Deficiencies (last 6 years)
Deficiencies (over 6 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
48 residents
Based on a November 2015 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 28, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint at Hickory Villa on January 28-29, 2019, involving allegations related to resident safety, misappropriation, medication competency, investigation completeness, narcotic diversion, abuse protection, and abuse reporting.
Complaint Details
The complaint investigation included seven allegations: failure to provide a safe environment for residents at risk of elopement, failure to ensure residents are free from misappropriation, failure to ensure staff competency in medication administration, failure to ensure complete written investigations, failure to protect narcotics from diversion, failure to protect residents from abuse, and failure to report allegations of abuse. The narcotic diversion allegation was substantiated, but the facility took appropriate corrective action.
Findings
The facility was found to be in compliance with regulatory requirements for all allegations investigated, including providing a safe environment for residents at risk of elopement, protecting residents from misappropriation and abuse, ensuring staff competency in medication administration, completing written investigations, reporting narcotic diversion and abuse allegations, and taking appropriate corrective actions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Author of the inspection report letter |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 2, 2017
Visit Reason
An unannounced visit was conducted to investigate complaints at Hickory Villa regarding the facility's pest control program.
Complaint Details
The complaint alleged that the facility failed to maintain an effective pest control program. The allegation was not substantiated as the facility was found compliant.
Findings
The facility was found to maintain an effective pest control program with no signs of pests observed. Rooms with signs of bed bugs were treated twice, resident clothing was washed, residents were assisted with baths, mattress covers were placed on all mattresses, and ongoing monitoring was in place. The facility was determined to be in compliance with regulatory requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the report and identified as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health |
| Cecil Wissink | Administrator | Interviewed regarding pest control program |
Notice
Capacity: 60
Deficiencies: 0
Date: Mar 28, 2016
Visit Reason
The document is a licensure renewal application for the assisted-living facility Hickory Villa, including certification of licensure and occupancy.
Findings
The documents certify that Hickory Villa meets statutory requirements as an assisted-living facility with a licensed capacity of 60 beds and includes a certificate of occupancy issued by the Nebraska State Fire Marshal.
Report Facts
Renewal Fees: 1650
Total licensed beds: 60
Maximum Occupancy: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cecil Wissink | Administrator | Named as administrator on the licensure renewal application. |
| Larry W Smith | Authorized Representative | Signed the licensure renewal application. |
| Dana C Rasic | Authorized Representative | Signed the licensure renewal application and is listed as President, Board Chairman of Bethesda Foundation. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 6
Date: Nov 2, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint survey at Hickory Villa on November 2-3, 2015, by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint investigation was substantiated with multiple medication administration errors, delayed call light responses, lack of resident competency evaluations for self-medication, and incomplete background checks for staff. Other complaint allegations such as meal quality, service agreement compliance, protection from retaliation, and abuse reporting were found to be unsubstantiated or in compliance.
Findings
The facility failed to administer medications according to practitioner orders and the Five Rights, failed to follow medication documentation orders, failed to answer call lights promptly, failed to ensure residents' competence to self-administer medications, and failed to complete required registry checks for a direct care staff member. Other allegations such as meal palatability, service agreement compliance, protection from retaliation, and abuse reporting were found to be in compliance.
Deficiencies (6)
Failure to provide medications as ordered by a practitioner with 4 medication errors observed.
Failure to provide medications in accordance with the Five Rights with 4 medication errors observed.
Failure to follow practitioner's orders for medication documentation with 4 errors observed.
Failure to answer call notification systems promptly; call lights took 20-30 minutes to be answered on multiple occasions.
Failure to ensure residents are competent to administer own medications; no evaluation documented for 3 sampled residents.
Failure to complete Nebraska Sex Offender checks and APS/CPS registry checks for one sampled direct care staff member.
