Inspection Reports for
Primrose Retirement Community of Kansas City
8559 N Line Creek Pkwy, Kansas City, MO 64154, MO, 64154
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
6.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
91% occupied
Based on a October 2025 inspection.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 40
Deficiencies: 2
Date: Oct 21, 2025
Visit Reason
The inspection was conducted to assess compliance with tuberculosis screening requirements and medication review regulations for residents and staff at Primrose Retirement Community.
Findings
The facility failed to ensure required two-step tuberculosis screening for staff and monthly medication summaries for residents. Deficiencies were found in documentation and completion of TB tests and monthly summaries for sampled employees and residents.
Deficiencies (2)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to ensure required two-step tuberculosis screening was completed for four of five sampled employees. The facility census was 40.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: The facility failed to ensure monthly medication summaries were completed for three of four sampled residents. The facility census was 40.
Report Facts
Facility census: 40
Number of sampled employees with deficient TB testing: 4
Number of sampled residents with deficient monthly summaries: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daunnelle R. Kendrick | Executive Director | Signed the statement of deficiencies and plan of correction |
| Director of Clinical Operations | Interviewed regarding TB testing and monthly summaries | |
| Director of Nursing | Responsible for TB testing and monthly summaries; new Director started September 9th |
Inspection Report
Plan of Correction
Census: 31
Deficiencies: 3
Date: Jan 21, 2025
Visit Reason
The inspection was conducted to evaluate compliance with assisted living facility regulations, focusing on individual service plan review requirements, food safety, and resident rights.
Findings
The facility failed to ensure individual service plans were reviewed and updated after significant changes in residents' conditions, food was not consistently labeled and dated, and resident rights were not reviewed or documented upon admission and annually for sampled residents.
Deficiencies (3)
19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements. The facility failed to review and update individual service plans after significant changes in residents' conditions for four sampled residents. The facility census was 31 residents.
19 CSR 30-87.030(11) Food-Safe, Obtain From Appropriate Sources. The facility failed to ensure food was obtained from compliant sources and properly labeled and dated, with multiple unlabeled or undated food items observed.
19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review. The facility failed to ensure resident rights were reviewed and documented upon admission and annually for six sampled residents. The facility census was 31.
Report Facts
Facility census: 31
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding updating individual service plans and fall risk interventions | |
| Administrator | Interviewed regarding understanding of falls as a change of condition and resident rights review | |
| Executive Director | Responsible for reviewing resident rights and signatures in plan of correction | |
| Dining Manager | Responsible for ensuring food items are properly stored, labeled, and dated |
Inspection Report
Plan of Correction
Census: 25
Deficiencies: 1
Date: Apr 21, 2023
Visit Reason
The inspection was conducted to assess compliance with admission physical examination requirements for residents at Primrose Retirement Community.
Findings
The facility failed to ensure admission physicals were conducted for two of five sampled residents. The Director of Nursing acknowledged ongoing issues with missing admission physicals.
Deficiencies (1)
19 CSR 30-86.047(26) Admission Physical: The facility failed to ensure admission physical examinations were conducted for two of five sampled residents. Documentation of admission physicals was missing for these residents.
Report Facts
Residents sampled: 5
Residents without admission physical: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle R. Collins | Administrator | Signed the plan of correction and report |
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 4
Date: Mar 28, 2023
Visit Reason
This document is a plan of correction related to deficiencies found during a facility inspection conducted on 03/28/2023 at Primrose Retirement Community of Kansas City.
Findings
The facility failed to maintain exit corridors free of obstructions, use approved types of wastebaskets, limit oxygen storage in resident rooms, and provide documentation of electrical wiring inspections within the last two years. These issues potentially affected all 27 residents present during the inspection.
Deficiencies (4)
19 CSR 30-86.022(7)(G) Stairways/Corridors Free of Obstructions. The facility failed to maintain exit corridors free of obstructions, including old resident beds, furniture, and assistive devices.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility failed to ensure all wastebaskets were the approved metal or UL/FM-fire-resistant types.
19 CSR 30-86.022(17) Oxygen Storage Requirements. The facility failed to limit oxygen bottle storage in resident rooms to one in use and one spare, violating NFPA 99 standards.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to provide documentation of electrical wiring inspections within the last two years as required.
Report Facts
Facility census: 27
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 5
Date: Mar 2, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Primrose Retirement Community following a survey conducted on March 2, 2022. The visit was to assess compliance with state regulations related to criminal background checks, medication administration, medication storage, facility cleanliness, and food safety.
Findings
The facility was found deficient in completing criminal background checks for new hires, ensuring a safe and effective medication system including proper medication administration and controlled substance counts, proper medication storage and disposal of expired medications, cleanliness of vents and food storage areas, and maintaining food safety standards. The facility census was 27 during the survey.
Deficiencies (5)
19 CSR 30-86.047(13)(A) Criminal Background Check Requirements: The facility failed to complete required criminal background checks for two of five sampled employees prior to allowing access to residents.
19 CSR 30-86.047(46) Safe & Effective Medication System: The facility failed to ensure medications were administered per physician orders, medication administration records were properly signed, and controlled substance counts had two signatures per shift.
