WILLOWS NURSING AND REHAB

The information listed below provides an in-depth look into the type and quality of care offered at Willows Nursing and Rehab. It is important to note that when evaluating if a nursing home is right for you or a loved one, ratings should not be taken as the sole deciding factor, but as one of many aspects to be considered.

Address

WILLOWS NURSING AND REHAB
41 RICKEL RD
SUN PRAIRIE, WI 53590
(608) 837-8529

Nursing Home Ratings

Health Inspections
Quality Measures
Nursing Staff
R.N. Staff Only

Overall Rating

Percent of Beds Occupied

89%

Number of Residents and Certified Beds

Residents: 51
Certified Beds: 57

This Facility Accepts

Medicare
Medicaid

Operational Details

Operated By For Profit - Corporation
Offers Only Resident Counseling
This Facility is Part of a Chain or Franchise

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Nearby Cities:

Madison | Waunakee | Middleton

Resident Services

The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Ultra-High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by Willows Nursing and Rehab. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.

Resident Services

Resident Conditions

Percent of Service Days

Very High Rehabilitation Plus Extensive Services

Rehabilitation 500 Minutes Per Week Minimum

At least one rehabilitation discipline five days/week
Tracheostomy care
Ventilator or respirator
Isolation for active infectious disease while a resident
Activities of Daily Living (ADL) score of 2 or more

ADL Index Range: 2-10	3.4%
Total Percent:	3.4%

Ultra-High Rehabilitation

Rehabilitation 720 Minutes Per Week Minimum

At least one rehabilitation discipline five days/week
A second rehabilitation discipline three days/week

ADL Index Range: 11-16	28.6%
ADL Index Range: 6-10	37.7%
ADL Index Range: 0-5	3.5%
Total Percent:	69.8%

Very High Rehabilitation

Rehabilitation 500 Minutes Per Week Minimum

At least one rehabilitation discipline five days/week

ADL Index Range: 11-16	4.3%
ADL Index Range: 6-10	11.2%
ADL Index Range: 0-5	3.0%
Total Percent:	18.4%

High Rehabilitation

Rehabilitation 325 Minutes Per Week Minimum

At least one rehabilitation discipline five days/week

ADL Index Range: 11-16	0.3%
ADL Index Range: 0-5	1.3%
Total Percent:	1.6%

Medium Rehabilitation

Rehabilitation 150 Minutes Per Week Minimum

Five days any combination of three rehabilitation disciplines

ADL Index Range: 6-10	3.2%
ADL Index Range: 0-5	1.5%
Total Percent:	4.7%

Extensive Services

Tracheostomy care
Ventilator or respirator
Isolation for active infectious disease while a resident
Activities of Daily Living (ADL) score of 2 or more

ADL Index Range: 2-16 - Tracheostomy care or ventilator/respirator	1.5%
Total Percent:	1.5%

Special Care High

Comatose
Septicemia
Diabetes with daily injections and a change of order two or more days
Quadriplegia with ADL score greater or equal to 5
Chronic Obstructive Pulmonary Disease (COPD) and shortness of breath when lying flat
Fever with pneumonia, or vomiting, or weight loss, or feeding tube
Parenteral/IV feedings
Respiratory therapy for 7 days
Activities of Daily Living (ADL) score of 2 or more

ADL Index Range: 11-14 - No Signs of depression	0.2%
Total Percent:	0.2%

Clinically Complex

Pneumonia, hemiplegia with ADL score >=5
Surgical wounds or open lesions with treatment
Burns
Chemotherapy while a resident
Oxygen therapy while a resident
IV medications or transfusions while a resident
Extensive Services, Special Care High or Special Care Low qualifier and ADL score of 0 or 1

ADL Index Range: 0-1 - No Signs of depression	0.3%
Total Percent:	0.3%

Rating Details For Willows Nursing and Rehab

Nursing Staff -

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Nursing Hours Per Resident Per Day	Reported	Expected
Registered Nurse (RN) Hours	36 Minutes	1 Hour and 40 Minutes
Licensed Practical/Vocational Nurse (LPN/LVN) Hours	39 Minutes	56 Minutes
Certified Nursing Assistant (CNA) Hours	2 Hours and 2 Minutes	2 Hours and 42 Minutes
Total Licensed Nurse Hours	1 Hour and 14 Minutes	2 Hours and 35 Minutes
Total Nurse Hours	3 Hours and 16 Minutes	5 Hours and 17 Minutes

Quality of Care -

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Wisconsin are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

