Inspection Reports for Primrose Retirement Community of Grand Island

NE, 68803

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Deficiencies per Year

4 3 2 1 0
2010
2016
2023
2024
Unclassified

Census Over Time

28 32 36 40 44 Nov '10 Jan '16
Inspection Report Renewal Capacity: 42 Deficiencies: 0 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
NameTitleContext
Sophia AcostaAdministratorNamed as the facility administrator and emergency contact.
Mark McNearyAuthorized RepresentativeSigned the renewal application as an authorized representative.
Brian MorganAuthorized RepresentativeSigned the renewal application as an authorized representative and listed as Treasurer in ownership/control listing.
Inspection Report Renewal Capacity: 42 Deficiencies: 0 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
NameTitleContext
Sophia AcostaAdministratorNamed as administrator on renewal application
Mark McNearyAuthorized RepresentativeSigned renewal application
Brian MorganAuthorized RepresentativeSigned renewal application
Inspection Report Renewal Census: 38 Deficiencies: 2 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)
Description
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
NameTitleContext
Tom BrownAdministratorInterviewed confirming missing registry checks for Direct Care Staff
Vicki LepantRegistered NurseSurveyor who conducted the inspection
Susan GriepenstrohRegistered NurseSurveyor who conducted the inspection
Inspection Report Complaint Investigation Census: 34 Deficiencies: 2 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.
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.
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.
Deficiencies (2)
Description
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
NameTitleContext
Frances ProkopRegistered NurseSurveyor conducting complaint investigation
Barbara SamsonSanitarianSurveyor conducting complaint investigation
Melanie HansenDietary ManagerConducted educational in-service on food safety and signed plan of correction
Tonya VanPeltDirector of NursingConducted resident education on medication storage and signed plan of correction
Thomas BrownCommunity ManagerSigned plan of correction letters
Document Capacity: 42 Deficiencies: 0 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
NameTitleContext
Tom BrownAdministratorNamed as administrator on the licensure renewal application on page 2.
Brian MorganTreasurerListed as Treasurer in ownership/control information on page 4.
William J. Schaufbauer, IIVice PresidentNamed as Vice President in ownership/control information on page 4 and author of letter on page 3.
James L. TharesPresidentListed as President in ownership/control information on page 4.
Mark W. McNearySecretaryListed as Secretary in ownership/control information on page 4.
Notice Capacity: 42 Deficiencies: 0 APP2017
Visit Reason
This document serves as the licensure renewal application and verification for the assisted-living facility license of Primrose Retirement Community of Grand Island, including ownership information and occupancy permit details.
Findings
The documents confirm that Primrose Retirement Community of Grand Island is licensed as an assisted-living facility with a total licensed capacity of 42 beds. The occupancy permit issued by the Grand Island Fire Department also authorizes an occupant load of 42.
Report Facts
Total licensed beds: 42 Occupant load: 42
Notice Capacity: 42 Deficiencies: 0 APP2018
Visit Reason
This document serves as a licensure renewal application and verification for the assisted-living facility Primrose Retirement Community of Grand Island, including ownership information and occupancy permit details.
Findings
The documents confirm that the facility is licensed as an assisted-living facility with a total licensed capacity of 42 beds and includes an occupancy permit valid from 01/17/2018 to 01/17/2019 with an occupant load of 564 total and 42 assisted living.
Report Facts
Total licensed beds: 42 Occupant load: 564 Assisted living occupant load: 42
Employees Mentioned
NameTitleContext
Tonya Van PeltAdministratorNamed as facility administrator and emergency contact in licensure and occupancy permit documents.
James L. TharesPresidentListed as President of TSMM Management, LLC, the ownership entity.
William J. SchaefbauerVice PresidentListed as Vice President of TSMM Management, LLC, the ownership entity.
Mark W. McNearySecretaryListed as Secretary of TSMM Management, LLC, the ownership entity.
Brian MorganTreasurerListed as Treasurer of TSMM Management, LLC, the ownership entity.
Notice Capacity: 42 Deficiencies: 0 APP2019
Visit Reason
This document serves as a licensure renewal application and verification that the assisted-living facility is licensed through the indicated renewal date.
Findings