Report Facts
Medication errors observed: 4
Medication documentation errors: 4
Call light delays: 20
Residents sampled for self-administration evaluation: 3
Direct care staff: 12
Facility census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cecil Wissink | Administrator | Facility administrator addressed in the report. |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Author of the inspection report letter. |
| Ron Chase | Registered Nurse Surveyor | Surveyor conducting the complaint investigation. |
| Kay Reeves | Nutrition/dietitian Surveyor | Surveyor conducting the complaint investigation. |
| Medication Aide A | Direct care staff member with missing registry checks and involved in medication administration errors. | |
| Licensed Practical Nurse Health Service Coordinator | Licensed Practical Nurse | Interviewed regarding call light expectations and medication self-administration evaluations. |
| Business Manager | Confirmed missing registry checks for Medication Aide A and responsible for correction. | |
| LPN Health Services Director | Licensed Practical Nurse | Responsible for corrective actions related to medication administration, self-administration evaluations, and call light response. |
| RN Consultant | Registered Nurse Consultant | Responsible for medication aide competencies and corrective actions. |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 9
Date: Jan 21, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Hickory Villa from January 15 to January 21, 2014, to assess compliance with licensure regulations and investigate allegations of noncompliance.
Complaint Details
The complaint alleged failure to provide appropriate notices for involuntary discharges, failure to provide services as agreed upon, failure to prevent medication errors, failure to ensure medications are administered according to the five rights, failure to inform cognitive residents of medication errors, failure to ensure adequate housekeeping, failure to protect residents from abuse, failure to answer call notifications promptly, failure to provide service foods in accordance with the Food Code, failure to address grievances/complaints, and failure to ensure resident records are accurate and complete.
Findings
The facility was found to be in compliance with some allegations such as providing notices for involuntary discharges and services as agreed upon, but failed to prevent medication errors, ensure medication administration according to the five rights, complete medication error reports, and maintain accurate resident records. Other findings included incomplete nurse aide registry checks, failure to assess resident rights, medication availability issues, and deficiencies in medication administration and documentation.
Deficiencies (9)
Failed to ensure nurse aide registry checks were completed for new direct care staff members.
Failed to have evidence of resident receipt of rights for 5 residents.
Failed to have medications available to administer to 4 residents.
Failed to administer medications according to the five rights; medication administration was incomplete and medications were not always available.
Failed to complete medication error reports for two medication errors.
Failed to ensure resident records were accurate and complete, including medication administration records.
Failed to provide written instruction for medication aides performing insulin injections.
Failed to complete medication self-administration assessments for Resident 6.
Failed to complete medication error reports and documentation for medication errors.
Report Facts
Total census: 52
Number of new direct care staff missing registry checks: 7
Number of residents without evidence of receipt of rights: 5
Number of residents without medications available: 4
Number of medication errors without reports: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Schmidt | Registered Nurse | Surveyor conducting the inspection |
| Kay Reeves | Nutrition/dietitian | Surveyor conducting the inspection |
| Eve Lewis | Program Manager | Office of Long Term Care Facilities, signed correspondence and findings |
| Sennora Washington | Administrator | Facility administrator named in correspondence and plan of compliance |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Date: Dec 6, 2011
Visit Reason
The inspection was conducted following a complaint investigation at Hickory Villa regarding allegations of abuse reporting failures, staff training on abuse/neglect policies, and medication administration errors.
Complaint Details
The complaint investigation revealed that the facility failed to immediately report allegations of abuse, with one allegation reported 11 days after the incident. The facility also failed to ensure staff training on abuse/neglect policies and procedures. Medication administration errors were reported and addressed appropriately. The allegation regarding failure to report medication errors was substantiated without a violation.
Findings
The facility was found to have failed to ensure timely reporting of abuse allegations and adequate staff training on abuse and neglect policies. Medication administration errors were reported and appropriate corrective actions were taken. The facility was cited for failure to ensure training of 2 out of 11 direct care staff on abuse and neglect policies.
Deficiencies (1)
Failure to ensure that 2 out of 11 direct care staff received training on abuse and neglect policies and procedures.
Report Facts
Staff training deficiency: 2
Medication errors: 4
Medication administrations observed: 20
Direct care staff total: 11
Facility census: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kay Reeves | Nutrition/dietitian | Surveyor who conducted the complaint investigation. |
| Lisa Graper-Fuller | Administrator / Executive Director | Facility administrator receiving the report and submitting plan of correction. |
| Eve Lewis | RN-C, Administrator | Office of Long Term Care Facilities, Licensure Unit administrator who signed the cover letter. |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Date: Feb 8, 2011
Visit Reason
The inspection was conducted following a complaint investigation at Hickory Villa on February 8, 2011, regarding noncompliance with licensure regulations for Assisted-Living Facilities.
