Inspection Reports for
Primrose Retirement Community of Jefferson City
MO, 65109
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
4.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
82% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 40
Deficiencies: 1
Date: Apr 22, 2025
Visit Reason
The visit was conducted to address deficiencies related to the facility's failure to maintain active second business licenses for ancillary services including wellness program, outpatient therapy, beauty salon, and housekeeping services for Independent Living apartments.
Findings
The facility failed to maintain active second business licenses for office space used for wellness, therapy, beauty salon, and housekeeping services. The administrator was unaware of the expired licenses and the facility did not have the licenses posted during the inspection.
Deficiencies (1)
19 CSR 30-86.047(6) Operator/Administrator Responsibilities: The facility failed to maintain active second business approval for office space used for wellness program, outpatient therapy, beauty salon, and housekeeping services. The facility census was 40.
Report Facts
Facility census: 40
Inspection Report
Plan of Correction
Census: 44
Deficiencies: 2
Date: Aug 14, 2024
Visit Reason
The inspection was a fire safety inspection conducted at Primrose Retirement Community of Jefferson City to assess compliance with elevator requirements and wastebasket regulations.
Findings
The facility failed to comply with elevator inspection requirements as the elevator inspection expired on June 18, 2024. The facility also failed to ensure only metal or UL/FM-fire-resistant wastebaskets were used, with more than twenty-seven unapproved plastic wastebaskets observed throughout the ALF II side of the building.
Deficiencies (2)
19 CSR 30-86.012(25) Elevator Requirements: The elevator inspection expired on June 18, 2024, and the regulation was not met as evidenced by Class II deficiency.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: The facility used more than twenty-seven unapproved plastic wastebaskets instead of only metal or UL/FM-fire-resistant rated wastebaskets, affecting all 44 residents.
Report Facts
Facility census: 44
Unapproved plastic wastebaskets: 27
Inspection Report
Plan of Correction
Census: 42
Deficiencies: 2
Date: Jun 14, 2024
Visit Reason
The inspection was conducted to assess compliance with tuberculosis (TB) screening requirements for staff at Primrose Retirement Community of JEI.
Findings
The facility failed to ensure that staff received the required two-step TB screening test. Personnel files for six sampled staff members lacked documentation of the second step TB skin test, and the facility did not have a policy for TB requirements.
Deficiencies (2)
A4724 19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility did not ensure staff received the required two-step tuberculosis screening test. Six sampled staff personnel files lacked documentation of the second step TB skin test administered.
The facility did not provide a policy for tuberculosis (TB) screening requirements for employees.
Report Facts
Facility census: 42
Staff missing second step TB test: 6
Inspection Report
Plan of Correction
Census: 37
Deficiencies: 12
Date: Jun 22, 2023
Visit Reason
The inspection was conducted to identify deficiencies related to new employee orientation and training requirements at Primrose Retirement Community of Jefferson City.
Findings
The facility failed to ensure new staff received required orientation training on job responsibilities, emergency response procedures, infection control/handwashing, confidentiality, resident dignity, abuse/neglect, employee disqualification, resident rights/property, resident mental illness, and safe transfers. The facility lacked written policies and documentation for these trainings for sampled staff.
Deficiencies (12)
19 CSR 30-86.047(62)(A) Orientation - job responsibilities. 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.
19 CSR 30-86.047(62)(B) Orientation - emergency response procedures. The facility staff failed to ensure new staff received orientation training on emergency response prior to or on the first day of work for two of four sampled staff.
19 CSR 30-86.047(62)(C) Orientation - infection control/handwashing. 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.
19 CSR 30-86.047(62)(D) Orientation - confidentiality. The facility staff failed to ensure new staff received orientation training on confidentiality prior to or on the first day of work for two of four sampled staff.
19 CSR 30-86.047(62)(E) Orientation - resident dignity. 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.
19 CSR 30-86.047(62)(F) Orientation - abuse/neglect info. The facility staff failed to ensure new staff received orientation training on abuse/neglect prior to or on the first day of work for two of four sampled staff.
19 CSR 30-86.047(62)(G) Orientation - EDL. The facility staff failed to ensure new staff received orientation training on employee disqualification prior to or on the first day of work for four of four sampled staff.
19 CSR 30-86.047(62)(H) Orientation - resident rights/property. 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.
19 CSR 30-86.047(62)(I) Orientation - resident mental illness. 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.
19 CSR 30-86.047(62)(J) Orientation - person centered care/social model. The facility staff failed to ensure new staff received orientation training on person-centered care/social model prior to or on the first day of work for two of four sampled staff.
19 CSR 30-86.047(63)(A) Alz/Dementia Training-Direct Care Staff, 3 hr. The facility failed to ensure new staff received orientation training on Alzheimer's disease and related dementias prior to or on the first day of work for two of four sampled staff.
19 CSR 30-86.047(65)(A) Safe Transfers Training Requirements. The facility failed to ensure new staff received orientation training on safe transfers prior to or on the first day of work for two of four sampled staff.