19 CSR 30-86.047(56)(EX)(1-2) Medications-Return to RX / Destroy, Records: The facility failed to ensure expired medications were removed from medication carts and overflow cabinets and properly destroyed within 30 days.
19 CSR 30-87.020(19) List Fixtures, Vent Covers, Décor Cleanable: The facility failed to keep vent covers in the kitchen and resident rooms clean and free from dirt and debris.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: The facility failed to ensure food was stored in sealed, labeled, and dated containers and discarded food items that were not properly stored.
Report Facts
Facility census: 27
Number of sampled employees without CBC: 2
Number of residents affected by medication deficiencies: 4
Number of expired medication instances: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Named in medication administration and expired medication findings | |
| Executive Director | Executive Director | Interviewed regarding criminal background checks and facility policies |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and medication storage |
| Cook A | Interviewed regarding food storage and safety | |
| Maintenance Supervisor | Interviewed regarding cleaning of vents |
Inspection Report
Plan of Correction
Census: 28
Deficiencies: 2
Date: Aug 24, 2021
Visit Reason
This document is a Statement of Deficiencies related to a plan of correction following a facility inspection.
Findings
The facility failed to ensure all medications were secured behind at least one locked door or cabinet for three sampled residents. The facility also failed to develop and implement a safe and effective medication control and use system for the same residents.
Deficiencies (2)
19 CSR 30-86.047(41)(A) Resident Controlled Access to Meds: The facility failed to ensure all medications were secured behind at least one locked door or cabinet for three sampled residents. Resident rooms were observed unlocked with medications accessible and no documentation of medication administration was found.
19 CSR 30-86.047(46) Safe & Effective Medication System: The facility failed to develop and implement a safe and effective system of medication control and use for three sampled residents. There was no designated staff assigned to ensure medications were kept locked or recorded on the MAR.
Report Facts
Resident census: 28
Number of sampled residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding medication storage and MAR procedures | |
| Executive Director | Interviewed regarding medication administration policies |
Inspection Report
Life Safety
Census: 26
Deficiencies: 5
Date: May 13, 2021
Visit Reason
The inspection was a licensure inspection focused on fire safety and life safety code compliance at Primrose Retirement Community of Kansas City.
Findings
The facility failed to maintain exit corridors free of obstructions, maintain the complete fire alarm system, maintain self-closing smoke partition doors, maintain emergency lighting in good repair, and use approved wastebaskets. These deficiencies affected all 26 residents present during the inspection.
Deficiencies (5)
19 CSR 30-86.022(7)(G) Stairways/Corridors Free of Obstructions. The facility failed to keep exit corridors free of obstructions, including kitchen items and old resident furniture.
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain. The facility failed to maintain the complete fire alarm system, including improper placement of a smoke detector near a ceiling fan.
19 CSR 30-86.022(10)(A) Hazardous Area Requirements. The facility failed to maintain self-closing smoke partition doors separating the kitchen area from the rear dining area egress route.
19 CSR 30-86.022(12)(A) Emergency Lighting - locations. The facility failed to maintain all emergency lights in good repair, with several lights not working properly.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility failed to ensure all wastebaskets were approved types, with several rooms having improper wastebaskets.
Report Facts
Facility census: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| maintenance director | Interviewed regarding corrective actions for deficiencies | |
| dietary manager | Re-educated dietary staff on keeping corridors and doors free of obstruction | |
| executive director | Responsible for observing corridors and re-educating residents and families |
Inspection Report
Plan of Correction
Census: 29
Deficiencies: 1
Date: Oct 14, 2020
Visit Reason
The inspection was conducted to assess compliance with licensing requirements, specifically regarding the designation of a licensed administrator at the facility.
Findings
The facility failed to designate an individual with a current license from the Missouri Board of Nursing Home Administrators as the administrator. The previous administrator's Temporary Emergency License expired, and the acting administrator did not have a current license at the time of inspection.
Deficiencies (1)
19 CSR 30-86.047(5) Administrator - Licensed. The operator failed to designate an individual currently licensed as an administrator by the Missouri Board of Nursing Home Administrators. The acting administrator did not have a current license at the time of inspection.
Report Facts
Facility census: 29
Inspection Report
Plan of Correction
Census: 31
Deficiencies: 5
Date: Feb 5, 2020
Visit Reason
The inspection was conducted to assess compliance with tuberculosis screening, medication reconciliation, food safety, chemical sanitization, and individualized evacuation plans at Primrose Retirement Community of Kansas City.
Findings
The facility failed to maintain compliance with tuberculosis screening for staff, reconcile controlled substance medications each shift, ensure food was protected from contamination, maintain proper chemical sanitization levels, and include individualized evacuation plans for residents needing assistance.
Deficiencies (5)
19 CSR 30-86.047(19) TB Screen Residents & Staff. The facility failed to screen four of five sampled employees for tuberculosis as required, with no documentation of TB tests found for several staff members.
