Maplewood of Sauk Prairie

In the surveyor’s words

From the most serious findings on record at Maplewood of Sauk Prairie, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 2, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF678Jul 6, 2021

  Based on interview and record review the facility failed to immediately provide basic life support, including CPR (Cardiopulmonary Resuscitation), to a resident requiring emergency care and failed to immediately notify emergency medical personnel for 1 of 3 total sampled Residents (R1). R1 was found pulseless and not breathing on [DATE]. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff failed to immediately initiate CPR and immediately contact emergency medical personnel. Facility failure to immediately begin cardiopulmonary resuscitation and immediately summon emergency medical personnel, created a finding of immediate jeopardy that began on [DATE]. […]

• Actual harm, isolatedF684Aug 19, 2026

  Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice (N6 Wisconsin Nurse Practice Act) to meet each resident's physical needs for 1 of 3 sampled residents (R1). R1 experienced a change in condition with no bowel movements for five (5) days which lead to a distended abdomen, nausea and vomiting, severe constipation, ileus (a condition where the intestine slows down or stops pushing food and waste through the body) requiring a nasogastric tube (a tube passed through the nose and into the stomach for decompression) and aggressive bowel regimen. […]

• Actual harm, isolatedF760Aug 19, 2026

  Based on interview and record review, the facility did not ensure that residents are free of any significant medication errors for 1 of 1 resident (R3) reviewed for medication errors out of a sample of 3.R3 had sliding scale orders for her insulin lispro administration. R3's PM blood sugar reading fell outside of the order parameters, but R3 was administered insulin lispro without a provider being contacted one hour before dinner was scheduled to start. This resulted in actual harm when R3's became hypoglycemic, and after multiple failed interventions, was required to go to the ED (Emergency Department) for IV (intravenous) fluids.This is evidenced by:The facility's policy, titled Insulin Administration Policy, implemented 02/2011, states in part: Policy: It is the policy.to provide timely… […]

• Actual harm, isolatedF600Jan 27, 2021

  Based on interview and record review, the facility failed to ensure each resident is free from verbal abuse by a registered nurse for 1 of 7 residents reviewed for abuse (R1). Findings include: The facility's abuse policy states: -All residents have the right to be free from any type of mistreatment or abuse. The facility will put into place policies and procedures that assure the residents of the facility are safe, comfortable and free from abuse. -The facility will assure through screening, training, and identification, that all residents are free from abuse. This facility will not tolerate abuse, neglect, or misappropriation of a resident's property. All allegations of abuse, neglect, or misappropriation and any injury of which the source cannot be identified will be investigated. […]