Inspection Reports for Parsons House Assisted Living and Memory Care

14325 EAGLE RUN DRIVE MEMORY CARE ENDORSE, OMAHA, NE, 68164

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Deficiencies (last 6 years)

Deficiencies (over 6 years) 2.3 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

45% better than Nebraska average
Nebraska average: 4.2 deficiencies/year

Deficiencies per year

8 6 4 2 0
2011
2014
2016
2017
2018
2019

Census

Latest occupancy rate 144 residents

Based on a January 2019 inspection.

Census over time

135 140 145 150 155 160 Dec 2011 Apr 2014 Sep 2014 Feb 2017 May 2017 Jan 2019
Inspection Report Renewal Capacity: 180 Deficiencies: 0 Apr 9, 2019
Visit Reason
This document is a renewal licensure application and certification for Parsons House on Eagle Run, an assisted-living facility, verifying licensure through the indicated expiration date.
Findings
The facility is licensed as an assisted-living facility with a maximum capacity of 180 beds. The renewal application includes detailed ownership information, certification of compliance, and an Alzheimer's Memory Care Endorsement with disclosure of care philosophy, staffing, environment, and resident activities.
Report Facts
Maximum Occupancy: 180 Monthly Fee: 6195 Monthly Fee: 7595
Employees Mentioned
NameTitleContext
Collette MieresAdministratorNamed as facility administrator in renewal application and Alzheimer's Memory Care Endorsement.
Andrew ReevesManagerNamed as manager and contact for legal owning entity Gen3 Holdings LLC.
Kimberly C. ReevesNamed as voting member of ownership entity Gen3 Holdings LLC.
Inspection Report Complaint Investigation Census: 144 Deficiencies: 2 Jan 31, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility failed to ensure residents are free from abuse.
Findings
The allegation of abuse was not substantiated; residents and staff interviews revealed no concerns. However, deficiencies were cited for failure to complete nurse aide registry checks on new hires and failure to ensure a medication aide met the 40-hour certification requirement.
Complaint Details
The complaint alleged the facility failed to ensure residents are free from abuse. The allegation was not substantiated after investigation.
Deficiencies (2)
Description
Failure to complete nurse aide registry checks on new hires.
Failure to ensure medication aide had met the requirements for certification as a medication aide 40 hour.
Report Facts
Census: 144 Number of direct care staff missing nurse aide registry checks: 4 Number of medication aides sampled: 2 Number of medication aides not meeting 40-hour certification: 1 Days to complete medication aide training: 45
Employees Mentioned
NameTitleContext
Dan TaylorRN, Training CoordinatorSigned the complaint investigation report.
Collette MieresAdministratorFacility administrator addressed in the report.
Employee Relations SpecialistReported on nurse aide registry checks and responsible for corrective actions.
Director of Health CareConfirmed medication aide passed medications at the facility and responsible for competency testing oversight.
Notice Capacity: 180 Deficiencies: 0 Mar 1, 2018
Visit Reason
This document package serves as a licensure renewal for Parsons House On Eagle Run Assisted Living Facility, including renewal application, ownership details, fire marshal occupancy certificate, and Memory Care Endorsement application.
Findings
The documents confirm the facility's licensure renewal through April 30, 2019, with a total licensed capacity of 180 beds. The facility includes special care units for Alzheimer's and dementia with detailed care philosophies, admission criteria, staffing patterns, and physical environment descriptions. No deficiencies or inspection findings are reported.
Report Facts
Total licensed capacity: 180 Monthly fee: 6195 Monthly fee: 7595 Staff training hours: 4 Memory care unit capacities: 14 Memory care unit capacity: 18
Employees Mentioned
NameTitleContext
Collette MieresAdministrator, Executive Director, LPN, CDP, ALANamed as facility administrator and signatory on renewal and Memory Care Endorsement application.
Andrew ReevesManager, Contact for Ownership EntityNamed as manager and contact for Gen3 Holdings LLC, the legal owning entity.
Kimberly C. ReevesVoting MemberNamed as voting member of Gen3 Holdings LLC.
Andrew K ReevesVoting MemberNamed as voting member of Gen3 Holdings LLC.
David MausbachInspectorInspected the facility for the Nebraska State Fire Marshal Certificate of Occupancy.
Inspection Report Complaint Investigation Census: 149 Deficiencies: 1 May 15, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint survey regarding the facility's failure to protect residents from injury.
Findings
The facility failed to protect residents from potential injury due to accessible hot water dispensers in memory care unit kitchens, which posed a hazard. The facility had a burn injury investigation and was found in violation of safety regulations.
