Maplewood of Sauk Prairie

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, are reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 3 Residents reviewed. R1 made an allegation of sexual abuse, and the facility did not report this to law enforcement. This is evidenced by:The Facilities Policy and Procedure entitled Abuse, Neglect, and Exploitation dated 06/2025, documents in part: . Sexual Abuse is non-consensual sexual contact of any type with a resident .VII. Reporting/Response A. Facility will have written procedures that include: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (R3) reviewed for wandering and elopement potential out of a sample of 6 Residents. R3 was identified as having a behavior of exit seeking. R3's elopement risk assessment was not accurate or complete and R3's care plan did not contain interventions or goals related to exit seeking. When R3 eloped, staff did not follow the facility policy and procedures for a missing resident, for wandering/elopement, and for a code alert. The facility's failure to assess, care plan, and supervise a resident who was at risk for elopement, created a finding of immediate jeopardy that began on 3/16/26. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on 6/23/26 at 1:21 PM. [...]

Inspectors wroteBased on interview and record review, the facility did not include as part of its QAPI (Quality Assurance and Performance Improvement) program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for 5 of 5 randomly sampled Certified Nursing Assistants (CNA). This had the potential to affect all residents who reside in the facility. CNA J, CNA K, CNA L, CNA M, and CNA N did not receive and have documented mandatory yearly QAPI in-service training. Evidenced by:The Facility Assessment, last reviewed 1/2026, states in part:. Staff Training/Education and Competencies/Recruitment/Retention: 3.4 Staff will be provided with training and education to assure competent care is provided to residents in the facility. [...]

Inspectors wroteBased interview and record review, the facility did not include as part of its compliance and ethics program an effective way to communicate the program's standards, policies, and procedures through a training program for 5 of 5 CNAs (Certified Nursing Assistants) randomly sampled. This had the potential to affect all residents who reside in the facility. CNA J, CNA K, CNA L, CNA M, and CNA N did not receive and have documented yearly compliance and ethics in-service training. Evidenced by:The Facility Assessment, last reviewed 1/2026, states in part:. Staff Training/Education, and Competencies/Recruitment/Retention: 3.4 Staff will be provided with training and education to assure competent care is provided to residents in the facility. Training/education will be provided upon hire with the orientation process, routinely on a yearly basis and as needed if issues arise. [...]

Inspectors wroteBased interview and record review, the facility did not ensure the continuing competence of nurse aides must be no less than 12 hours per year and did not include dementia management training and resident abuse prevention training for 5 of 5 CNAs (Certified Nursing Assistants) randomly sampled. This had the potential to affect all residents who reside in the facility. CNA J, CNA K, CNA L, CNA M, and CNA N did not receive and have documented yearly 12 hours of continuing education including dementia management and abuse prevention training. Evidenced by:The Facility Assessment, last reviewed 1/2026, states in part:. Staff Training/Education, and Competencies/Recruitment/Retention: 3.4 Staff will be provided with training and education to assure competent care is provided to residents in the facility. [...]

Inspectors wroteBased on interview and record review, 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. This has the potential to affect the census (76). The facility staff line lists do not monitor specific symptoms. The facility staff line lists do not record dates of last symptoms or return to work dates. Evidenced by:The facility policy, entitled Infection Control Policy, dated 6/2025, states, in part: . Policy: It is the policy of Maplewood of Sauk Prairie to ensure the Infection Control Program is designed to provide a safe, sanitary, and comfortable environment that helps prevent the development and transmission of disease and infection. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This has the potential to affect 1 of 2 residents (R49) reviewed for activities. Per Surveyor interview with R49 and staff, R49 could not leave her room for activities due to her roommate being on isolation for gastroenteritis symptoms. R49 was not offered any activities in her room during this time. R49 participated in activities regularly prior. Evidenced by: The facility policy entitled Activities Policy, dated 6/2025, states, in part: . It is the policy of Maplewood of Sauk Prairie to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. [...]

Inspectors wroteBased on interview and record review the facility did not establish an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 Supplemental Resident (R98) and 1 of 1 sampled resident (R4). R4 and R98 were treated with antibiotics without meeting McGeers Criteria. The facility did not have an antibiotic stewardship conversation with R4 and R98's Provider. Evidenced by:The facility's policy entitled Antibiotic Stewardship Program Policy, dated 7/2025, states, in part: . Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Policy Explanation and Compliance Guidelines: .4. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized for 1 of 5 residents (R29) reviewed for immunizations. R29 was not offered the pneumococcal vaccine. The facility does not have a declination or consent for the pneumococcal vaccine for R29. Evidenced by:The facility policy, titled Immunization/Vaccination Policy, dated 6/2025, states, in part: . Policy: It is the policy of Maplewood to minimize the risk of acquiring, transmitting or experiencing complications from infectious disease by offering our residents, staff members, and volunteer workers immunization/vaccination against such diseases. Policy Explanation and Compliance Guidelines: .2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 1 of 1 abuse allegations involving a resident (R1). On 11/6/25, an allegation of sexual abuse toward R1 from a staff member was reported to the facility and the facility did not report the allegation of abuse to the State Agency. The facility's abuse policy states, in part:*An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.*The facility will have written procedures that include: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are thoroughly investigated for 1 of 3 residents (R1) reviewed for abuse. On 11/6/25, an allegation of sexual abuse toward R1 from a staff member was reported to the facility and the facility did not investigate the allegation. The facility's abuse policy states, in part:*An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.*The facility will have written procedures that include: reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the State Survey Agency for 3 of 3 residents reviewed for abuse (R4, R5, and R6). R4 filed a grievance regarding R5 verbally abusing R4. Staff observed R5 throw a cup of soup across the room and swear. Then staff observed R4, who was in the room at the time to be in an upset state. The facility did not report the resident to resident allegation/verbal abuse to the state agency. R6 voiced an allegation of a male coming in her room and attacking her, pulling off her stockings and pants without notice, and leaving her to feel violated. The facility failed to report this allegation of abuse to the state agency.

