ElderGrade

Inspection citations at Primrose Post-Acute

71 citations on record, 1 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 6 0
2025 17 0
2024 24 1
2023 2 0
2022 22 0
D May 6, 2026 Tag F0657 Complaint investigation Corrected May 2026

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D February 11, 2026 Tag F0842 Complaint investigation Corrected Mar 2026

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D February 11, 2026 Tag F0658 Complaint investigation Corrected Mar 2026

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D February 11, 2026 Tag F0656 Complaint investigation Corrected Mar 2026

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D February 11, 2026 Tag F0553 Complaint investigation Corrected Mar 2026

Resident Rights Deficiencies

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

No actual harm, potential for more than minimal harm

D February 11, 2026 Tag F0550 Complaint investigation Corrected Mar 2026

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E September 3, 2025 Tag F0583 Complaint investigation Corrected Sep 2025

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

No actual harm, potential for more than minimal harm

D May 23, 2025 Tag F0745 Complaint investigation Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

No actual harm, potential for more than minimal harm

D May 23, 2025 Tag F0686 Complaint investigation Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

B May 23, 2025 Tag F0912 Corrected Jun 2025

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

No actual harm, minimal potential

D May 23, 2025 Tag F0881 Corrected Jun 2025

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, potential for more than minimal harm

D May 23, 2025 Tag F0880 Corrected Jun 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D May 23, 2025 Tag F0806 Corrected Jun 2025

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

No actual harm, potential for more than minimal harm

D May 23, 2025 Tag F0804 Corrected Jun 2025

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

D May 23, 2025 Tag F0689 Corrected Jun 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D May 23, 2025 Tag F0658 Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D May 23, 2025 Tag F0645 Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

No actual harm, potential for more than minimal harm

D May 23, 2025 Tag F0644 Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

No actual harm, potential for more than minimal harm

D May 23, 2025 Tag F0610 Complaint investigation Corrected Jun 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

D May 23, 2025 Tag F0558 Corrected Jun 2025

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

E May 23, 2025 Tag F0865 Corrected Jun 2025

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

No actual harm, potential for more than minimal harm

E May 23, 2025 Tag F0641 Complaint investigation Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

F May 23, 2025 Tag F0812 Corrected Jun 2025

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

D December 11, 2024 Tag F0609 Complaint investigation Corrected Jan 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D November 4, 2024 Tag F0689 Complaint investigation Corrected Nov 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D October 31, 2024 Tag F0609 Complaint investigation Corrected Nov 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D October 8, 2024 Tag F0609 Complaint investigation Corrected Nov 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

B May 10, 2024 Tag F0912 Corrected Jun 2024

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

No actual harm, minimal potential

D May 10, 2024 Tag F0773 Corrected Jun 2024

Administration Deficiencies

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

No actual harm, potential for more than minimal harm

D May 10, 2024 Tag F0755 Corrected Jun 2024

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D May 10, 2024 Tag F0726 Corrected Jun 2024

Nursing and Physician Services Deficiencies

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.

No actual harm, potential for more than minimal harm

D May 10, 2024 Tag F0698 Corrected Jun 2024

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

No actual harm, potential for more than minimal harm

D May 10, 2024 Tag F0695 Corrected Jun 2024

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D May 10, 2024 Tag F0658 Corrected Jun 2024

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D May 10, 2024 Tag F0641 Corrected Jun 2024

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D May 10, 2024 Tag F0580 Corrected Jun 2024

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, potential for more than minimal harm

E May 10, 2024 Tag F0814 Corrected Jun 2024

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

No actual harm, potential for more than minimal harm

E May 10, 2024 Tag F0812 Corrected Jun 2024

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E May 10, 2024 Tag F0761 Corrected Jun 2024

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

E May 10, 2024 Tag F0656 Corrected Jun 2024

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.