Inspection Reports for Primrose Retirement Community
1801 East Kanesville Blvd., Council Bluffs, IA, 51503
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 14, 2024, identified deficiencies related to service plan development and updates, nurse reviews, and life safety emergency policies, particularly involving a tenant with cognitive impairment. Earlier inspections showed a mixed pattern, with prior deficiencies often involving service plan updates, nurse reviews, staffing competency, and safety measures, while some complaint investigations found no regulatory insufficiencies. Complaint investigations were mostly unsubstantiated, though some substantiated cases involved tenant falls, service plan issues, and safety concerns. Enforcement actions included a $500 civil penalty in 2012 for medication administration deficiencies, but no license suspensions or revocations were listed in the available reports. The facility’s inspection history shows ongoing challenges with service plan accuracy and nurse reviews, with no clear trend of improvement or worsening over time.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
2.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
41% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
35 residents
Based on a November 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 3
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.
Deficiencies (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
Total census: 35
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
Renewal
Census: 36
Deficiencies: 0
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
Total census: 36
Inspection Report
Renewal
Census: 34
Deficiencies: 0
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
Total census: 34
Inspection Report
Renewal
Census: 26
Deficiencies: 3
Date: May 23, 2018
Visit Reason
The inspection was a recertification survey and investigation of regulatory compliance at Primrose Retirement Community, an assisted living program, focusing on staffing, admission/retention criteria, and service plans.
Findings
The survey found deficiencies in staffing competency, failure to ensure staff were trained and competent within 60 days of employment, failure to discharge a tenant who exceeded level of care, and failure to update tenant service plans to reflect changes in condition. These deficiencies affected multiple tenants and staff.
Deficiencies (3)
Staffing: The newly hired Director of Nursing (DON) failed to ensure 4 of 4 staff reviewed were competent to perform health and personal care tasks for tenants.
Criteria for Admission/Retention of Tenants: The program failed to discharge 1 tenant who exceeded the level of care due to being bed-bound.
Service Plans: The Program Registered Nurse failed to update tenant service plans with changes in condition for 2 of 3 tenants reviewed.
Report Facts
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 4
Total census: 26
Staff reviewed for competency: 4
Tenants reviewed for service plans: 3
Tenants affected by service plan deficiency: 2
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Date: Dec 13, 2017
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #71199-C at Primrose Retirement Community.
Complaint Details
The complaint investigation found that the service plan was not updated after multiple falls and a nurse review, despite a significant change in the tenant's condition. The Executive Director and Director of Nursing confirmed the lack of a comprehensive evaluation and service plan modification.
Findings
The program failed to complete a comprehensive assessment and update the service plan following a significant change in condition for one tenant. Specifically, after multiple falls and a nurse review on 3/24/17, the tenant's service plan was not revised to include mobility management interventions.
Deficiencies (1)
Failure to complete a comprehensive assessment and update the service plan following a change in condition for Tenant #1.
Report Facts
Number of tenants without cognitive disorder: 17
Number of tenants with cognitive disorder: 4
Total census: 21
Dates of tenant falls: Falls occurred on 2/26/17, 3/01/17, 3/02/17, 3/13/17, 3/17/17, and 3/21/17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Confirmed lack of comprehensive evaluation and service plan modification | |
| Director of Nursing | Confirmed lack of comprehensive evaluation and service plan modification and completed nurse review on 3/24/17 |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Date: Dec 13, 2017
Visit Reason
The inspection was conducted as part of an investigation of Complaint #71199-C regarding regulatory insufficiency related to service plans at Primrose Retirement Community.
Complaint Details
The visit was complaint-related, investigating Complaint #71199-C. The complaint was substantiated by findings that the service plan was not updated after significant changes in Tenant #1's condition.
Findings
The program failed to complete a comprehensive assessment and update the service plan following a change in condition for one of two tenants reviewed. Specifically, Tenant #1 with Alzheimer's disease had multiple falls, but the service plan was not revised to include mobility management interventions after the nurse review and significant changes.
Deficiencies (1)
Failure to complete a comprehensive assessment and update the service plan following a change in condition for Tenant #1.
Report Facts
Number of tenants without cognitive disorder: 17
Number of tenants with cognitive disorder: 4
Total census of Assisted Living Program: 21
Dates of tenant falls: Falls occurred on 2/26/17, 3/01/17, 3/02/17, 3/13/17, 3/17/17, and 3/21/17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Completed nurse review on 3/24/17 and confirmed lack of comprehensive evaluation on 12/12/17 |
| Executive Director | Executive Director | Confirmed on 12/12/17 that comprehensive evaluation had not been completed |
Inspection Report
Renewal
Census: 21
Deficiencies: 6
Date: Jul 19, 2016
Visit Reason
The inspection was conducted as a recertification to determine compliance with certification for an Assisted Living Program, including investigation of a complaint #59458-C.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #59458-C.
