Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maplewood Of Sauk Prairie during CMS and state inspections, most recent first.
Incomplete Infection Control Surveillance for Staff Illness: The facility did not maintain an effective infection prevention and control program because staff illness surveillance line lists were incomplete. The records often lacked dates of last symptoms and return-to-work dates, and some entries used nonspecific symptoms such as “sick,” “respiratory,” and “metabolic disorder.” The DON stated that specific symptoms should be tracked and that return-to-work timing depends on the last symptom, but the line lists did not show that staff returned at the appropriate time.
A resident with CVA, aphasia, and moderate cognitive impairment was regularly participating in preferred activities such as cards, dice, music, and 1:1 interaction, but staff kept her in her room because her roommate was on isolation for gastroenteritis symptoms. The resident said she missed activities and was not offered in-room activities, and staff interviews confirmed she was not on precautions herself and had not been provided an activity alternative while confined to her room.
Antibiotic Stewardship Program Not Implemented: The facility did not have an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. Two residents were treated with antibiotics for UTIs without meeting McGeers criteria, and the DON stated the facility would typically discuss such cases with the provider but could not find documentation of any provider conversation in either resident's chart.
Failure to Offer Pneumococcal Immunization: A resident with prior pneumococcal vaccinations was not offered the next recommended PCV20 or PCV21 dose, and the record contained no declination or consent for the vaccine. The DON could not provide documentation that the vaccine was offered, and agreed the resident should have been offered the pneumococcal immunization per CDC guidance.
A resident's allegation of sexual abuse by a male CNA was reported to the facility by an outside agency. Despite facility policy requiring immediate reporting of such allegations to the State Agency, the DON and NHA did not report the incident, citing the time elapsed since the resident's discharge and uncertainty about the staff member's identity.
A resident alleged that a male CNA inappropriately washed her breasts during a bath. The facility received this report from an outside agency after the resident's discharge but did not investigate the allegation, interview staff or other residents, or report the incident to the State Agency, contrary to its abuse policy.
The facility failed to report allegations of abuse involving three residents to the State Survey Agency. A resident filed a grievance against her roommate for verbal abuse, which was observed by staff but not reported. Another resident alleged a male entered her room and violated her, but the facility did not report this potential sexual misconduct. The facility did not adhere to its policy requiring immediate reporting of abuse allegations.
The facility failed to thoroughly investigate allegations of abuse involving three residents. A resident reported verbal abuse and aggressive behavior from a roommate, while another resident alleged a male entered her room and violated her. The facility did not conduct comprehensive investigations, as required by their policy, by failing to interview other potential witnesses or involved staff.
The facility failed to ensure proper air-drying of plates before storage, as observed in the kitchenette serving areas on the Oak and Evergreen hallways. The Dietary Manager confirmed that plates were put away wet, which could increase the risk of foodborne illness. This deficiency potentially affected 31 residents across two hallways.
The facility did not meet daily staffing posting requirements, affecting all residents. The staffing sheet at the nursing station lacked details like census, CNA, LPN, RN numbers, and working hours. The DON and Administrator confirmed no policy existed for posting nurse staffing information.
A resident was observed with medications left at her bedside without a self-administration order. Despite being cognitively intact, her medical record lacked a Self-Administration Assessment, and her care plan did not authorize self-administration. An LPN admitted to leaving the medications unattended, and the DON confirmed this was against protocol.
A facility failed to document, investigate, and resolve grievances for a resident whose spouse raised concerns about care, including ADLs, fluid intake, and staffing. Despite these concerns being communicated to the Social Worker and DON, they were not treated as grievances per the facility's policy. Interviews revealed a misunderstanding of the grievance process, with both staff members reporting zero grievances, indicating a failure to recognize and address the concerns formally.
