Inspection Reports for
The Willows Assisted Living

806 S STREET, NELIGH, NE, 68756

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Deficiencies (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/year

Deficiencies per year

4 3 2 1 0
2011
2018

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

70% 77% 84% 91% 98% 105% Nov 2011 Dec 2018

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
NameTitleContext
Karen KeeRegistered NurseNamed as person responsible for correction of medication direction deficiency
Connie VogtProgram Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHSSigned 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
NameTitleContext
Anna HarrisonRegistered NurseSurveyor who conducted the inspection
Alice O'DonnellRegistered NurseSurveyor who conducted the inspection
Eve LewisRN-C, AdministratorAdministrator of Office of Long Term Care Facilities who signed the letter
Jayne PrinceAdministratorFacility 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
NameTitleContext
Jayne PrinceAdministrator, ManagerNamed as the facility administrator in the licensure renewal application.
Todd BrehmDeputy State Fire MarshalInspected 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
NameTitleContext
Jayne PrinceAdministrator, ManagerNamed as facility administrator on renewal application
Robert FolckDeputy State Fire MarshalInspected and approved occupancy permit
Mary BurgessAuthorized representative signing renewal application
Deborah RiceAuthorized representative signing renewal application

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