Findings
No regulatory insufficiencies were cited during the complaint investigation. However, several deficiencies were cited during the recertification, including issues with the occupancy agreement, failure to notify the department of a major injury, incomplete background checks for employees, lack of nurse reviews for adverse medication reactions, inadequate food service training, and absence of a policy addressing sexual relationships between tenants and staff.
Deficiencies (6)
Occupancy agreement did not include all tenant rights, including the right to be free from restraints and criteria for involuntary transfer.
Failure to notify the Department within 24 hours of a major injury when a tenant fell and sustained a head injury.
Background checks were not completed prior to employment for four employees.
Nurse reviews did not monitor for adverse reactions, ensure prescription orders were current, or confirm administration was consistent with orders.
Employees responsible for food service did not have annual in-service training on food protection.
Program did not have a policy and procedure for addressing sexual relationships between tenants and staff.
Report Facts
Number of tenants without cognitive disorder: 17
Number of tenants with cognitive disorder: 4
Total population of program at time of on-site: 21
Number of employees lacking background checks: 4
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Date: Jul 21, 2015
Visit Reason
The inspection was conducted as a complaint investigation following an allegation related to admission/discharge at Primrose Retirement Community.
Complaint Details
Allegation: Admission/Discharge. Findings: Unsubstantiated. Based on review of tenant files, incident reports, policies, and staff interviews, no concerns were found regarding admission/discharge criteria related to the complaint #52701-C.
Findings
The allegation was investigated and found to be unsubstantiated. No regulatory insufficiencies were identified during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 1
Total Population of Program at time of on-site: 28
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 6
Date: Feb 9, 2015
Visit Reason
A final complaint investigation and recertification monitoring evaluation was conducted due to complaints regarding TB tests not administered or read, tenants admitted without physician orders, medication errors, insufficient food, quality of care, staffing, outdated service plans, and level of care concerns.
Complaint Details
The complaint investigation addressed allegations of TB tests not administered or read, tenants admitted without physician orders, medication errors, insufficient food, quality of care, staffing, outdated service plans, and level of care concerns. All allegations were found not substantiated.
Findings
All allegations investigated were found to be not substantiated based on observations, interviews, and record reviews. However, regulatory insufficiencies were noted in occupancy agreement, medications, evaluation of tenant, service plans, nurse review, and food service, requiring a plan of correction.
Deficiencies (6)
The program failed to operate in accordance with the terms of the occupancy agreement.
The program failed to ensure medications/treatments were administered according to physician orders, standard nursing practice, and without error.
The program failed to include required statements in the occupancy agreement and supporting documents.
The program failed to develop/update service plans according to tenants' needs.
The program failed to conduct nurse reviews at least every 90 days regarding prescription medications and referrals.
The program failed to ensure provision of 100% of the recommended dietary allowances to tenants.
Report Facts
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 0
Total population of program at time of on-site: 29
Number of tenant files reviewed for medication errors: 17
Number of tenant files reviewed for complaint allegations: 9
Number of tenant files reviewed for complaint allegations: 9
Number of tenant files reviewed for complaint allegations: 8
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 3
Date: Aug 20, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation following a report that Tenant #1 had fallen when staff assisted with toileting, and other allegations involving tenant care and safety.
Complaint Details
Complaint/Incident Intake #44694-I involved allegations of tenant falls, physical aggression, and sexual inappropriate behavior by tenants. The complaint was substantiated with multiple documented incidents and regulatory insufficiencies identified.
Findings
The investigation found substantiated regulatory insufficiencies related to tenant falls, inadequate evaluation of tenants' functional and cognitive status, and insufficient service plans addressing physical aggression and inappropriate sexual behavior among tenants. Multiple incidents of physical aggression and sexual inappropriateness were documented.
Deficiencies (3)
Failure to evaluate each tenant’s functional, cognitive and health status within 30 days of occupancy and as needed with significant change.
Failure to individualize service plans to address tenant needs and preferences, including physical aggression and inappropriate sexual behavior.
Failure to not knowingly admit or retain tenants who are dangerous to self or others, including those with chronic elopement, physical or sexual aggression, or unmanageable verbal abuse.
Report Facts
Total census: 34
Tenants without cognitive disorder: 31
Tenants with cognitive disorder: 3
Incidents of verbal sexual comments: 3
Incidents of physical aggression: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor for the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 0
Date: Mar 20, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation triggered by allegations regarding a tenant's incontinence and malodor, as well as difficulty finding their apartment.
Complaint Details
Complaint/Incident Intake #42765-C involved allegations of tenant incontinence with malodor and difficulty locating the apartment. The complaint was investigated and found to be unsubstantiated with no regulatory insufficiencies identified.
Findings
The investigation found no regulatory insufficiencies. Tenant files and staff interviews indicated no unmanageable incontinence or malodor issues, and service plans were reflective of tenant needs.