Incomplete Infection Control Surveillance for Staff Illness
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. The facility’s Infection Control Policy stated that the infection control program would investigate, control, and prevent infections, and that employee health status would be surveilled through monitoring of employee call-ins to determine possible outbreaks or exposure to residents. Record review showed the facility’s staff surveillance line lists for November 2025, December 2025, and January 2026 were incomplete. The line lists included fields for date of first symptom, date of call in, symptoms, treatment, tests, and date infection resolved/work return date, but many entries did not include a date of last symptom or a return-to-work date. Some entries used nonspecific symptoms such as “sick,” “respiratory,” and “metabolic disorder,” and the DON stated these were not specific symptoms to track. The DON also stated that return-to-work dates should be based on 48 hours after the last symptom, but the line lists did not show the date of last symptom, so there was no evidence that staff returned to work at the appropriate time.
Failure to Provide Activities for a Resident Confined to Room
Penalty
Summary
The facility did not provide an ongoing program of activities designed to meet each resident’s interests and physical, mental, and psychosocial well-being. The deficiency involved one resident who had diagnoses including cerebrovascular disease and aphasia, and whose quarterly MDS showed a BIMS score of 12 indicating moderate cognitive impairment. The resident’s care plan and daily care guideline identified preferred activities such as dice, cards, Protestant church, music programs, outdoor visits, pet visits, and 1:1 interaction, and the activity attendance log showed regular participation before the event in question. Surveyor observation and interviews showed that the resident could not leave her room because her roommate was on isolation for gastroenteritis symptoms, even though the resident herself was not sick and was not on precautions. The resident indicated she missed being able to go to activities, that it was difficult not to leave the room, and that staff did not bring activities into her room. The resident also indicated staff explained why she could not leave her room, but did not ask whether she was okay with not leaving. Staff interviews were inconsistent about the resident’s status. A CNA and RN stated the resident was kept in her room because of the roommate’s illness, while the Activity Director stated the resident had not been able to attend activities recently and had not been offered in-room activities, despite acknowledging the resident liked activities such as dice, cards, music, and anything done in activities. The DON stated the resident should not be isolated to her room and said there may be confusion among staff, but the report documents that the resident had been unable to attend activities and had not received an in-room activity offering during that time.
Antibiotic Stewardship Program Not Implemented
Penalty
Summary
The facility did not establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 supplemental resident and 1 sampled resident. The facility policy stated that the antibiotic stewardship program was part of the infection prevention and control program and included use of CDC NHSN surveillance definitions and updated McGeer criteria, along with monitoring response to antibiotics, laboratory results, and antibiotic orders from consulting, specialty, or emergency providers. For R4, the January 2026 line list identified a UTI with symptoms of increased agitation, hallucinations, and combativeness, and treatment with sulfamethoxazole trimethoprim 800-160 mg twice daily. The urine culture dated 1/30/26 showed Escherichia coli greater than 100,000 CFU/mL. During interview, the DON stated that by following McGeers, R4 did not meet criteria to be treated with an antibiotic and that the facility would typically talk with the provider in such cases, but she could not find documentation of any provider conversation in the medical record. For R98, the November 2025 line list identified a UTI with frequency, decreased urine output, hematuria, and a temperature of 99.3 F, and treatment with Macrobid 100 mg twice daily for 5 days. The urine culture dated 11/16/2025 showed Escherichia coli 50,000 to 60,000 CFU/mL. During interview, the DON stated that the culture did not meet the threshold to treat under McGeers, that the facility would typically talk with the provider about treating an infection without meeting criteria, and that she could not find documentation of any provider conversation in the resident's medical record.
