Inspection Reports for
Primrose Retirement Community of Grand Island
NE, 68803
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
1 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
76% better than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Occupancy
Latest occupancy rate
90% occupied
Based on a January 2016 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Renewal
Capacity: 42
Deficiencies: 0
Date: Mar 8, 2024
Visit Reason
The document is a renewal application and license verification for the Primrose Retirement Community of Grand Island, an assisted-living facility, to renew its license and confirm compliance with state regulations.
Findings
The facility is licensed as an assisted-living facility with a total licensed capacity of 42 beds. The renewal application was completed and signed by authorized representatives, and the occupancy use permit confirms approval for 42 beds.
Report Facts
Total licensed beds: 42
Renewal license expiration date: Apr 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sophia Acosta | Administrator | Named as the facility administrator and emergency contact. |
| Mark McNeary | Authorized Representative | Signed the renewal application as an authorized representative. |
| Brian Morgan | Authorized Representative | Signed the renewal application as an authorized representative and listed as Treasurer in ownership/control listing. |
Inspection Report
Renewal
Capacity: 42
Deficiencies: 0
Date: Mar 28, 2023
Visit Reason
The document is a renewal application and certification for the assisted-living facility license of Primrose Retirement Community of Grand Island, verifying that the facility is licensed through the renewal date.
Findings
The facility meets statutory requirements as an assisted-living facility and is licensed for 42 beds. The renewal application was completed and signed by authorized representatives on 03/28/2023.
Report Facts
Total licensed beds: 42
Renewal license expiration date: Apr 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sophia Acosta | Administrator | Named as administrator on renewal application |
| Mark McNeary | Authorized Representative | Signed renewal application |
| Brian Morgan | Authorized Representative | Signed renewal application |
Inspection Report
Renewal
Census: 38
Deficiencies: 2
Date: Jan 6, 2016
Visit Reason
The inspection was a licensure compliance inspection for the Assisted-Living Facility to assess compliance with licensure regulations.
Findings
The facility failed to ensure that required registry checks (Nurse Aide Registry, Adult Protective Services Central Registry, and Child Protective Services Central Registry) were completed for some sampled Direct Care Staff. The violations did not create imminent danger or immediate adverse effects on residents.
Deficiencies (2)
Failure to complete Nurse Aide Registry check for one Direct Care Staff (DCS-A).
Failure to complete Adult Protective Services (APS) Central Registry and Child Protective Services (CPS) Central Registry checks for two Direct Care Staff (DCS-A and DCS-B).
Report Facts
Direct Care Staff sampled: 6
Facility census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tom Brown | Administrator | Interviewed confirming missing registry checks for Direct Care Staff |
| Vicki Lepant | Registered Nurse | Surveyor who conducted the inspection |
| Susan Griepenstroh | Registered Nurse | Surveyor who conducted the inspection |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
Date: Nov 2, 2010
Visit Reason
The inspection was conducted following a complaint investigation at Primrose Retirement Of Grand Island regarding allegations of failure to protect residents from abuse, failure to prepare and serve food according to residents' needs, failure to protect residents from accident, injury or infection, failure to maintain clinical records, and failure to provide services as agreed upon in the contract.
Complaint Details
The complaint investigation was conducted due to allegations of failure to protect residents from verbal/mental abuse, physical abuse, failure to prepare/serve food according to needs, failure to protect from accident/injury/infection, failure to maintain clinical records, and failure to provide agreed services. The facility was found compliant with all these allegations. The inspection uncovered an unrelated violation.
Findings
The facility was found to be in compliance with regulations related to the complaint allegations, with no violations found in areas of abuse, food service, accident/injury protection, clinical records, or services provided. However, an unrelated violation regarding medication storage and food safety was discovered during the inspection.
Deficiencies (2)
The facility failed to ensure that 2 out of 3 residents who self-administered medications kept medications in secured areas.
Potentially hazardous foods were cooled without required food safety parameters, posing a risk to all residents.
Report Facts
Facility census: 34
Sample size: 4
Temperature of corned beef: 148.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Frances Prokop | Registered Nurse | Surveyor conducting complaint investigation |
| Barbara Samson | Sanitarian | Surveyor conducting complaint investigation |
| Melanie Hansen | Dietary Manager | Conducted educational in-service on food safety and signed plan of correction |
| Tonya VanPelt | Director of Nursing | Conducted resident education on medication storage and signed plan of correction |
| Thomas Brown | Community Manager | Signed plan of correction letters |
Document
Capacity: 42
Deficiencies: 0
Date: APP2016
Visit Reason
The documents pertain to the renewal of the assisted-living facility license for Primrose Retirement Community of Grand Island and related administrative and ownership information.
Findings
No inspection findings or deficiencies are reported. The documents include a licensure renewal application, ownership details, a correction letter for tax identification, a fire prevention certificate indicating maximum occupancy, and floor plans highlighting two-bedroom apartments.
Report Facts
Total licensed beds: 42
Maximum occupancy: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tom Brown | Administrator | Named as administrator on the licensure renewal application on page 2. |
| Brian Morgan | Treasurer | Listed as Treasurer in ownership/control information on page 4. |
| William J. Schaufbauer, II | Vice President | Named as Vice President in ownership/control information on page 4 and author of letter on page 3. |
| James L. Thares | President | Listed as President in ownership/control information on page 4. |
| Mark W. McNeary | Secretary | Listed as Secretary in ownership/control information on page 4. |
Notice
Capacity: 42
Deficiencies: 0
Date: APP2021
Visit Reason
This document serves to verify the licensure renewal of the Primrose Retirement Community of Grand Island as an assisted-living facility, confirming the facility is licensed through the date indicated on the renewal card.
Findings
The document confirms that the facility meets statutory requirements for licensure renewal as an assisted-living facility. It includes ownership information, licensing details, and occupancy permit data.
Report Facts
Total licensed beds: 42
Renewal license expiration date: Expires 4/30/2022 as shown on the renewal card
Occupant load: 564
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tonya Van Pelt | Administrator | Named as emergency contact and administrator in the renewal application |
| Mark McNeary | Authorized Representative | Signed the renewal application as authorized representative |
| Brian Morgan | Authorized Representative and Treasurer | Signed the renewal application as authorized representative and listed as Treasurer in ownership/control listing |
| James L. Thares | President | Listed in ownership/control listing |
| William J. Schaefbauer, II | Vice President | Listed in ownership/control listing |
| Mark W. McNeary | Secretary | Listed in ownership/control listing |
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