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are thoroughly investigated for 3 of 3 residents reviewed for abuse (R4, R5, and R6). R4 filed a grievance regarding R5 verbally abusing R4. Staff observed R5 throw a cup of soup across the room and swear. Then staff observed R4, who was in the room at the time to be in an upset state. The facility did not conduct a thorough investigation including interviewing other residents who may have knowledge of R5's behavior or the incident. R6 voiced an allegation of a male coming into her room and attacking her, pulling off her stockings and pants without notice, and leaving her to feel violated. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure kitchen staff properly air-dried plates prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 31 of 31 residents who resided on 2 of 4 hallways out of a total census of 71.

Inspectors wroteBased on observation, interviews, and staffing document review, the facility failed to ensure daily posted staffing requirements were in place to include the census, number of staff, and number of staff hours for 71 of 71 residents residing at the facility. This failure had the potential to affect the ability of residents and families to view the staffing information daily.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 resident (R3) observed during screening. R3 was observed to have her medications left at the bedside. This is evidenced by: The facility's policy titled Addendum: Self Administration of Medications, undated, states in part, . Policy: Prior to allowing a resident to administer medications without direct supervision by licensed nursing staff, the resident's ability to do so will be assessed and doctor's order will be obtained . 2. Physician will be updated with resident's desire to administer medications without direct staff supervision, following set up of the medications by nursing. [...]

Inspectors wroteBased on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 3 residents reviewed for grievances (R1). The facility's Social Worker (SW) documented that R1's spouse had concerns with Activities of Daily Living (ADLs), fluid intake, soiled bed linens, and staffing; these concerns were not documented as grievances, investigated as grievances, or had a resolution provided to R1's spouse. Evidenced by: The facility's policy titled Grievance Policy and Procedure no date, states in part .Grievances can include things such as concerns about care and treatment provided or not provided, behavior of staff or other residents and any concerns related to the resident's stay in the facility .3. To file a grievance, the resident and/ or resident representative shall contact the facility grievance officer(s). [...]

Inspectors wroteBased on interview and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 3 residents reviewed (R1) for falls. R1 had multiple falls while at the facility. Facility staff did not update the care plan after each fall, notify the physician promptly after a fall with a head injury, and complete and document neurological checks timely. This is evidenced by: The facility's policy titled Fall Prevention and Assistive devices for Fall Prevention last updated on [DATE], states in part: .Procedure: 1. Each resident will have a fall risk assessment tool completed (located within [EHR (Electronic Health Record)] upon admission, quarterly, with a significant change, following a fall and at the nurses' discretion .3. Each resident who is at risk for falls based on the falls assessment tool will have a falls care plan .5. [...]

Inspectors wroteExample 3 The facility policy entitled, Infection Control Policy and Procedure, updated 6/23, states in part: . Hand Hygiene: Consistent and proper hand hygiene practices are critical in preventing the spread of infection by preventing the spread of germs, including multi-drug resistant organisms. Hand hygiene means cleaning your hands by means of hand washing (using soap and water) or alcohol-based hand sanitizer (also referred to alcohol-based hand rub or ABHR) . 1. The following is a list of some situations that require hand hygiene. Note: there are many situations which require hand hygiene, and it is not possible to list all these situations . g. before and after handling food. (Hand washing with soap and water). h. Before and after assisting a resident with meals . p. Before donning and after doffing gloves and after removing PPE (Personal Protective Equipment) . 2 . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 out of 4 sampled residents (R63, R326, and R32). R63, R326 and R32 had multiple medication errors related to not receiving medication timely as ordered by the physician. This is evidenced by: The facility policy entitled, Medication Administration Policy and Procedure, dated July 2022, states, in part: . Policy: Medication will be delivered to resident in accordance with the Physician's orders, manufacturer's specifications regarding preparation and administration and the accepted professional standards and principles. Procedure: Medication Administration Times ~ AM: 7am to 10:30am ~ Midday: 11am to 2:30pm ~ PM: [...]

Inspectors wroteBased on interview and record review, the facility must develop policies and procedures to ensure that residents and/or resident responsible party receives education regarding the benefits and potential side effects of the immunization prior to offering the immunization and documentation is noted in the medical record on whether the resident received or declined the immunization, this affected 2 of 5 residents (R20 and R1) reviewed for immunizations of 18 sampled residents. R20 did not have a pneumococcal immunization offered and no documentation. R1 did not have a pneumococcal immunization offered and no documentation. This is evidenced by: The facility's Immunization Policy and Procedure, dated 10/22, states, in part: . Policy: [...]