Inspection Reports for
The Willows Assisted Living
806 S STREET, NELIGH, NE, 68756
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
2 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
52% better than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Occupancy
Latest occupancy rate
78% occupied
Based on a December 2018 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 1
Date: Dec 4, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at The Willows Assisted Living Facility from December 4, 2018 to December 6, 2018. The investigation included review of resident records, observation of care and services, and interviews with residents, family members, and staff.
Complaint Details
The complaint alleged the facility failed to administer medications according to the Five Rights and failed to protect residents from abuse. Both allegations were investigated and found to be unsubstantiated as the facility was in compliance with related regulatory requirements.
Findings
The investigation found the facility was in compliance with regulatory requirements regarding medication administration and protection from abuse. However, the facility failed to have specific directions for how as needed medications would be provided to 4 of 4 sampled residents, potentially affecting all sampled residents.
Deficiencies (1)
Facility failed to have specific directions for how as needed medications will be provided to 4 of 4 sampled residents.
Report Facts
Residents sampled: 4
Facility census: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Kee | Registered Nurse | Named as person responsible for correction of medication direction deficiency |
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the inspection report letter |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 3
Date: Nov 30, 2011
Visit Reason
The inspection was conducted following a compliance inspection at The Willows Assisted Living Facility to investigate noncompliance with licensure regulations related to medication administration.
Complaint Details
The inspection was complaint-related, triggered by concerns about medication administration practices. The report does not explicitly state substantiation status.
Findings
The facility was found to have failed to implement policies and procedures to ensure residents receive medications only as legally prescribed, with specific issues noted in medication transcription and alteration of medication administration records.
Deficiencies (3)
Facility failed to implement policies and procedures to ensure residents receive medications only as legally prescribed by medical practitioner.
Facility staff altered medication administration record labels by changing dosages and frequencies without proper authorization.
Facility failed to implement a policy and procedure relating to medication transcription from medication order to the MAR's record by facility staff.
Report Facts
Facility census: 29
Sample size: 5
Residents reviewed for medication compliance: 4
Staff trained: 2
Days to correct violations: 90
Working days to submit compliance statement: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anna Harrison | Registered Nurse | Surveyor who conducted the inspection |
| Alice O'Donnell | Registered Nurse | Surveyor who conducted the inspection |
| Eve Lewis | RN-C, Administrator | Administrator of Office of Long Term Care Facilities who signed the letter |
| Jayne Prince | Administrator | Facility Administrator who responded to the compliance letter |
Notice
Capacity: 32
Deficiencies: 0
Date: APP2017
Visit Reason
This document serves as a licensure renewal application and verification for The Willows Assisted Living Facility, confirming the facility's license status and renewal through the indicated expiration date.
Findings
The documents confirm that The Willows Assisted Living Facility is licensed and meets statutory requirements as an assisted-living facility with a total licensed capacity of 32 beds. The renewal application includes ownership and business information, and a fire marshal occupancy permit certifies the maximum occupancy of 32 beds.
Report Facts
Total licensed capacity: 32
Renewal expiration date: Apr 30, 2018
Fire marshal occupancy permit date: Apr 13, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jayne Prince | Administrator, Manager | Named as the facility administrator in the licensure renewal application. |
| Todd Brehm | Deputy State Fire Marshal | Inspected the facility and approved the occupancy permit. |
Document
Capacity: 32
Deficiencies: 0
Date: APP2019
Visit Reason
The documents pertain to the renewal of the assisted living facility license for The Willows Assisted Living Facility, including submission of renewal application, occupancy permit, and ownership information.
Findings
No inspection findings or deficiencies are reported. The documents certify licensure renewal, occupancy permit approval, and provide ownership/shareholder details.
Report Facts
Total licensed beds: 32
Shares: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jayne Prince | Administrator, Manager | Named as facility administrator on renewal application |
| Robert Folck | Deputy State Fire Marshal | Inspected and approved occupancy permit |
| Mary Burgess | Authorized representative signing renewal application | |
| Deborah Rice | Authorized representative signing renewal application |
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