Complaint Details
The complaint investigation was substantiated, finding the facility failed to protect residents from injury due to accessible hot water dispensers in memory care cottages.
Deficiencies (1)
Description
Facility failed to maintain a safe environment related to accessibility of hot water in memory care units, with hot water temperatures measured between 147.5 and 180 degrees Fahrenheit accessible to residents.
Report Facts
Resident census: 149 Memory care residents: 39 Self-mobile, cognitively impaired residents: 31 Hot water temperature: 147.5 Hot water temperature: 180 Hot water temperature: 157
Employees Mentioned
NameTitleContext
Eve LewisProgram Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHSSigned the complaint investigation letter
Kay ReevesNutrition/dietitian SurveyorConducted the onsite inspection
Collette MieresAdministratorConfirmed hot water hazard and responsible for corrective actions
Notice Capacity: 180 Deficiencies: 0 Apr 27, 2017
Visit Reason
This document serves to verify the licensure renewal of Parsons House On Eagle Run as an Assisted Living Facility and includes the application for Alzheimer's Special Care Unit Disclosure and Memory Care Endorsement.
Findings
The facility is licensed with a total capacity of 180 beds and has met statutory requirements for renewal. The Memory Care Endorsement application details the facility's philosophy, staffing, physical environment, and care criteria for residents with Alzheimer's or related dementia.
Report Facts
Total licensed beds: 180 Memory care unit capacities: 14 Memory care unit capacities: 14 Memory care unit capacities: 18 Monthly fee: 6195 Monthly fee: 6595
Employees Mentioned
NameTitleContext
Penny BowdenAdministratorNamed as facility administrator in licensure renewal and Memory Care Endorsement application
Andrew ReevesManagerNamed as manager and contact for legal owning entity Gen3 Holdings LLC
Notice Deficiencies: 3 Feb 22, 2017
Visit Reason
The notice was issued to inform Parsons House On Eagle Run Assisted-Living Facility of disciplinary action including probation and a daily fine due to violations related to resident care and failure to implement interventions to prevent sexual behaviors.
Findings
The facility was found in violation of licensure regulations pertaining to resident care, specifically failing to identify and implement interventions to prevent sexual behaviors. The disciplinary action includes probation for 90 days starting March 9, 2017, and a $10 per day fine beginning February 7, 2017, until compliance is demonstrated.
Complaint Details
The disciplinary action was based on a complaint investigation report dated February 22, 2017, which evidenced the facility's failure to identify and implement interventions to prevent sexual behaviors.
Deficiencies (3)
Description
Failure to identify and implement interventions to prevent sexual behaviors.
Violation of licensure regulation 175 NAC 4-006.11A related to Resident Care.
Violation of 175 NAC 4-006.12A related to Resident Records.
Report Facts
Probation period: 90 Daily fine amount: 10 Fine payment: 980
Employees Mentioned
NameTitleContext
Eve LewisRNC, Program ManagerContact for submission of reports and correspondence related to the disciplinary action
Thomas L. WilliamsMD, Chief Medical Officer, Director, Division of Public HealthSigned the Notice of Disciplinary Action
Becky WisellAdministrator, Licensure UnitSigned correspondence acknowledging receipt and payment
Inspection Report Complaint Investigation Census: 151 Deficiencies: 2 Feb 2, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to protect residents from abuse and to ensure residents' privacy.
Findings
The facility failed to protect residents from abuse by one resident exhibiting inappropriate sexual behaviors toward other residents, which were not properly documented. However, the facility was found to be in compliance with privacy regulations.
Complaint Details
The complaint investigation found substantiated evidence that the facility failed to protect residents from abuse by one resident who was inappropriately touching other residents. The facility also failed to document these unusual events properly. The facility was compliant with privacy requirements.
Deficiencies (2)
Description
Failure to protect residents from abuse related to one resident exhibiting inappropriate sexual behaviors toward other residents.
Failure to document unusual events related to inappropriate resident behaviors.
Report Facts
Census: 151 Survey dates: Investigation conducted from February 2, 2017 to February 7, 2017
Employees Mentioned
NameTitleContext
Penny BowdenAdministratorReported on Resident 1's inappropriate touching behaviors and family notifications
Eve LewisProgram Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHSSigned the letter regarding the complaint investigation