Report Facts
Census: 37
Deficiencies cited: 12
Inspection Report
Plan of Correction
Census: 45
Deficiencies: 1
Date: Jul 14, 2022
Visit Reason
The inspection was conducted to assess compliance with tuberculosis screening requirements for residents and staff as required by Missouri state regulations for long-term care facilities.
Findings
The facility failed to properly screen or administer tuberculosis tests to ten of fourteen sampled employees, resulting in noncompliance with state tuberculosis screening regulations. Several personnel records lacked documentation of required two-step tuberculin skin tests and annual TB tests.
Deficiencies (1)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to screen or administer tuberculosis tests for ten of fourteen sampled employees as required by state regulations.
Report Facts
Facility census: 45
Sampled employees: 14
Employees failed screening: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in tuberculosis screening deficiency |
| CMT B | Certified Medication Technician | Named in tuberculosis screening deficiency |
| CMT C | Certified Medication Technician | Named in tuberculosis screening deficiency |
| CMT D | Certified Medication Technician | Named in tuberculosis screening deficiency |
| CMT E | Certified Medication Technician | Named in tuberculosis screening deficiency |
| CMT F | Certified Medication Technician | Named in tuberculosis screening deficiency |
| Director of Nursing | DON | Named in tuberculosis screening deficiency |
| Director of Dining Services | DDS | Named in tuberculosis screening deficiency |
| Dietary aide A | Dietary aide | Named in tuberculosis screening deficiency |
| Administrator | Named in tuberculosis screening deficiency |
Inspection Report
Plan of Correction
Census: 44
Capacity: 45
Deficiencies: 2
Date: Aug 1, 2019
Visit Reason
The inspection was conducted to assess compliance with regulations related to maintenance, cleaning, and food safety at Primrose Retirement Community.
Findings
The facility failed to properly store cleaning tools and chemicals, risking contamination of food and utensils. Additionally, kitchen equipment was not maintained in a clean manner, with buildup and unidentified substances observed on the juice machine.
Deficiencies (2)
19 CSR 30-87.030(8) Maintenance & Cleaning Tools Storage: The facility failed to maintain and store vacuum cleaners and chemicals in a way that does not contaminate food, utensils, equipment, or linens.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Facility staff failed to maintain kitchen equipment clean to prevent contamination of food products, with buildup and unidentified substances observed on the juice machine.
Report Facts
Facility census: 44
Facility capacity: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding chemical storage and kitchen cleaning expectations | |
| Dietary Manager | Responsible for monitoring chemical storage and kitchen cleaning logs |
Inspection Report
Plan of Correction
Census: 43
Deficiencies: 1
Date: May 6, 2019
Visit Reason
The visit was conducted to assess compliance with fire drill requirements and emergency preparedness regulations.
Findings
The facility failed to conduct one full evacuation fire drill within a twelve-month period as required by regulation 19 CSR 30-86.022(5)(D). The facility census on the date of inspection was 43 residents.
Deficiencies (1)
19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation: The facility did not conduct one full evacuation fire drill within a twelve-month period as required. The fire drill regulation was not met as evidenced by record review and interviews.
Report Facts
Facility census: 43
Required fire drills: 12
Unannounced fire drills: 4
Inspection Report
Plan of Correction
Census: 42
Deficiencies: 3
Date: Aug 10, 2018
Visit Reason
The inspection was conducted to assess compliance with resident condition/medication review, food protection and temperature standards, and cleanliness of kitchen equipment and utensils.
Findings
The facility failed to complete monthly summaries for sampled residents, improperly stored and labeled food items, and did not maintain cleanliness of kitchen equipment including stove burners and toaster. These deficiencies had the potential to affect all residents.
Deficiencies (3)
19 CSR 30-86.047 (58)(3) Resident Condition/Medication Review: The facility failed to complete monthly summaries for four sampled residents. Records lacked required monthly summaries.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Facility staff failed to store food properly to protect from contamination. Multiple food items were unlabeled, undated, or improperly stored.
19 CSR 30-87.030(64) Grills/Griddles/Microwaves/Other-Clean Daily: Facility staff failed to ensure stove burners and toaster were clean and free of debris. Cleaning logs for August 2018 were incomplete.
Report Facts
Facility census: 42
Deficiencies cited: 3
Inspection Report
Life Safety
Census: 43
Deficiencies: 1
Date: Apr 24, 2018
Visit Reason
The inspection was a fire safety portion of the licensure inspection conducted on April 24, 2018, to assess compliance with fire alarm system testing and maintenance regulations.
Findings
The facility failed to have the fire alarm system inspected semi-annually by a qualified service representative as required by NFPA 72, 1999 edition. The last semi-annual inspection was not conducted, with the most recent annual inspections performed in June 2017 and June 2016.
Deficiencies (1)
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: The facility failed to have the fire alarm system inspected semi-annually by a qualified service representative as required by NFPA 72, 1999 edition. The last semi-annual inspection was not conducted.
Report Facts
Facility census: 43
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