Inspection Reports for
Primrose Retirement Community
1801 East Kanesville Blvd., Council Bluffs, IA, 51503
Back to Facility Profile5 Reports
Inspection Report — May 7, 2026
Renewal
Date: May 7, 2026
Visit Reason
The visit was a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia. The investigation also covered incidents #131138-A and #131139-M involving theft allegations.
Complaint Details
Incident #131138-A and #131139-M involving theft of personal belongings by Staff A.
Findings
Regulatory insufficiencies were cited related to tenant rights violations involving theft of personal belongings by a staff member, incomplete criminal background checks for several staff, and failure to complete required dementia-specific education within 30 days of employment for one staff member.
Violations (3)
481-67.3(1) Tenant Rights: Staff A failed to treat residents with consideration and respect by stealing personal belongings from Tenant #1, including pawning a wedding ring and other items. The facility investigated, cooperated with law enforcement, and terminated Staff A.
481-67.18(3) Record Checks: The program failed to complete required criminal history and child/dependent adult abuse background checks prior to employment for Staff A, Staff B, Staff C, and Staff D, and failed to maintain documentation of these checks.
481-69.30(1) Dementia-Specific Education: Staff A did not complete the required minimum eight hours of dementia-specific education within 30 days of employment as required by regulation.
Inspection Report — Nov 14, 2024
Complaint Investigation
Date: Nov 14, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to Incident #121513-1 involving service plan deficiencies and tenant safety concerns at Primrose Retirement Community.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #123014-C. Deficiencies were cited during the investigation of Incident #121513-1 related to service plans, nurse reviews, and door alarm systems.
Findings
The investigation found no regulatory insufficiencies related to Complaint #123014-C but identified deficiencies in service plan development and updates, nurse reviews, and life safety emergency policies, particularly concerning a tenant with cognitive impairment who eloped from the facility.
Violations (3)
Failure to ensure service plans were based on evaluations, included specific service needs, and were updated as needed for a tenant with cognitive impairment.
Failure to complete nurse reviews every 90 days for tenants, specifically for one discharged tenant.
Failure to ensure an operating door alarm system was connected to each exit door in the dementia-specific program.
Report Facts
Number of tenants without cognitive impairment: 25
Number of tenants with cognitive impairment: 10
Global Deterioration Scale (GDS) score: 5
Average annual daily traffic: 10000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding elopement incident and response | |
| Staff C | Interviewed regarding elopement incident and wandering behavior | |
| Staff D | Interviewed regarding tenant safety and door alarms | |
| Staff E | Interviewed regarding door alarm system status | |
| Nursing Director | Nursing Director | Confirmed findings and provided information on nurse reviews and door alarms |
| Executive Director | Executive Director | Confirmed findings and provided information on door alarms and elopement incident |
Inspection Report — Nov 12, 2024
Enforcement
Date: Nov 12, 2024
Visit Reason
This citation was issued following a survey conducted from November 12 to November 14, 2024, regarding failure to develop and update service plans based on evaluations. The citation addresses the program's failure to ensure service plans met specific service needs and were updated as needed for a former tenant.
Findings
The program failed to ensure service plans were based on evaluations, included specific service needs, and were updated as needed for one former tenant. The tenant eloped from the program due to inadequate door alarms and lack of interventions addressing wandering behavior.
Violations (1)
67.26(1) A service plan was not developed based on evaluations, did not include specific service needs, and was not updated as needed for one former tenant. The plan failed to address the tenant's wandering behaviors and history of elopement despite repeated episodes.
Report Facts
Fine amount: 4500
Inspection Report — May 7, 2024
Renewal
Date: May 7, 2024
Visit Reason
The visit was conducted as a recertification to determine compliance with certification rules for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit. The program met criteria to be an Assisted Living Program for People with Dementia by definition for two sequential certification monitoring visits.
Report Facts
Number of tenants without cognitive impairment: 27
Number of tenants with cognitive impairment: 9
Inspection Report — Nov 10, 2020
Renewal
Date: Nov 10, 2020
Visit Reason
The visit was a recertification inspection of the Assisted Living Program to ensure compliance with certification rules and to assess dementia threshold status.
Complaint Details
Complaint #92337-C was investigated and no regulatory insufficiencies were found.
Findings
No regulatory insufficiencies were cited during the complaint investigation, the onsite infection control survey, or the recertification visit.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 7
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