Kay ReevesNutrition/dietitian SurveyorConducted the complaint investigation
Inspection Report Complaint Investigation Deficiencies: 0 Jan 19, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Parsons House On Eagle Run from January 19, 2017 to January 23, 2017 by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was found to be in compliance with all related regulatory requirements across multiple allegations including care to prevent skin breakdown, providing a safe environment, ensuring meals are attractive and palatable, meeting retention criteria, maintaining cleanliness and grooming, sufficient staffing, preventing pressure sores and dehydration, following Food Code, protecting skin integrity, and preventing resident injury.
Complaint Details
The complaint investigation included allegations that the facility failed to provide care and treatment to prevent skin breakdown, failed to provide a safe environment, failed to ensure meals were attractive and palatable, failed to ensure residents met retention criteria, failed to ensure cleanliness and grooming, failed to ensure sufficient staffing, failed to prevent pressure sores, failed to ensure sufficient fluids to prevent dehydration, failed to follow Food Code to prevent illness, failed to provide interventions to protect skin integrity, and failed to protect residents from injury. All allegations were found to be unsubstantiated as the facility was determined to be in compliance.
Employees Mentioned
NameTitleContext
Dan TaylorRN, Training Coordinator, Licensure Unit, Division of Public Health-DHHSSigned the report and identified as the Training Coordinator responsible for the Licensure Unit.
Inspection Report Complaint Investigation Deficiencies: 0 Mar 16, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility failed to protect residents from abuse.
Findings
The facility was found to protect residents from abuse with no concerns observed during care provision or staff interactions. Interviews with family members and staff confirmed no abuse had been witnessed or reported, and the facility was in compliance with regulatory requirements.
Complaint Details
The complaint alleged the facility failed to protect residents from abuse. The investigation found no evidence of abuse, and the facility was determined to be in compliance with all related regulatory requirements.
Employees Mentioned
NameTitleContext
Eve LewisProgram ManagerSigned the complaint investigation report
Inspection Report Renewal Capacity: 180 Deficiencies: 0 Mar 2, 2016
Visit Reason
The document is related to the renewal of the assisted living facility license for Parsons House On Eagle Run, including approval for the Memory Care Endorsement.
Findings
The facility meets statutory requirements as an assisted living facility with a Memory Care Endorsement. The renewal application and supporting documents confirm compliance with licensing and endorsement requirements.
Report Facts
Total licensed capacity: 180 Memory care unit beds: 47 Renewal fees: 1950
Employees Mentioned
NameTitleContext
Penny BowdenAdministratorNamed as facility administrator in multiple documents including renewal application and correspondence.
Eve LewisProgram ManagerSigned letter acknowledging Memory Care Endorsement approval.
Andy ReevesManagerListed as manager of the legal owning entity Gen3 Holdings LLC.
David MausbachInspectorInspected the facility for fire marshal certificate of occupancy.
Kimberly C. ReevesVoting MemberListed as voting member of the ownership entity Gen3 Holdings LLC.
Inspection Report Complaint Investigation Census: 149 Deficiencies: 0 Sep 2, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint at Parsons House On Eagle Run on September 2, 2014, involving review of resident records, observation of care, and interviews with residents, family members, and staff.
Findings
The facility was found to be in compliance with all related regulatory requirements for the allegations investigated, including provision of services as outlined in resident agreements, freedom from abuse, acting on resident grievances, access to communication, provision of therapeutic diets, medication administration, and personal hygiene.
Complaint Details
The complaint alleged the facility failed to provide services as outlined in resident service agreements, ensure residents were free from abuse, act upon resident grievances, ensure access to communication, provide therapeutic diets, provide medications as ordered, and ensure clean and groomed hair, skin, teeth, and nails. All allegations were found to be unsubstantiated with the facility in compliance.
Report Facts
Facility census: 149 Residents interviewed: 3 Residents observed for medication administration: 6 Employee files reviewed: 5 Resident records reviewed for medication: 3
Employees Mentioned
NameTitleContext
Kelly SchmidtRegistered NurseConducted the investigation visit