Complaint Details
The complaint investigation found the facility failed to protect residents from abuse and failed to report incidents of abuse to Adult Protective Services for one sampled resident. The failure was a violation of 175 NAC 4-006.02.
Findings
The facility failed to protect residents from abuse and failed to report incidents of abuse to Adult Protective Services as required by law. The facility also failed to notify guardians or legal representatives of changes in resident condition for one sampled resident.
Deficiencies (2)
The facility failed to protect the residents from abuse.
The facility failed to report incidents of abuse.
Report Facts
Total census: 52
Sampled residents: 5
Residents with allegation: 1
Days to correct violations: 90
Days to submit statement of compliance: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kay Reeves | Nutrition/dietitian | Surveyor who conducted the complaint investigation |
| Eve Lewis | RN-C, Administrator | Office of Long Term Care Facilities, Licensure Unit, Division of Public Health |
Notice
Capacity: 60
Deficiencies: 0
Date: APP2017
Visit Reason
This document serves as a licensure renewal application and verification for the assisted-living facility Hickory Villa, including a certificate of occupancy confirming the maximum licensed capacity.
Findings
The document confirms that Hickory Villa is licensed as an assisted-living facility with a maximum occupancy of 60 beds, and includes ownership and administrative information along with the fire marshal's certificate of occupancy.
Report Facts
Total licensed capacity: 60
Renewal expiration date: Apr 30, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cecil Wissink | Administrator | Named as facility administrator in licensure renewal application |
Notice
Capacity: 60
Deficiencies: 0
Date: APP2018
Visit Reason
This document serves as a licensure renewal application and verification for the assisted-living facility Hickory Villa, including certification of occupancy and ownership information.
Findings
The documents confirm the facility's licensure renewal status, ownership by Bethesda Foundation, and a maximum occupancy of 60 persons as certified by the Nebraska State Fire Marshal.
Report Facts
Total licensed beds: 60
Maximum occupancy: 60
Renewal fees: 950
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cecil Wissink | Administrator | Named as facility administrator in the renewal application. |
| Dana L. Rasic | Authorized Representative | Signed the renewal application as an authorized representative. |
| Nathan D. Merrill | Authorized Representative | Signed the renewal application as an authorized representative. |
| Dan Cosgrove | Inspector | Inspected the facility for the Nebraska State Fire Marshal Certificate of Occupancy. |
Document
Capacity: 60
Deficiencies: 0
Date: APP2019
Visit Reason
The documents serve to verify licensure renewal status, provide renewal application details, ownership and officer information, and fire marshal occupancy certification for the assisted-living facility Hickory Villa.
Findings
No inspection findings or deficiencies are reported. The documents confirm licensure renewal, ownership details, and fire marshal occupancy certification with a maximum capacity of 60 beds.
Report Facts
Total licensed beds: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cecil Wissink | Administrator | Named in the Assisted-Living Facility Licensure Renewal Application. |
| Don A. Morgan | Director | Listed as a director of Bethesda Foundation, the owner of the facility. |
| Mark Pluimer | Director | Listed as a director of Bethesda Foundation, the owner of the facility. |
| Dale Turner | Director | Listed as a director of Bethesda Foundation, the owner of the facility. |
| Rick Summers | Director | Listed as a director of Bethesda Foundation, the owner of the facility. |
| Dana Rasic | President, Board Chairman | Listed as an officer of Bethesda Foundation, the owner of the facility. |
| Daniel C. Vagle | Vice Chairman | Listed as an officer of Bethesda Foundation, the owner of the facility. |
| Nathan Merrill | Treasurer | Listed as an officer of Bethesda Foundation, the owner of the facility. |
| Larry Smith | Vice President | Listed as an officer of Bethesda Foundation, the owner of the facility. |
| Jenny Kennedy | Secretary | Listed as an officer of Bethesda Foundation, the owner of the facility. |
| Tom Workman | Assistant Secretary | Listed as an officer of Bethesda Foundation, the owner of the facility. |
Document
Capacity: 60
Deficiencies: 0
Date: APP2020
Visit Reason
The documents serve to verify the renewal of the assisted-living facility license for Hickory Villa and provide related ownership, occupancy, and facility layout information.
Findings
The documents confirm that Hickory Villa is licensed as an assisted-living facility with a maximum occupancy of 60 beds, owned by Bethesda Foundation. The Nebraska State Fire Marshal certificate confirms the occupancy limit and inspection date.
