Inspection Reports for
Primrose Retirement Community of Jefferson City

19 CSR 30-86.047(6) Operator/Administrator Responsibilities: Based on observation, interview, and record review, facility staff failed to maintain active second business approval for office space (wellness program), office space for outpatient therapy services, a beauty salon, and housekeeping services provided to Independent Living apartments; the facility did not provide a policy for second business approvals, and the facility census was 40.

19 CSR 30-86.012(25) Elevator Requirements: Record review showed the elevator inspection had expired on June 18, 2024 and the facility did not have a current inspection; maintenance reported the inspection/testing was scheduled.

19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: Observations found more than twenty-seven unapproved plastic wastebaskets in use throughout the ALF II side, and the facility failed to ensure only metal or UL/FM-rated wastebaskets were used; the maintenance director stated he would address the issue.

19 CSR 30-86.047(19) TB Screen Residents & Staff: Based on interview and record review, facility staff failed to ensure the required two-step tuberculosis (TB) screening test was administered for six of seven sampled staff members and the facility did not provide a policy for TB requirements.

19 CSR 30-86.047(62)(A) Orientation - job responsibilities: Based on interview and record review, the facility staff failed to ensure new staff received orientation training on job responsibilities prior to or on the first day of work for two of four sampled staff (Dietary Assistant A and Certified Medication Aide B).

19 CSR 30-86.047(62)(B) Orientation - emergency response procedures: Based on interview and record review, the facility staff failed to ensure new staff received orientation training on emergency response procedures prior to or on the first day of work for two of four sampled staff (Dietary Assistant A and Certified Medication Aide B).

19 CSR 30-86.047(62)(C) Orientation - infection control/handwashing: Based on interview and record review, the facility staff failed to ensure new staff received orientation training on infection control and handwashing prior to or on the first day of work for two of four sampled staff (Dietary Assistant A and Certified Medication Aide B).

19 CSR 30-86.047(62)(D) Orientation - confidentiality: Based on interview and record review, the facility staff failed to ensure new staff received orientation training on confidentiality/Health Insurance Portability and Accountability Act prior to or on the first day of work for two of four sampled staff (Dietary Assistant A and Certified Medication Aide B).

19 CSR 30-86.047(62)(E) Orientation - resident dignity: Based on interview and record review, the facility staff failed to ensure new staff received orientation training on preservation of resident dignity prior to or on the first day of work for two of four sampled staff (Dietary Assistant A and Certified Medication Aide B).

19 CSR 30-86.047(62)(F) Orientation - Abuse/Neglect info.: Based on interview and record review, the facility staff failed to ensure new staff received orientation training regarding abuse/neglect information and reporting prior to or on the first day of work for two of four sampled staff (Dietary Assistant A and Certified Medication Aide B).

19 CSR 30-86.047(62)(G) Orientation - EDL: Based on interview and record review, the facility staff failed to ensure new staff received orientation training regarding the Employee Disqualification List prior to or on the first day of work for four of four sampled staff (Dietary Assistant A, Certified Medication Aide B, Resident Assistant C and Housekeeper D).

19 CSR 30-86.047(62)(H) Orientation - resident rights/property: Based on interview and record review, the facility staff failed to ensure new staff received orientation training on resident rights and protection of property prior to or on the first day of work for two of four sampled staff (Dietary Assistant A and Certified Medication Aide B).

19 CSR 30-86.047(62)(I) Orientation - resident mental illness: Based on interview and record review, the facility staff failed to ensure new staff received orientation training on working with residents with mental illness prior to or on the first day of work for two of four sampled staff (Dietary Assistant A and Certified Medication Aide B).

19 CSR 30-86.047(62)(J) Orientation-person centered care/social model: Based on interview and record review, the facility staff failed to ensure new staff received orientation training on person-centered care/social model of care prior to or on the first day of work for two of four sampled staff (Dietary Assistant A and Certified Medication Aide B).

19 CSR 30-86.047(63)(A) Alz/Dementia Training-Direct Care Staff, 3 hr: Based on interview and record review, the facility staff failed to ensure new staff received Alzheimer’s/dementia orientation training prior to or on the first day of work for two of four sampled staff (Dietary Assistant A and Certified Medication Aide B).

19 CSR 30-86.047(65)(A) Safe Transfers Training Requirements: Based on interview and record review, the facility staff failed to ensure new staff received orientation training related to safe transferring prior to or on the first day of work for two of four sampled staff (Dietary Assistant A and Certified Medication Aide B).

19 CSR 30-86.047(19) TB Screen Residents & Staff: Based on interview and record review, facility staff failed to screen or administer a tuberculosis test for ten of fourteen sampled employees (Administrator, Director of Nursing (DON), Certified Medication Technician (CMT) A, CMT B, CMT C, CMT D, CMT E, CMT F, Director of Dining Services (DDS) A, and Dietary aide A). Review of personnel records showed these staff did not document the required two-step or annual TB testing.

19 CSR 30-87.030(8) Maintenance & Cleaning Tools Storage: Based on observation and interview, facility staff failed to maintain and store vacuum cleaners and chemicals in a way that did not contaminate food, utensils, equipment or linens.

19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Based on observation and interview, facility staff failed to maintain kitchen equipment in a clean manner, including buildup on the juice machine that could contaminate food.

19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation: Based on record review and interview during the fire safety portion of the licensure inspection, the facility failed to conduct one full evacuation fire drill within a twelve month period; record review showed no full evacuation fire drill between May 2018 and April 2019.

19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: Based on record review and interview, the facility failed to complete monthly summaries of residents' general condition and needs for sampled residents; records for Residents #1, #3, and #4 did not contain monthly summaries.

19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Based on observation and interview, staff failed to store, label and protect food from potential contamination and to maintain required practices; numerous unlabeled, undated, uncovered or expired items were observed in dry storage, prep areas, freezer and refrigerators.

19 CSR 30-87.030(64) Grills/Griddles/Microwaves/Other-Clean Daily: Based on observation and interview, staff failed to ensure stove burners and toaster remained clean and free of debris; thick black build-up and debris were observed on stove burners and buildup was noted on toaster vents, and cleaning documentation was lacking for August 2018.

19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: The facility failed to have the fire alarm system inspected semi-annually as required; record review showed no semi-annual inspection and only annual inspections in 2016 and 2017, affecting all residents.