Eve LewisProgram ManagerSigned the report as Program Manager, Office of Long Term Care Facilities
Inspection Report Complaint Investigation Census: 147 Deficiencies: 0 Apr 8, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint at Parsons House On Eagle Run on April 8, 2014, regarding allegations of sexual abuse and failure to protect residents from abuse.
Findings
The facility was found to ensure residents were free from sexual abuse and protected from abuse. Investigations included review of records, staff interviews, and observation. Staff were educated on abuse policies and resident doors were secured.
Complaint Details
The complaint alleged the facility failed to ensure residents were free from sexual abuse and failed to protect residents from abuse. The allegations were investigated and followed up on, with findings that the facility did protect residents.
Report Facts
Facility census: 147 Employee files reviewed: 5
Employees Mentioned
NameTitleContext
Kelly SchmidtRegistered NurseRepresentative conducting the investigation
Carol NenemanSocial WorkerRepresentative conducting the investigation
Eve LewisProgram ManagerSigned correspondence as Program Manager of Office of Long Term Care Facilities
Inspection Report Complaint Investigation Census: 146 Deficiencies: 6 Dec 19, 2011
Visit Reason
The inspection was conducted as a compliance inspection and complaint investigation at Parsons House On Eagle Run to determine compliance with licensure regulations for Assisted-Living Facilities.
Findings
The facility was found to have multiple violations related to administration, housekeeping, maintenance, food safety, resident record documentation, and infection control. The violations did not create imminent danger or serious harm but required a plan of correction.
Complaint Details
The complaint allegations included failure to put interventions in place for residents identified as fall risk, failure to ensure residents do not require complex nursing, failure to provide care according to practitioner's orders, and failure to follow family directions on discharge planning. The facility was found compliant with these allegations.
Deficiencies (6)
Description
Failing to update a Resident Service Agreement and document blood pressures; ensuring residents needing supervision did not elope; safety of residents; kitchen cleanliness; food temperatures; hand washing times; housekeeping and maintenance problems; failure to implement a preventative maintenance program.
Failure to document blood pressure for two residents and ensure accuracy of documentation for two residents.
Failure to maintain potentially hazardous food temperatures above 135 degrees Fahrenheit.
Failure to implement a preventative maintenance program to ensure equipment and furnishings are safe and functional.
Failure to provide housekeeping and maintenance services necessary to maintain the environment.
Failure to protect residents from potential cross-contamination due to handwashing practices and non-use of protective barriers.
Report Facts
Census: 146 Survey sample size: 17 Plan of correction completion date: 2012 Food temperature requirement: 135
Employees Mentioned
NameTitleContext
Penny SchweitzerExecutive DirectorNamed in plan of correction letter and responsible for ongoing compliance.
Eve LewisRN-C, AdministratorSigned the cover letter for the inspection report.
Karlene GreenleafRegistered NurseSurveyor who conducted the inspection.
Ron ChaseRegistered NurseSurveyor who conducted the inspection.
Carol NenemanSocial WorkerSurveyor who conducted the inspection.
Kay ReevesNutrition/dietitianSurveyor who conducted the inspection.
Mary FeitRN, Nurse ConsultantPresented infection control in-service on January 17, 2012.
Kathy CannonRNPresented nursing staff in-service on documentation on January 20, 2012.
Notice Capacity: 180 Deficiencies: 0 APP2020
Visit Reason
This document serves to verify that Parsons House on Eagle Run is licensed as an assisted-living facility through the expiration date indicated on the renewal card and provides renewal application and ownership information.
Findings
The document confirms licensure status, ownership details, facility capacity, and includes floor plans and certification of occupancy. It does not report inspection findings or deficiencies.
Report Facts
Total licensed beds: 180 Maximum occupancy: 180 Alzheimer's beds capacity: 46 Monthly fee range: 6195 Monthly fee range: 7595
Employees Mentioned
NameTitleContext
Jessica WunderlichAdministratorNamed as facility administrator on renewal application and Alzheimer's Disclosure Form (pages 2 and 14).
Andrew K ReevesAuthorized RepresentativeSigned renewal application as authorized representative (page 2).
Kimberly C ReevesAuthorized RepresentativeSigned renewal application as authorized representative (page 2).
Notice Capacity: 180 Deficiencies: 0 APP2021
Visit Reason