The documents confirm that the Primrose Retirement Community of Grand Island meets statutory requirements as an assisted-living facility and is licensed through the renewal date. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 42 Occupant load: 564
Employees Mentioned
NameTitleContext
Tonya Van PeltAdministratorNamed as the facility administrator and emergency contact.
Mark McNearyAuthorized RepresentativeSigned the renewal application as an authorized representative.
BJ SchaefbauerAuthorized RepresentativeSigned the renewal application as an authorized representative.
James L. TharesPresidentListed in ownership/control of TSMM Management, LLC.
William J. Schaefbauer, IIVice PresidentListed in ownership/control of TSMM Management, LLC.
Mark W. McNearySecretaryListed in ownership/control of TSMM Management, LLC.
Brian MorganTreasurerListed in ownership/control of TSMM Management, LLC.
Notice Capacity: 42 Deficiencies: 0 APP2020
Visit Reason
This document package serves as the renewal licensure application and certification for the Primrose Retirement Community of Grand Island, an assisted-living facility, including verification of licensure through the renewal date and related ownership and occupancy information.
Findings
The documents confirm that the facility meets statutory requirements for licensure renewal as an assisted-living facility with a total licensed capacity of 42 beds. The occupancy permit and ownership details are also provided.
Report Facts
Total licensed beds: 42 Occupant load: 42
Employees Mentioned
NameTitleContext
Tonya Van PeltNamed as Administrator and Emergency Contact in renewal application and occupancy permit.
Mark McNearyAuthorized RepresentativeSigned renewal application as authorized representative.
Brian MorganAuthorized RepresentativeSigned renewal application as authorized representative.
James L. TharesPresidentListed in ownership/control listing for TSMM Management, LLC.
William J. Schaefbauer, IIVice PresidentListed in ownership/control listing for TSMM Management, LLC.
Notice Capacity: 42 Deficiencies: 0 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
NameTitleContext
Tonya Van PeltAdministratorNamed as emergency contact and administrator in the renewal application
Mark McNearyAuthorized RepresentativeSigned the renewal application as authorized representative
Brian MorganAuthorized Representative and TreasurerSigned the renewal application as authorized representative and listed as Treasurer in ownership/control listing
James L. TharesPresidentListed in ownership/control listing
William J. Schaefbauer, IIVice PresidentListed in ownership/control listing
Mark W. McNearySecretaryListed in ownership/control listing
Notice Capacity: 42 Deficiencies: 0 APP2022
Visit Reason
This document serves as a renewal application and verification that the Primrose Retirement Community of Grand Island is licensed as an assisted-living facility through the indicated renewal date.
Findings
The document confirms the facility meets statutory requirements for licensure renewal as an assisted-living facility with a total licensed capacity of 42 beds. It includes ownership information, licensing fees, and occupancy permit details.
Report Facts
Total licensed beds: 42 Occupant load: 564
Employees Mentioned
NameTitleContext
Tonya Van PeltAdministratorNamed as emergency contact and administrator on the renewal application and occupancy permit
Mark McNearyAuthorized RepresentativeSigned the renewal application as authorized representative and listed as Secretary in ownership/control listing
Brian MorganAuthorized RepresentativeSigned the renewal application as authorized representative and listed as Treasurer in ownership/control listing
James L. TharesPresidentListed in ownership/control listing
William J. Schaefbauer, IIVice PresidentListed in ownership/control listing
Notice Capacity: 42 Deficiencies: 0 APP2025
Visit Reason
This document serves as a renewal application and license verification for the Primrose Retirement Community of Grand Island assisted-living facility, confirming licensure and ownership details.
Findings
The documents confirm the facility's licensure status, ownership information, and occupancy permit details, including the licensed bed capacity and permit validity dates.
Report Facts
Total licensed beds: 42 Renewal expiration date: 2025 Occupancy permit validity: Permit valid from 08/01/2024 to 08/01/2026
Employees Mentioned
NameTitleContext
Sophia AcostaAdministratorNamed as facility administrator and emergency contact
Mark W. McNearySecretaryListed in ownership/control and signed renewal application
Brian MorganTreasurerListed in ownership/control and signed renewal application
James L. TharesPresidentListed in ownership/control
William J. Schaefbauer, IIVice PresidentListed in ownership/control
Dennis MillerInspectorNamed as issuing official on occupancy permit

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