Health inspection·September 3, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings:During an observation on 9/3/2025 at 11:50 a.m. with the Maintenance Supervisor (MS), and the Director of Nursing (DON), five boxes containing invoices from dietary purchases, lab services, intravenous services and equipment purchases, with Resident personal and/or medical information such as resident name, date of birth [DOB], room number and/or resident medical record number [MRN], were observed at the facility parking lot unattended. During a review of Resident 1 admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dysphagia (difficulty in swallowing), Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and Acute Kidney Failure (a condition in which the kidneys lose the ability to remove waste and balance fluids).During a review of Resident 1 Minimum data Set ([MDS] a resident assessment tool) dated 6/5/2025, the MDS indicated Resident 1 had severe cognitive (ability to think and reason) impairment but was usually able to understand others. The MDS indicated Resident 1 was totally dependent on staff for Activities of Daily Living (ADLs) such as toileting, dressing and personal hygiene. During a review of the facility's Pathology (laboratory) Services Invoice dated 11/1/2021, the Invoice included Resident 1's name, MRN, DOB and lab charges. During a review of Resident 2 admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body, DM, and Hypertension (HTN- high blood pressure).During a review of Resident 2 MDS dated [DATE], the MDS indicated Resident 2 had moderate cognitive impairment but was able to understand others. The MDS indicated Resident 2 was totally dependent on staff for ADLs such as toileting and dressing. During a review of the facility's Radiology (medical specialty that uses various imaging technologies such as X-rays [creates images of the inside of the body] and Computed Tomography [CT-uses x-rays to create detailed cross-sectional images of the body] to diagnose diseases and injuries) Invoice dated 9/3/2021, the Invoice included Resident 2's DOB, exam charge and reason for exam (leg pain). During a review of the facility's Pathology Services Invoice dated 11/1/2021, the Invoice included Resident 2's name, Medical Record Number, DOB and lab charges. During a review of Resident 3 admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's disease (a progressive disorder of the nervous system marked by tremor, muscular rigidity and slow imprecise movement), Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease causing difficulty in breathing) and Major Depression (a mood disorder that causes a Residents Affected - Some Page 1 of 2 055608 055608 09/03/2025 Primrose Post-Acute 515 Centinela Ave. Inglewood, CA 90302

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some persistent feeling of sadness and loss of interest).During a review of Resident's 3 MDS dated [DATE], the MDS indicated Resident 3 has severe cognitive impairment, but was able to understand others. The MDS indicated Resident 3 was totally dependent on staff for ADLs such as eating, lower body dressing and personal hygiene. During a review of the facility's Pathology (laboratory) Services Invoice dated 11/1/2021, the Invoice included Resident 3's name, Medical Record Number, date of birth (DOB) and lab charges.During an interview on 9/3/2025 at 12:15 p.m. with the MS, the MS stated he brought out the five boxes (containing facility invoices) from the storage and left them outside in the parking lot approximately two weeks ago. The MS stated, he planned on disposing of them later. During an interview on 9/3/2025 at 1:00 p.m. with the DON, the DON stated she was not aware of the boxes filled with records containing patient information left outside in the parking lot. The DON stated any documents from the facility should not have been left outside and all documents with resident 's information needing to be disposed of, should be placed in the shredder.During a review of the facility's policy and procedure (P&P) titled, Compliance Risks- Privacy, Security, and Breach Notifications, dated 4/2025, the P&P indicated the facility complies with the laws governing privacy, security and breach notification of protected health information as set forth in the Health Insurance Portability and Accountability Act (HIPAA) and other privacy and security rules. The P&P indicated the facility maintains policies and procedures ensuring resident privacy and confidentiality including maintaining the privacy and confidentiality of residents' medical records and resident access to personal and medical records. 055608 Page 2 of 2