This document set serves to verify the licensure renewal of Parsons House on Eagle Run as an assisted-living facility and includes related licensure and occupancy certificates, ownership information, and facility floor plans.
Findings
No inspection findings or deficiencies are reported; the documents primarily confirm licensure status, ownership, facility capacity, and provide floor plans and Alzheimer's special care unit disclosures.
Report Facts
Total licensed beds: 180 Maximum occupancy: 180 Maximum capacity for Alzheimer's beds: 43 Monthly fee range: 6195 Monthly fee range: 7595
Employees Mentioned
NameTitleContext
Nolan ClareAdministratorNamed as facility administrator on renewal application and Alzheimer's unit disclosure (pages 2 and 15).
Andrew ReevesManager / ContactNamed as facility manager and contact person on ownership letter and renewal application (pages 3 and 15).
Kimberly ReevesNamed as voting member in ownership information (page 3).
Notice Capacity: 180 Deficiencies: 0 APP2022
Visit Reason
This document set serves to verify the licensure renewal of Parsons House on Eagle Run as an assisted-living facility and includes the renewal application, ownership information, fire marshal certificate of occupancy, floor plans, and Alzheimer's special care unit disclosure.
Findings
No inspection findings or deficiencies are reported. The documents confirm licensure status, renewal application details, ownership, facility capacity, and special care unit endorsement.
Report Facts
Total licensed capacity: 180 Number of beds for Alzheimer's Memory Care: 47 Renewal licensure fee: 1650 Monthly care fee range: 6395 Monthly care fee range: 7895
Employees Mentioned
NameTitleContext
Heather HerzbergAdministratorNamed as facility administrator in renewal application and Alzheimer's special care unit disclosure.
Andrew ReevesAuthorized RepresentativeSigned renewal application and Alzheimer's special care unit disclosure as owner and authorized representative.
Kimberly C. ReevesAuthorized RepresentativeNamed as authorized representative on renewal application.
Notice Capacity: 180 Deficiencies: 0 APP2023
Visit Reason
This document serves to verify the assisted-living facility license renewal for Parsons House on Eagle Run and includes the renewal application for licensure.
Findings
The document confirms that Parsons House on Eagle Run meets statutory requirements as an assisted-living facility and is licensed through April 30, 2024. It includes detailed facility information, ownership, and licensing fees.
Report Facts
Total licensed beds: 180 Alzheimer's beds capacity: 47 Monthly fee range: 6630
Employees Mentioned
NameTitleContext
Heather HerzbergAdministratorNamed as facility administrator and signed the Alzheimer's special care unit disclosure.
Andrew K. ReevesAuthorized RepresentativeAuthorized representative who signed the renewal application.
Kim ReevesAuthorized RepresentativeAuthorized representative who signed the renewal application.
Notice Deficiencies: 0 APP2024
Visit Reason
This document serves as a license renewal verification and licensure confirmation for Parsons House on Eagle Run, an assisted living facility. It includes renewal application details, floor plans, bed census listings, and Alzheimer's special care unit endorsement application.
Findings
The document contains no inspection findings or deficiencies. It provides administrative and licensing information, including facility capacity, ownership, and bed census data across multiple floors and cottages.
Report Facts
Total number of beds to be relicensed: 180 Maximum occupancy: 180 Number of beds in Alzheimer's special care unit: 180 Total number of apartments: 154 Total number of beds: 429 Active beds: 156 Inactive beds: 273
Document Capacity: 180 Deficiencies: 0 APP2025
Visit Reason
The documents serve to verify licensure, renewal of the assisted-living facility license, certification of occupancy by the fire marshal, and application for Alzheimer's special care unit endorsement and memory care.
Findings
The documents confirm that Parsons House Assisted Living and Memory Care meets statutory requirements for licensure, has a maximum licensed capacity of 180 beds, and includes detailed facility floor plans and Alzheimer's care unit disclosures.
Report Facts
Total licensed capacity: 180 Maximum occupancy: 180 Renewal application date: 2025 Fire marshal inspection date: 2025 Alzheimer's special care unit renewal date: 2025
Employees Mentioned
NameTitleContext
Heather HerzbergAdministratorNamed as facility administrator on renewal application and Alzheimer's special care unit disclosure.
Andrew ReevesAuthorized RepresentativeSigned renewal application and listed as contact name on Alzheimer's special care unit disclosure.
Kim ReevesAuthorized RepresentativeSigned renewal application.
Donald DavisFire Marshal InspectorInspected facility for Certificate of Occupancy.

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