Primrose Retirement Community of Pueblo

A relicensure and complaint revisit was completed on 7/29/25 for all previous deficiencies cited on 3/18/25. A deficiency was cited.The regulations governing Assisted Living Residences were revised, and the new Chapter VII regulations were implemented on 7/1/25. Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S (A-I), affecting 43 current residents.This deficiency was cited previously during a survey and complaint investigation concluded on 3/18/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 7/29/25 at approximately 8:17 a.m., the Involuntary Discharge Grievance Policy was requested. The residence was unable to provide an Involuntary Discharge Grievance Policy. On 7/29/25 at approximately 3:00 p.m., the administrator stated the corporate office was responsible for creating the policies and procedures for the residence. She stated that after the previous event on 3/18/25, she sent the regulation to the corporate office, and they reviewed their involuntary discharge policy. She further stated that the corporate office did not make any changes and submitted their plan of correction to the department, which was accepted. The administrator stated that because their plan of correction was accepted, she was under the impression that everything was fine.

12.2.1 (Generic Tag) Infectious Disease Mitigation, Vaccine, and Treatment Plans (A) All facilities licensed under this chapter shall establish and maintain an infectious disease mitigation, vaccine and treatment plan. This plan shall address, at a minimum, the following:(1) Identification of designated staff who shall coordinate vaccine information,.. 12.2.2 (Generic Tag) Infection Control Officer(B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility ' s Infection Prevention and Control Program and training. This individual shall be responsible for the following:(1) Completing an infection prevention and control training from a nationally-recognize.. A relicensure survey with complaint #CO38127 was completed on 3/18/25. Deficiencies were cited. Based on interview and records review, the residence failed to document routinely completed audits of the accuracy and completeness of medication administration records (MARs), controlled substance lists, medication error reports, and medication disposal records affecting 42 current residents.This deficiency was cited previously during a licensure.. Based on record review and interview the residence failed to define procedures to prevent the spread of influenza from unvaccinated healthcare workers, affecting 42 current residents.Findings include:On 3/18/25 at 7:42 a.m., the residence' s policy and procedure for unvaccinated workers was requested but not provided. On 3/18/25 at 3:00 p.m... Based on record review and interview the residence failed to develop policies and procedures to establish a fall management program which detailed in each resident ' s care plan the individualized approach necessary to address fall risk, affecting five of five sample residents. (#5, #7, #11, #24, and #25).Specifically, Resident #25 had three docu.. Based on record review and interview the residence failed to have a roster of current residents which included emergency contact information and residence diagram showing room locations, affecting 42 current residents. (Cross-reference S914)Findings include:On 3/18/25 at approximately 7:30 a.m., a resident roster was requested.On 3.. Based on record review and interview the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S (A-I), affecting 42 current residents. Findings include:On 3/18/25 at approximately 7:30 a.m. the Involuntary Discharge Grievance Policy was requested. The residence was unable to pro.. Based on record review and interview the residence failed to have at least one staff member onsite at all times who was certified in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognised organization, affecting 42 current residents. (Cross-reference S914)Findings include:On 3/18/25 the residence provid.. Based on record review and interview the residence failed to prepare or administer only medication that has been ordered by an authorized practitioner, affecting four of four sample residents (#5, #11, #24, and #25).Findings include:Resident #24 was admitted to the residence on 2/14/23 with a diagnosis of prostatic hyperplasia, osteoarthri.. Based on record review and interview, the residence failed to develop policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency, affecting 42 current residents. (Cross-reference S0734 and S910)Findings include:On 3/18/25 at approximately 7:30 a.m., all eme.. Based on record review and interview, the residence failed to ensure the administrator completed the additional 10 hours of training as required, affecting 42 current residents.Findings include:The personnel record for the administrator contained a certificate for a 30-hour administrator training course dated 5/24/17. The record did not c..