Report Facts
Total licensed beds: 60
Renewal license expiration date: License expiration date is April 30, 2021, as shown on the renewal verification.
Renewal license fees: 950
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cecil Wissink | Administrator | Named as administrator on the renewal application. |
| Larry W. Smith | Authorized Representative | Signed the renewal application as authorized representative. |
| Dana L. Rasic | Authorized Representative | Signed the renewal application as authorized representative and listed as President and Board Chairman of Bethesda Foundation. |
| Dan Cosgrove | Inspector | Named as inspector on the Nebraska State Fire Marshal Certificate of Occupancy. |
Notice
Capacity: 60
Deficiencies: 0
Date: APP2025
Visit Reason
This document package serves to verify the licensure of Hickory Villa as an assisted-living facility and includes the renewal application for the facility license.
Findings
The documents confirm that Hickory Villa meets statutory requirements as an assisted-living facility with a licensed capacity of 60 beds. The renewal application is completed and signed, and the Nebraska State Fire Marshal certificate of occupancy is included.
Report Facts
Total licensed beds: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tawny McWilliams | Administrator | Named in the renewal application form. |
| Dana Rasic | President, Board Chairman | Named as authorized representative signing the renewal application and listed as an officer of Bethesda Foundation. |
| Nathan Merrill | Treasurer | Named as authorized representative signing the renewal application and listed as an officer of Bethesda Foundation. |
Notice
Capacity: 60
Deficiencies: 0
Date: APP2021
Visit Reason
The document serves to verify the renewal of the assisted-living facility license and includes a renewal application form.
Findings
The documents confirm that Hickory Villa meets statutory requirements as an assisted-living facility and is licensed through the date indicated on the renewal card. It also includes ownership information and a fire marshal certificate of occupancy.
Report Facts
Total licensed beds: 60
Renewal license fees: 950
Renewal license fees: 1450
Renewal license fees: 1650
Renewal license fees: 1950
Maximum occupancy: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dana L. Rasic | Authorized Representative | Signed the renewal application and listed as President and Board Chairman of Bethesda Foundation. |
| Rick Summers | Authorized Representative | Signed the renewal application and listed as Vice President of Bethesda Foundation. |
Document
Capacity: 60
Deficiencies: 0
Date: APP2022
Visit Reason
The documents pertain to the renewal of the assisted-living facility license for Hickory Villa, including submission of renewal application and verification of licensure status.
Findings
No inspection findings or deficiencies are reported. The documents confirm licensure renewal and provide ownership and facility capacity information.
Report Facts
Total licensed beds: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Cundall | Administrator | Named as facility administrator in the renewal application. |
| Rick Summers | Authorized Representative | Signed the renewal application as authorized representative. |
| Dana L. Rasic | Authorized Representative, President, Board Chairman | Signed the renewal application and listed as President and Board Chairman of Bethesda Foundation ownership. |
Notice
Capacity: 60
Deficiencies: 0
Date: APP2023
Visit Reason
This document serves to verify the renewal of the assisted-living facility license for Hickory Villa and includes related licensure and certification information.
Findings
The documents confirm that Hickory Villa meets statutory requirements as an assisted-living facility and is licensed through the indicated renewal date. Additional documents include ownership information, fire marshal certificate of occupancy, and floor plans.
Report Facts
Total licensed beds: 60
Renewal expiration date: 2023
Fire marshal certificate issue date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shandra Wilkins | Administrator | Named as facility administrator in renewal application. |
| Rick Summers | Authorized Representative | Signed renewal application as authorized representative. |
| Dana L. Rasic | Authorized Representative | Signed renewal application as authorized representative. |
Notice
Capacity: 60
Deficiencies: 0
Date: APP2024
Visit Reason
The documents serve to verify and renew the assisted-living facility license for Hickory Villa, including submission of renewal application and confirmation of compliance with licensing requirements.
Findings
The documents confirm that Hickory Villa meets statutory requirements as an assisted-living facility and is licensed through the renewal date. The fire marshal certificate indicates a maximum occupancy of 60 persons/beds.
Report Facts
Total licensed beds: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linnea Parde | Administrator | Named in the renewal application form. |
| Rick Summers | Authorized Representative | Signed renewal application as authorized representative. |
| Dana L. Rasic | Authorized Representative | Signed renewal application as authorized representative. |
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