Failure to Offer Pneumococcal Immunization
Penalty
Summary
The facility did not ensure that each resident was offered a pneumococcal immunization unless medically contraindicated or already immunized. During review of 1 of 5 residents, R29 was found not to have been offered the pneumococcal vaccine, and there was no declination or consent for the vaccine in the record. The facility policy dated 6/2025 states residents are to be offered immunizations based on current CDC guidance, screened before receiving immunizations, and have signed consent documented in the medical record. R29 was admitted to the facility and had prior pneumococcal vaccinations documented as Pneumovax 23 on 10/20/1993, Prevnar 13 on 8/11/15, and Pneumovax 23 on 12/12/16. The record did not show that R29 was offered PCV20 or PCV21 five years after the last pneumococcal vaccination per CDC recommendations, and there was no documentation that the next pneumococcal vaccine was offered. On 2/11/26 at 1:04 PM, the DON was interviewed and could not provide documentation that pneumococcal vaccines were offered to R29; after review of the Pneumo Recs Vax recommendation, the DON agreed PCV20 or PCV21 should have been offered.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of sexual abuse involving a resident was reported to the State Agency within the required timeframe. On 11/6/25, the facility received an allegation from an outside agency that a resident had experienced inappropriate touching by a male CNA during a bath. The resident described the CNA as a bald, brown-skinned man with a black beard, and stated that the CNA washed only her breasts while she was naked in the tub, then left the room. The incident was alleged to have occurred during the resident's stay, and the resident had only one bath with a male CNA on 9/23/25. Despite the facility's abuse policy requiring immediate reporting of all alleged violations to the State Agency and other authorities within specified timeframes, the DON and NHA did not report the allegation. They reasoned that the report was received nearly a month after the resident had been discharged and that no staff member perfectly matched the description of the alleged perpetrator. As a result, the facility did not fulfill its obligation to report the abuse allegation as required by policy and regulation.
Failure to Investigate and Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident who had previously been discharged. On 11/6/25, the facility received a report from an outside agency that a resident alleged a male CNA, described as a bald, brown-skinned man with a black beard, had washed only her breasts while she was naked in the tub after dinner one evening. The incident was reported to have occurred during the resident's stay, with the only documented bath with a male CNA taking place on 9/23/25. Despite the facility's abuse policy requiring immediate investigation and reporting of all alleged violations, the facility did not initiate an investigation into the allegation. The Nursing Home Administrator (NHA) and Director of Nursing (DON) stated that, because the allegation was reported nearly a month after the resident's discharge and no staff member perfectly matched the description, they did not believe any action could be taken. As a result, they did not conduct interviews with staff or residents to identify the alleged perpetrator, nor did they assess or interview other residents to ensure their safety. The incident was also not reported to the State Agency as required by facility policy.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving three residents to the State Survey Agency as required by their policy and state regulations. Resident R4 filed a grievance against her roommate, R5, for verbal abuse, including name-calling and throwing items. Staff observed R5's aggressive behavior, which left R4 visibly upset. Despite recognizing these actions as potential abuse, the facility did not report the incident to the state agency within the mandated two-hour timeframe. In another incident, Resident R6 alleged that a male entered her room, removed her stockings and pants without explanation, and left her feeling violated. This was potentially an allegation of sexual misconduct. Although the Director of Nursing (DON) acknowledged the seriousness of the claim and considered reporting it, the previous Nursing Home Administrator advised against filing a report, resulting in the facility's failure to notify the state agency or local law enforcement. The facility's policy mandates immediate reporting of abuse allegations to the state agency and law enforcement within specific timeframes. However, in both cases, the facility did not adhere to these requirements, failing to report the incidents within the stipulated time, thereby not following their own abuse prevention and investigation procedures.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to ensure thorough investigations of alleged violations involving abuse, neglect, exploitation, or mistreatment for three residents. Resident R4 filed a grievance against her roommate, R5, for verbal abuse and throwing items. Staff observed R5's aggressive behavior, including swearing and throwing a cup of soup, which left R4 upset. Despite these observations, the facility did not conduct a comprehensive investigation, as they failed to interview other residents who might have witnessed the behavior or the incident. Resident R6 reported an incident where a male allegedly entered her room, removed her stockings and pants without notice, and left her feeling violated. The facility's investigation was inadequate as it did not include interviews with all staff who had recently worked with R6 or other residents who might have had knowledge of the alleged incident. The facility's policy requires that all allegations of abuse be thoroughly investigated, but this was not adhered to in R6's case. The facility's policy on abuse prevention and investigation mandates that all allegations of abuse, neglect, or mistreatment be investigated and reported according to state and federal laws. However, in both cases involving R4 and R6, the facility did not follow its own policy, as the investigations were not thorough, and the necessary interviews were not conducted. This lack of thorough investigation constitutes a deficiency in the facility's handling of abuse allegations.