This Facility

Wisconsin Average

Long-Term Stay Preventive Actions

Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season	90-100%	94%
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination	90-100%	95%

Long-Term Stay Deficiencies

Percent of Long-Stay Residents Who Had a Urinary Tract Infection	15%	8%
Percent of Long-Stay Residents Who Lose Too Much Weight	13%	8%
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder	18%	7%
Percent of Long-Stay Residents Who Were Physically Restrained	-	3%
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores	14%	8%
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair	8%	3%
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased	13%	14%
Percent of Long-Stay Residents Who Have Moderate to Severe Pain	4%	4%
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder	71%	49%
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse	13%	11%
Percent of Long-Stay Residents Who Are More Depressed or Anxious	28%	18%

Short-Term Stay Preventive Actions

Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season	90-100%	90%
Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination	90-100%	92%

Short-Term Stay Deficiencies

Percent of Short-Stay Residents Who Had Moderate to Severe Pain	32%	26%
Percent of Short-Stay Residents Who Have Delirium	1%	3%
Percent of Short-Stay Residents Who Have Pressure Sores	3%	10%

Health Inspection Details -

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 03/03/2011.

Degree of Harm

- Potential for Minimal Harm
- Minimal Harm or Potential for Harm
- Resident Harmed
- Immediate Jeopardy to Resident Health

Residents Affected

- Isolated
- Some Residents
- Many Residents

Deficiencies Found By Inspectors

Degree of Harm

Residents Affected

Administration

Post Nurse Staffing Information. Inspection Date: 03/03/2011 Correction Date: 01/01/1900
Keep Accurate and Appropriate Medical Records. Inspection Date: 03/03/2011 Correction Date: 04/02/2011

Environmental

Keep All Essential Equipment Working Safely. Inspection Date: 12/02/2009 Correction Date: 01/02/2010
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 03/03/2011 Correction Date: 04/02/2011
Have a Program to Keep Infection from Spreading. Inspection Date: 03/03/2011 Correction Date: 04/02/2011

Mistreatment

Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment. Inspection Date: 12/02/2009 Correction Date: 01/02/2010
1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents. Inspection Date: 12/02/2009 Correction Date: 01/02/2010
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property. Inspection Date: 12/02/2009 Correction Date: 01/02/2010
1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents. Inspection Date: 03/03/2011 Correction Date: 04/02/2011
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property. Inspection Date: 03/03/2011 Correction Date: 04/02/2011

Nutrition and Dietary

Use Properly Trained Paid Feeding Assistants, Provide Licensed Nursing Supervision of the Feeding Assistants, or Properly Monitor the Feeding of Its Residents. Inspection Date: 09/24/2008 Correction Date: 10/22/2008
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 03/03/2011 Correction Date: 04/02/2011

Pharmacy Service

Keep the Rate of Medication Errors (Wrong Drug, Wrong Dose, Wrong Time) to Less Than 5%.

Inspection Date: 03/03/2011
Correction Date: 04/02/2011

Quality Care

Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary. Inspection Date: 09/24/2008 Correction Date: 10/22/2008
Give Professional Services That Follow Each Resident's Written Care Plan. Inspection Date: 12/02/2009 Correction Date: 01/02/2010
Give Professional Services That Follow Each Resident's Written Care Plan. Inspection Date: 03/03/2011 Correction Date: 04/02/2011
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores. Inspection Date: 03/03/2011 Correction Date: 04/02/2011
Give or Get Dental Care for Each Resident. Inspection Date: 03/03/2011 Correction Date: 04/02/2011

Resident Rights

Immediately Tell the Resident, Doctor, and a Family Member If: the Resident is Injured, There is a Major Change in Resident's Physical/Mental Health, There is a Need to Alter Treatment Significantly, or the Resident Must Be Transferred or Discharged. Inspection Date: 03/03/2011 Correction Date: 04/02/2011
Send and Promptly Deliver Unopened Mail to Residents. Inspection Date: 03/03/2011 Correction Date: 01/01/1900

Deficiencies from Complaints and Incidents

The table below lists incident reports by the nursing staff or administration for Willows Nursing and Rehab, as well as complaints by residents or their family in the previous three years.

Degree of Harm

- Potential for Minimal Harm
- Minimal Harm or Potential for Harm
- Resident Harmed
- Immediate Jeopardy to Resident Health

Residents Affected

- Isolated
- Some Residents
- Many Residents

Formal Complaints

Degree of Harm

Residents Affected