PRIMROSE RETIREMENT COMMUNITY OF JEFFERSON CITY.

PRINTED: 05/05/2025 FORM APPROVED Missourd Department of Health and Senior Services STATEMENT OF DEFICIENCIES Ott} PROVIDER/SUPPLIER/CLIA (%2) MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUL.DING: 8. WING 29697 04/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1214 FREEDOM BLVD PRIMROSE RETIREMENT COMMUNITY OF JE! JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY Must BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION x) {EACH CORRECTIVE ACTION SHOULD 8E COMPLETE CAOSS-REFERENCEDO TO THE APPROPRIATE BATE SERICIENCY) A4704, 19 CSR 30-86.047(6) Operator/Administrator Responsibilities The operator shali be responsible to assure compliance with all applicable laws and regulations. The administrator shall be fully authorized and empowered to make decisions tegarding the operation of the facility and shafi be held responsible for the actions of all employees, The administrator ‘ s responsibilities shall include oversight of residents to assure that they receive care as defined in the individualized service plan. iil This regulation is not met as evidenced by: Class tit Based on observation, interview, and record review, facility staff failed to maintain active second business approval for office space for a weliness program, office space for an outpatient therapy program, a beauty safon, and housekeeping services provided to independent Living apartments. The facility census was 40. The facility staff did not pravide a policy for second business approvals, Review of the state of Missourt database for second business licenses by fong term care communities showed: -The facility second business license for office space (wellness center program) which expired on July 31, 2024; -The facility second business license for office space (outpatien! therapy services) which expired on July 31, 2024; -Tha facility second business license for office ome (beauty salon) which expired on July 34, OS OR PROVIDERSUPPLIER REPRESENTATIVES SIGNATURE TLE - (8) DATE: BRE Ed ale A a }3 15 AS rE OW ° wae T16A11 Wowtrumion atest 1002 | Seanned with | CamScanner’: PRINTED: 05/05/2025 ; FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 29697 B. WING ea 04/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1214 FREEDOM BLVD PRIMROSE RETIREMENT COMMUNITY OF JEF JEFFERSON CITY, MO 65109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i CROSS-REFERENCED TO THE APPROPRIATE DATE | i DEFICIENCY) : Continued From page 1 -The facility second business license for ancillary | services (housekeeping - Independent Living ‘ apartments) which expired on July 31, 2024. Observation on 04/22/25 during a tour of the facility showed the facility did not have second business licenses displayed. During an interview on 04/22/25 at 2:50 P.M., the | administrator said he/she began working at the | facility in August 2024, and he/she was not made | aware the facility had any second business licenses. The administrator said active second ' business licenses were not posted because he/she was unaware of the existence of the licenses. The administrator said the facility was continuing to offer beauty saion services, therapy | services, wellness program services and housekeeping services to the people residing in Independent Living at the facility. Missouri Department of Health and Senior Services STATE FORM sa98 416A11 ff continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier aneee Primrose Retirement Community of Jefferson City Street Address, 1214 Freedom Blvd City, Zip: Jefferson City, MO 65109 Date of Survey: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER iD PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A4704 The expired second business license had the potential to impact all assisted living residents. We will maintain an active 2. business license and have this posted in the facility. We submitted for renewal of the 24 business ticense related to wellness center program, office space for outpatient therapy services, and the space for the beauty saion on June13, 2024. We have been working with a representative from the Department of Health & Senior Services Section for Long-Term Care Regulation Unit since November 5, 2024. We are actively working to secure a 3" party vendor to provide emergency call devices and support for the IL tenants. Following the contract being fully executed, our 2°¢ business license will be renewed. The Executive Director (ED) or designee will inspect the 2 business license to ensure it is posted monthly. The 2°¢ business license expiration date will be monitored by the Executive Director or designee and within 60 days ofthe =| expiration date, will submit for renewal. Results of the audit will tings to ensure Co: be reviewed in QA meeti mpliance. The contract with the 3% party vendor will be in place by June 5, 2025 to transition to emergency calls by IL tenants to be sup ported by 2 3 SJeaT T) vendor. The Administrator signing and dating the first page of the CMS-2567/State Form Is indicating thelr approval of the pian of correction being submitted on this form. Seanned with ‘ & CamScanner’:

PRINTED: 08/20/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY (X2} MULTIPLE CONSTRUCTION COMPLETED A. BUILDING: 8. WING 08/14/2024 STREET ADDRESS, CITY, STATE, ZiP CODE 1214 FREEDOM BLVD 1 Cc ITY OF PRIMROSE RETIREMENT COMMUN JEFFERSC JEFFERSON CITY, MO 65109 NAME OF PROVIDER OR SUPPLIER PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x8) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY GR LSC IDENTIFYING INFORMATION) (X4) 1D PREFIX TAG 19 CSR 30-86.012(25) Elevator Requirements Residential care facilities and facilities formerly licensed as residential care facilities whose plans were initially approved between December 31, 1987 and December 31, 1998, shall have at least one (1) hydraulic or electric motor-driven elevator if there are more than twenty (20) residents with bedrooms above the first floor. The elevator installation(s} shall comply with all local and state codes, American Society for Mechanical Engineers (ASME) A17.1, Safety Code for Elevators, Dumbwaiters, and Escalators, and the National Fire Protection Association 's applicable codes. All facilities with plans approved on or after January 1, 1999, shall comply with all local and state codes, ASME Ai7.1, 1993 Safety Code for Elevators and Escalators, and the 1996 Nationat Electrica! Code. These references are incorporated by reference in this rule and available at: American Society for Mechanical Engineers, Three Park Avenue, New York, NY 10016-5990; and The American National Standards institute, 11 West 42nd Street, 13th Floor, New York, NY 10036. This rule does not incorporate any additional amendments or additions. I| This regulation is not met as evidenced by: Class JI Residential care facilities and facilities formerly licensed as residential care facilities Ht shall have at least one (1) hydraulic or electric motor-driven elevator if there are more than twenty (20) residents with bedrooms above the first floor. The elevator installation(s) shall comply with all local and state codes, American Society for Mechanical Engineers (ASME) A17.1, Safety Code for Elevators, Dumbwaiters, and Escalators, and the National Fire Protection If continuation sheet 4 of 3 KGIP 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PRIMROSE RETIREMENT COMMUNITY OF JEFFERSC (X2) MULTIPLE CONSTRUCTION A. BUILDING: JEFFERSON CITY, MO 65109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 Association's applicable codes. All facilities shall also comply with all local and state codes, ASME A17.1, 1993 Safety Code for Elevators and Escalators, and the National Electrical Code. Record review on August 12, 2024 at 4:15 P.M. showed the elevator inspection expired on June 18, 2024. During an interview at 4:30 P.M., the maintenance director stated the inspection and testing was scheduled in the near future. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on August 12, 2024 the facility failed to ensure only metal or UL- or FM-fire-resistant rated wastebaskets were being used for trash. The facility census was 44. This deficiency affects 44 of 44 residents. Observation through out the fire inspection showed more than twenty seven unapproved plastic wastebaskets in use throughout the ALFIl side of the building. The following rooms were noted with one to five violations each during the inspection. Rooms in ALF wings: 122 x3, 126 x1, 128 x1, 131 x1, 135 x2, 219 x1, Missouri Department of Health and Senior Services STATE FORM 6899 KGIP11 PRINTED: 08/20/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/14/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1214 FREEDOM BLVD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1214 FREEDOM BLVD PRIMROSE RETIREMENT COMMUNITY OF JEFFERSC JEFFERSON CITY, MO 65109 PRINTED: 08/20/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/14/2024 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE A2286 | Continued From page 2 223 x2, 225 x5, 226 x3, 227 x1, 230 x2, 231 x1, 232 x1, 234 x1, 237 x1 & 238 x1. During an interview at 4:15 P.M. the maintinance director expressed his appologies and stated he would get the issue taken care of. Missouri Department of Health and Senior Services STATE FORM oeee KGIP11 DEFICIENCY) If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Suppli . Name: r/Supplier Primrose Retirement Community Street Address, 1214 Freedom Blvd. City, Zip: Jefferson City, MO 65109 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER a 1D PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE 19 CSR 30-86.022(15){A) Wastebaskets, Metal/UL/FM- A2286 - Requirements Upon the fire safety inspection that was completed at Primrose Retirement Community of Jefferson City, it was found that there was non compliance with “more than twenty seven unapproved plastic waste baskets were being used throughout the ALF I! side of the building". The plan of correction is to supply only metal/UL/FM-required trashcans to these ALF lH] apartments. The rooms are as listed: 122x3,126x1,128x1,131x1,135x2,219x1,223x2,225x5,226x3, 227X1,230x2,231x3,232x1 ,234x1,237x1,238x1. All rooms listed now have Metal/UL/FM rated trashcans. Interventions placed- All new residents will be advised of the regulation requirement of the waste baskets. All new move in apartments will be inspected by the Maintenance Director and Executive Director to ensure compliance. All personnel that remove waste from resident apartments are now educated on regulation versus non regulation waste baskets. A three (3) month inventory will be completed by assigned staff and confirmed by the Maintenance Director and or Executive Director. Results will be reported to QA to ensure compliance. Upon the fire safety inspection that was completed at Primrose Retirement Community of Jefferson City, it was found that there was non compliance with "all local and state codes, ASME A17.1, 1993 Safety Code for Elevators and Escalators, and the National Electrical Code”. Record review on August 12: 2024 at 4:15 P.M. showed the elevator inspection expired on June 18, 2024. The plan of correction is to have Superior Elevators, inspected on Tuesday, September 3, 2024 at noon. The written inspection will be forwarded for documentation upon completion of the elevators inspection. The Maintenance Director will ensure a timely plan of future inspections to maintain compliance timelines. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.