Improper Air-Drying of Plates in Kitchenette
Penalty
Summary
The facility failed to ensure that kitchen staff properly air-dried plates before storing them, which could increase the risk of foodborne illness. During an observation and interview in the kitchenette serving area on the Oak hallway, the Dietary Manager confirmed that three plates were found to be wet and had been placed in the cabinet for use. The Dietary Manager acknowledged that the plates were put away wet and should have been left out to air dry longer. The Oak hallway had a census of 15 residents. Similarly, in the kitchenette serving area on the Evergreen hallway, four plates were found to be wet and stored in the cabinet. The Dietary Manager again confirmed that these plates should have been left out to air dry longer. The Evergreen hallway had a census of 16 residents. This deficiency had the potential to affect 31 of 31 residents residing on these two hallways.
Failure to Post Complete Daily Staffing Information
Penalty
Summary
The facility failed to ensure that the daily posted staffing information met the required standards, affecting all 71 residents. During an observation and interview, it was found that the staffing assignment sheet, located at the nursing station, only included the facility name, staff names, and the current date. The Director of Nursing (DON) confirmed that the sheet lacked essential details such as the census, number of Certified Nurse Aides (CNAs), Licensed Practical Nurses (LPNs), Registered Nurses (RNs), and the number of working hours. Additionally, the DON and the Administrator both acknowledged the absence of a policy for posting nurse staffing information.
Failure to Ensure Proper Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that a resident was clinically assessed and authorized to self-administer medications. The resident, who was observed with medications left at her bedside, had a cognitive status indicating she was intact, as per her most recent Minimum Data Set (MDS). However, her medical record lacked a Self-Administration Assessment, and her care plan did not include any indication that she was to self-administer medications. Additionally, there was no physician order authorizing self-administration of medications for this resident. During the survey, it was observed that the resident's morning medications were left unattended on her bedside table. The resident confirmed that this was a regular practice and that she usually took her medications after breakfast. A Licensed Practical Nurse (LPN) admitted to leaving the medications at the bedside without a self-administration order. The Director of Nursing (DON) confirmed that medications should not be left unattended in a resident's room without a self-administration order, which the resident did not have.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to promptly document, investigate, and resolve grievances for a resident, identified as R1, as required by their grievance policy. R1's spouse expressed multiple concerns regarding R1's care, including issues with activities of daily living (ADLs), fluid intake, soiled bed linens, and staffing. Despite these concerns being communicated to the facility's Social Worker (SW) and Director of Nursing (DON), they were not documented as grievances, nor were they investigated or resolved as such. The facility's grievance policy outlines that grievances should be documented, investigated, and resolved with a written decision, but this process was not followed for R1's spouse's concerns. Interviews with the facility's SW and DON revealed a misunderstanding or misapplication of the grievance process. The SW, who is also the grievance officer, indicated that she encourages residents and family members to address concerns before they escalate to grievances, and she did not consider R1's spouse's concerns as grievances. The DON acknowledged that R1's spouse's concerns could be considered grievances but admitted they were not documented. Both the SW and DON reported that the facility had zero grievances, indicating a failure to recognize and address the concerns raised by R1's spouse as formal grievances.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sauk City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heartland Country Village | 9.4 mi | — | 0 | 0 |
| Dove Healthcare - Lodi | 11 mi | ★★★★★ | 11 | 0 |
| Complete Care At Jefferson Meadows Llc | 13.9 mi | ★★★★★ | 0 | 0 |
| Waunakee Valley Senior Living | 15.1 mi | ★★★★★ | 15 | 0 |
| Middleton Village Nursing And Rehab | 17.9 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.