19 CSR 30-86.047(51)(A)(1) Schedule II Meds-Reconcile Each Shift, Record. The facility failed to reconcile controlled substance medications each shift, with missing signatures on medication shift verification forms.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS. The facility failed to protect food from potential contamination, with unsealed food items and improper storage observed.
19 CSR 30-87.030(74) Chemical Sanitization, PPM Measured. The facility failed to ensure proper chemical concentration of sanitizer in the dishwasher, with no documentation for the first five days of February.
19 CSR 30-86.045(3)(A)(5) Individual Evacuation Plan - In Resident ISP. The facility failed to include individualized evacuation plans for four sampled residents needing physical assistance to evacuate.
Report Facts
Facility census: 31
Inspection Report
Plan of Correction
Census: 32
Deficiencies: 9
Date: Apr 9, 2019
Visit Reason
The inspection was conducted as a licensure inspection focusing on fire safety compliance and related regulatory requirements.
Findings
The facility failed to meet multiple fire safety regulations including inadequate fire drill documentation, obstructed corridors, missing smoke detectors, failure to test fire alarm systems monthly, incomplete sprinkler system maintenance records, insufficient emergency lighting, improper wastebasket types, exposed electrical wiring, and use of unapproved extension cords.
Deficiencies (9)
19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation. The facility failed to produce documentation of at least 12 fire drills conducted within the last year and failed to document at least one fire drill on each shift every other month including a resident evacuation.
19 CSR 30-86.022(7)(G) Stairways/Corridors Free of Obstructions. The 2nd floor West exit corridor had various items obstructing the egress pathway.
19 CSR 30-86.022(9)(A)(1) Smoke Detectors-NFPA 13. The facility failed to have smoke detectors installed in all required corridor spaces; several doors leading to rooms and corridors lacked smoke detectors.
19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test. The facility failed to test the fire alarm system monthly and provide documentation of activation.
19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13. The facility failed to ensure monthly pressure gauge readings and valve position checks of the sprinkler system were performed and documented.
19 CSR 30-86.022(12)(C) Emergency Lighting - Battery Powered, 1.5 hrs. Emergency lighting in resident corridors and key areas failed to operate during battery tests.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility used non-approved wire mesh wastebaskets in resident rooms.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to properly maintain electrical wiring, exposing direct electrical contact in the electrical room.
19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles. The facility failed to prevent use of unapproved extension cords and multiple items plugged into one cord.
Report Facts
Facility census: 32
Fire drills documented: 7
Inspection Report
Plan of Correction
Census: 34
Deficiencies: 4
Date: Feb 13, 2019
Visit Reason
The inspection was conducted to assess compliance with regulations related to community based assessments, resident condition and medication review, cleanliness of light fixtures and exhaust fans, and hand washing practices.
Findings
The facility failed to complete community based assessments semi-annually for sampled residents, maintain monthly summaries for residents, keep exhaust fans clean and in working order, and ensure staff washed hands and changed gloves properly during food preparation.
Deficiencies (4)
19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually. The facility failed to complete community based assessments at least semiannually for three sampled residents. The facility census was 34.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review. The facility failed to keep monthly summaries for three sampled residents. The facility census was 34.
19 CSR 30-87.020(19) Light Fixtures, Vent Covers, Decor Cleanable. The facility failed to maintain exhaust fans in working order and clean condition in residents' bathrooms. The facility census was 34.
19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails. Facility staff failed to wash hands and change gloves properly during food preparation. The facility census was 34.
Report Facts
Facility census: 34
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 5
Date: Jun 1, 2018
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident found outside the facility unresponsive and running a fever, and concerns about staffing and administrator absence.
Complaint Details
The complaint investigation was substantiated based on findings that the facility failed to provide adequate nursing assessment, protective oversight, timely notification to physicians and legally authorized representatives, and failed to report suspected abuse or neglect as required.
Findings
The facility failed to ensure licensed nurse responsibilities were met, including timely assessment and physician notification for a resident found outside unresponsive. The administrator failed to designate a staff member in charge during absences. Protective oversight was inadequate for a resident with dementia found unattended outside. The facility also failed to promptly report suspected abuse or neglect to the Department of Health and Senior Services.
Deficiencies (5)
19 CSR 30-86.045(4)(F) Staffing-Licensed Nurse Responsibilities: The licensed nurse was not available to assess a resident found outside unresponsive and running a fever, and the physician was not contacted as required.
19 CSR 30-86.047(8) Administrator Absence, Designee: The administrator failed to designate in writing a staff member in charge during absences when both the administrator and Director of Nursing were out for seven days.
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide 24-hour protective oversight when a resident with dementia was found unattended outside the facility unresponsive and running a fever.
19 CSR 30-86.047(37) Appropriate Action & Notification: The facility failed to promptly contact the resident's legally authorized representative when the resident was found outside unresponsive and running a fever.
19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: The facility failed to report an incident of suspected abuse or neglect to the Department of Health and Senior Services in a timely manner following a resident found outside unresponsive and running a fever.
Report Facts
Facility census: 29
Resident temperature: 102.6
Resident blood pressure: 91.54
Resident pulse: 57
Resident respiratory rate: 14
Oxygen saturation: 96
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