Cycle 1
Health 2024-10-16 · Fire 2024-10-16
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Gretna, NE
The Willows at Gretna
2-star overall rating with 2-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
700 Highway 6, Gretna, NE
(402) 332-3446
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
63
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avid Healthcare Group
Operator or chain grouping
Approved since
1994-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing
LPN hours / resident day
0.76
Licensed practical nurse staffing
Aide hours / resident day
2.67
Nurse aide staffing
Weekend hours
3.49
Weekend nurse staffing
RN turnover
100%
Annual RN turnover
Total nurse turnover
82%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.8
0.7 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.0
0.6 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 79.5% |
92.8%
13.3 pts worse
|
93.4%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.8% |
96.1%
6.3 pts worse
|
95.5%
5.7 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
4.5%
4.5 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 12.4% |
4.4%
8 pts worse
|
11.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 8.5% |
5.3%
3.2 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.1% |
19.5%
4.4 pts better
|
19.6%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 31.8% |
21.6%
10.2 pts worse
|
16.7%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 1.9% |
0.3%
1.6 pts worse
|
0.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.2% |
20.4%
4.2 pts better
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.6% |
19.9%
2.3 pts better
|
14.9%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
1.6%
1 pts worse
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.9%
2.9 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.6% |
26.6%
9 pts better
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
4.3%
2.7 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.8% |
80.5%
0.3 pts better
|
81.7%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.4% |
11.6%
9.8 pts worse
|
12.0%
9.4 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
2.4%
0.8 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.0% |
75.9%
0.9 pts worse
|
79.7%
4.7 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.4% |
20.9%
8.5 pts worse
|
23.9%
5.5 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-15 · Fire 2023-08-15
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
17 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Cycle 3
Health 2022-06-02 · Fire 2022-06-02
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
16 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-08
F · Potential for more than minimal harm
2023-08-15
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-15
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-15
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-15
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-08-15
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-09-28
F · Potential for more than minimal harm
2022-06-02
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-06-29
F · Potential for more than minimal harm
2022-06-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-12
F · Potential for more than minimal harm
2022-06-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-12
F · Potential for more than minimal harm
2022-06-02
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-06-29
F · Potential for more than minimal harm
2022-06-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-08-12
F · Potential for more than minimal harm
2022-06-02
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-06-29
F · Potential for more than minimal harm
2022-06-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-29
F · Potential for more than minimal harm
2022-06-02
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-06-29
E · Potential for more than minimal harm
2022-06-02
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-06-29
E · Potential for more than minimal harm
2022-06-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-06-29
E · Potential for more than minimal harm
2022-06-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-02
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-29
E · Potential for more than minimal harm
2022-06-02
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-06-29
E · Potential for more than minimal harm
2022-06-02
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2022-06-29
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-12
E · Potential for more than minimal harm
2025-08-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-12
G · Actual harm
2025-05-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-05
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-06-13
F · Potential for more than minimal harm
2024-10-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-30
E · Potential for more than minimal harm
2024-10-16
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-11-30
E · Potential for more than minimal harm
2024-05-02
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-05-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-01-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-16
E · Potential for more than minimal harm
2023-08-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-28
F · Potential for more than minimal harm
2022-06-02
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-06-26
D · Potential for more than minimal harm
2022-06-02
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-06-26
D · Potential for more than minimal harm
2022-06-02
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-06-26
D · Potential for more than minimal harm
2022-06-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-26
Penalties and ownership
What sits behind the stars
$0
2025-05-05
Payment Denial
Payment Denial · denial start 2025-05-23 · 21 days
21 day denial
Ownership
Brass Ne Trust
5% Or Greater Indirect Ownership Interest · Organization
Bsd Beis Health Trust
5% Or Greater Indirect Ownership Interest · Organization
Copper Ne Trust
5% Or Greater Indirect Ownership Interest · Organization
Douro Valley Investment, LLC
5% Or Greater Indirect Ownership Interest · Organization
Gold Ne Trust
5% Or Greater Indirect Ownership Interest · Organization
Hohensee, Kent
W-2 Managing Employee · Individual
Ne 11 Holdings Opco LLC
5% Or Greater Indirect Ownership Interest · Organization
Ne SNF Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Sf 4140 Olde Washington Boulevard Real Property LLC
5% Or Greater Indirect Ownership Interest · Organization
Silberstein, Ari
Corporate Officer · Individual
Silver Ne Trust
5% Or Greater Indirect Ownership Interest · Organization
Tulip Investments Ne LLC
5% Or Greater Indirect Ownership Interest · Organization
Weisz, David
5% Or Greater Indirect Ownership Interest · Individual
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