sampled residents (Resident 1 and Resident 2) were accurately accounted for. This deficient practice resulted in Resident 1 missing 30 tablets of Norco (strong pain medicine) and Resident 2 missing 30 tablets of oxycodone (medication to treat severe pain). It also had the potential of preventing Resident 1 and Resident 2 from getting pain medications and exposed staff and others to drug misuse.