Report Facts
Total census: 31
Tenants without cognitive disorder: 29
Tenants with cognitive disorder: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor for the complaint/incident investigation |
| Jim Berkley | Program Coordinator | Author of the cover letter for the Final Complaint/Incident Investigation Report |
| Paul Crane | Executive Director | Facility Executive Director named in the report |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 1
Date: Sep 13, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding regulatory insufficiencies related to medications and incidents involving tenants at Primrose Retirement Community.
Complaint Details
The complaint investigation involved incidents including a tenant fall with injury and missing tablets of Tramadol 50 mg for another tenant. The investigation included review of incident reports, medication administration records, and staff interviews. The regulatory insufficiency was substantiated in medication administration practices.
Findings
The report found regulatory insufficiencies in medication administration and documented incidents involving tenant falls and missing medications. A civil penalty of $500 was assessed, and a Plan of Correction was submitted and reviewed.
Deficiencies (1)
Regulatory Insufficiency in the area of Medications
Report Facts
Civil penalty amount: 500
Civil penalty reduced amount: 325
Total census: 25
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 3
Number of missing Tramadol tablets: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Contact person for appeal and enforcement process |
| Hal L. Chase | RN BSN MPH | Monitor for the complaint/incident investigation |
Inspection Report
Monitoring
Census: 28
Deficiencies: 2
Date: Mar 19, 2012
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to review the Plan of Correction and ensure compliance with regulatory requirements for the Primrose Retirement Community Assisted Living Program.
Findings
The report found no substantiated regulatory insufficiencies during the certification period. Tenant satisfaction was generally positive, though some concerns about evening meal temperature and staff availability for activities were noted. Medication administration practices were observed with some noted issues regarding insulin syringe disposal and medication charting.
Deficiencies (2)
Staff #3, LPN did not properly dispose the insulin syringe in a sharps container after use.
Staff #3, LPN did not administer medications in an applied standard of medication administration practice.
Report Facts
Number of tenants without cognitive disorder: 25
Number of tenants with cognitive disorder: 3
Total Population of Program at time of on-site: 28
Tenants attending community meeting: 26
Units of insulin administered: 5
Medication dosages administered: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the evaluation |
| Jim Berkley | Program Coordinator | Signed letter regarding certification |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Date: Sep 27, 2011
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding allegations about the assisted living entrance door being inoperable and other safety concerns.
Complaint Details
Complaint/Incident Intake #35051-C involved allegations that the assisted living entrance door was inoperable for an extended period and that the sidewalk outside the entrance was in need of repair, causing a fall. The investigation found no regulatory insufficiencies and documented maintenance and repairs addressing the issues.
Findings
No regulatory insufficiencies were identified during the investigation. The monitor observed repairs and maintenance activities related to the entrance doors and sidewalks, and reviewed incident reports with no tenant falls or injuries caused by the sidewalk issues.
Report Facts
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 4
Total Population of Program at time of on-site: 33
Dates of complaint investigation visit: September 27 and 28, 2011
Dates of maintenance work orders: Multiple dates from 1-5-11 to 4-7-11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maribeth Freland | RN | Monitor who conducted the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Date: Apr 13, 2011
Visit Reason
A complaint investigation was conducted at Primrose Retirement Community on April 13 and 14, 2011, in response to allegations regarding staff response times to call lights and adequacy of personal care services.
Complaint Details
The complaint alleged that it took staff 45 minutes or more to respond to call lights and that there was insufficient staff to provide personal care. The investigation found that call lights were generally answered within 2-15 minutes, with most answered in less than 10 minutes. Staff reported adequate staffing despite turnover. No tenants reported unmet personal needs.
Findings
The investigation found no regulatory insufficiencies during the certification period. Tenant and staff interviews indicated some concerns about staff turnover and response times, but no tenants reported unmet personal needs. Service plans for tenants were reviewed with some noted omissions regarding nursing facility care preferences, but no regulatory insufficiencies were noted.
Report Facts
Current number of tenants without cognitive disorder: 31
Current number of tenants with cognitive disorder: 3
Total Population: 34
Call light requests initiated: 46
Call light requests answered in less than 10 minutes: 39
Call light requests answered in 10-15 minutes: 6
Call light requests answered in 17 minutes: 1
Call light requests initiated: 39
Call light requests answered in less than 10 minutes: 30
Call light requests answered in 10-15 minutes: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor for the complaint investigation |
Inspection Report
Monitoring
Census: 27
Deficiencies: 0
Date: Jun 2, 2010
Visit Reason
An on-site monitoring evaluation was conducted at Primrose Retirement Community to assess compliance with assisted living program regulations.
Findings
The program was found to be in substantial compliance with regulations, with no substantiated regulatory insufficiencies during the certification period. Tenant satisfaction was positive, noting good staff conduct, food quality, and safety measures.
Report Facts
Current number of tenants without cognitive disorder: 25
Current number of tenants with cognitive disorder: 2
Total Population: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Streepy | RN | Monitor conducting the evaluation |
| Susan Bowen | Administrator | Administrator of Primrose Retirement Community |
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