A licensure complaint revisit was completed on 3/18/25 for all previous deficiencies cited on 7/20/22. The regulations governing Assisted Living Residences were revised. Chapter VII was implemented on 3/17/25. Based on interview and records review, the residence failed to document routinely completed audits of the accuracy and completeness of medication administration records (MARs), controlled substance lists, medication error reports, and medication disposal records affecting 42 current residents.This deficiency was cited previously during a complaint revisit on 7/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:The residence' s MARs audit tool titled Medication Pass Report included data of the residents receiving medications, the order start date, the date when the medications were administered, the pain level scale, and the medication route. The report also indicated they were .. Based on record review and interview the residence failed to develop policies and procedures to establish a fall management program which detailed in each resident ' s care plan the individualized approach necessary to address fall risk, affecting five of five sample residents. (#5, #7, #11, #24, and #25).Specifically, Resident #25 had three documented falls between 1/24/25 and 3/14/25. Two of the falls resulted in injuries such as a skin tear and bleeding from her head. The residence failed to update Resident #25' s care plan with individualized approaches necessary to address the resident' s fall risk. Additionally, staff were unaware of individualized fall interventions for Resident #25.This deficiency was cited previously during a complaint investigation on 7/20/22. Although the residence correct.. Based on record review and interview the residence failed to prepare or administer only medication that has been ordered by an authorized practitioner, affecting four of four sample residents (#5, #11, #24, and #25).This deficiency was cited previously during a complaint investigation on 7/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:Resident #24 was admitted to the residence on 2/14/23 with a diagnosis of prostatic hyperplasia, osteoarthritis, chronic kidney disease, and type 2 diabetes.A medication administration record for March 2025 read that Resident #24 received the following medications daily:Acetaminophen 325 mgCarvedilol 12.5 mgEliquis 5 mgFur.. Based on record review and interview, the residence failed to develop policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency, affecting 42 current residents. (Cross-reference S0734 and S910)This deficiency was cited previously during a licensure complaint revisit on 7/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 3/18/25 at approximately 7:30 a.m., all emergency preparedness policies were requested.On 3/18/25 at approximately 6:00 p.m., the residence provided a document titled Evacuation of Residents. The document provided failed to address the continuation of necess..

A licensure revisit was completed on 3/18/25 for all previous deficiencies cited on 7/20/22. The regulations governing Assisted Living Residences were revised. Chapter VII was implemented on 3/17/25. Based on interview and records review, the residence failed to document routinely completed audits of the accuracy and completeness of medication administration records (MARs), controlled substance lists, medication error reports, and medication disposal records affecting 42 current residents.This deficiency was cited previously during a licensure revisit on 7/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:The residence' s MARs audit tool titled Medication Pass Report included data of the residents receiving medications, the order start date, the date when the medications were administered, the pain level scale, and the medication route. The report also indicated they were .. Based on record review and interview the residence failed to develop policies and procedures to establish a fall management program which detailed in each resident ' s care plan the individualized approach necessary to address fall risk, affecting five of five sample residents. (#5, #7, #11, #24, and #25).Specifically, Resident #25 had three documented falls between 1/24/25 and 3/14/25. Two of the falls resulted in injuries such as a skin tear and bleeding from her head. The residence failed to update Resident #25 ' s care plan with individualized approaches necessary to address the resident ' s fall risk. Additionally, staff were unaware of individualized fall interventions for Resident #25.This deficiency was cited previously during a licensure revisit on 7/20/22. Although the residence corrected the .. Based on record review and interview the residence failed to have at least one staff member onsite at all times who was certified in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognised organization, affecting 42 current residents. (Cross-reference S914)This deficiency was cited previously during a licensure revisit on 7/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 3/18/25 the residence provided all CPR certifications for all certified staff, however, Staff #27 had a CPR certification that expired January 2025. A staff schedule of staff members certified in CPR for the dates 3/18/25 through 3/22/25 read that Staff #27 w.. Based on record review and interview, the residence failed to develop policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency, affecting 42 current residents. (Cross-reference S0734 and S910)This deficiency was cited previously during a licensure revisit on 7/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 3/18/25 at approximately 7:30 a.m., all emergency preparedness policies were requested.On 3/18/25 at approximately 6:00 p.m., the residence provided a document titled Evacuation of Residents. The document provided failed to address the continuation of necess..