Cycle 1
Health 2024-09-26 · Fire 2024-09-26
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Sauk City, WI
Maplewood Of Sauk Prairie
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
245 Sycamore St, Sauk City, WI
(608) 643-3383
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
107
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.76
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.16
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.61
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
4.68
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,059
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.02
Composite VBP score used to determine payment impact.
Payment multiplier
1.0065
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.23
Baseline 17.39% · Performance 19.01% · Measure score 5.23 · Achievement 5.23 · Improvement 0
Healthcare-associated infections
4.63
Baseline 5.25% · Performance 6.45% · Measure score 4.63 · Achievement 4.63 · Improvement 0
Total nurse turnover
5.90
Baseline 39.81% · Performance 39.56% · Measure score 5.90 · Achievement 5.90 · Improvement 0
Adjusted total nurse staffing
5.05
Baseline 4 hours · Performance 4.52 hours · Measure score 5.05 · Achievement 5.05 · Improvement 2.40
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.79% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 6.72% · Lower 95% interval 5.74% |
| Discharge to community | 60.41% |
50.57%
9.8 pts better
|
Better than the National Rate · Eligible stays 122 · Observed rate 60.66% · Lower 95% interval 52.84% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 134 · Denominator 134 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 134 |
| Discharge self-care score | 57.63% |
53.69%
3.9 pts better
|
Numerator 68 · Denominator 118 |
| Discharge mobility score | 73.73% |
50.94%
22.8 pts better
|
Numerator 87 · Denominator 118 |
| Pressure ulcers or injuries, new or worsened | 2.24% |
2.29%
About the same
|
Numerator 3 · Denominator 134 · Adjusted rate 3.35% |
| Healthcare-associated infections requiring hospitalization | 6.45% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 4.05% · Lower 95% interval 4.15% |
| Staff COVID-19 vaccination coverage | 0.54% |
8.2%
7.7 pts worse
|
Numerator 1 · Denominator 184 |
| Staff flu vaccination coverage | 32.56% |
42%
9.4 pts worse
|
Numerator 84 · Denominator 258 |
| Discharge function score | 73.73% |
56.45%
17.3 pts better
|
Numerator 87 · Denominator 118 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 76 · Denominator 76 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 34.43% |
25.2%
9.2 pts better
|
Numerator 21 · Denominator 61 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.2
0.9 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.2%
0.6 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 7.3% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.5% |
5.0%
0.5 pts worse
|
11.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 1.7% · Q3 5.6% · Q4 6.5% · 4Q avg 5.5% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
4.9%
1.2 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.1% · Q3 2.4% · Q4 4.5% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
16.6%
6.2 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 12.0% · Q3 13.0% · Q4 13.6% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.8% |
16.7%
8.1 pts worse
|
16.7%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 28.2% · Q3 24.2% · Q4 21.9% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.7% |
21.1%
2.6 pts worse
|
16.3%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 22.9% · Q3 32.1% · Q4 16.8% · 4Q avg 23.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.7% |
17.3%
5.4 pts worse
|
14.9%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 19.1% · Q3 34.9% · Q4 14.0% · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
2.3%
1.9 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
3.0%
0.8 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 1.9% · Q4 5.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.8% |
25.5%
6.3 pts worse
|
19.8%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.4% · Q2 23.8% · Q3 38.5% · Q4 31.3% · 4Q avg 31.8% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
5.5%
3.7 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.9% · Q4 3.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
86.8%
12.5 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.1% · Q4 98.4% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.0% |
15.0%
2 pts worse
|
12.0%
5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 15.9% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.3%
1.4 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 2.9% · Q3 1.2% · Q4 1.2% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.2% |
82.2%
10 pts better
|
79.7%
12.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
22.7%
1.4 pts worse
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 19.3% · Expected 19.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-24 · Fire 2023-08-24
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-06-21 · Fire 2022-06-21
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-26
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-21
E · Potential for more than minimal harm
2024-09-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-21
E · Potential for more than minimal harm
2024-09-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-26
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Not marked corrected
D · Potential for more than minimal harm
2024-09-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-21
F · Potential for more than minimal harm
2023-08-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-24
F · Potential for more than minimal harm
2023-08-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-09-24
E · Potential for more than minimal harm
2023-08-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-09-24
E · Potential for more than minimal harm
2023-08-24
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Not marked corrected
E · Potential for more than minimal harm
2023-08-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-24
E · Potential for more than minimal harm
2023-08-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-24
E · Potential for more than minimal harm
2023-08-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-24
E · Potential for more than minimal harm
2023-08-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-24
E · Potential for more than minimal harm
2023-08-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-24
D · Potential for more than minimal harm
2023-08-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-24
F · Potential for more than minimal harm
2022-06-21
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-07-21
F · Potential for more than minimal harm
2022-06-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-22
F · Potential for more than minimal harm
2022-06-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-07-21
E · Potential for more than minimal harm
2022-06-21
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-07-21
E · Potential for more than minimal harm
2022-06-21
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Not marked corrected
E · Potential for more than minimal harm
2022-06-21
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-07-21
E · Potential for more than minimal harm
2022-06-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-06-21
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-06-21
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-06-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-06-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-07-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-11-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-02-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-17
D · Potential for more than minimal harm
2025-02-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-17
E · Potential for more than minimal harm
2024-09-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-21
C · Minimal harm
2024-09-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-06-20
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-07-08
D · Potential for more than minimal harm
2024-06-20
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-07-08
D · Potential for more than minimal harm
2024-01-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-24
F · Potential for more than minimal harm
2023-08-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-24
D · Potential for more than minimal harm
2023-08-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-24
D · Potential for more than minimal harm
2023-08-24
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-24
F · Potential for more than minimal harm
2022-06-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-06-21
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-07-21
D · Potential for more than minimal harm
2022-06-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-07-21
Penalties and ownership
What sits behind the stars
Ownership
Arrow Cpas LLC
Operational/Managerial Control · Organization
Benish, Ron
5% Or Greater Direct Ownership Interest · Individual
Ecker, Carole
5% Or Greater Direct Ownership Interest · Individual
Ecker, Carole
Operational/Managerial Control · Individual
Ederer, Leah
Operational/Managerial Control · Individual
Galarnyk, Gregory
5% Or Greater Direct Ownership Interest · Individual
Galarnyk, Gregory
Corporate Director · Individual
Galarnyk, John
5% Or Greater Direct Ownership Interest · Individual
Kraemer, Kevin
5% Or Greater Direct Ownership Interest · Individual
Melli, Joseph
5% Or Greater Direct Ownership Interest · Individual
Nursing Homes Company
5% Or Greater Direct Ownership Interest · Organization
Reuschlein, Steven
5% Or Greater Direct Ownership Interest · Individual
Snyder, Michaeline
5% Or Greater Direct Ownership Interest · Individual
Wilkes, Carol
Operational/Managerial Control · Individual
Wilkes, Carol
Corporate Director · Individual
Wipfli Llp
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Dove Healthcare - Lodi
Lodi, WI
2-star overall rating with 2-star inspections with $24,183 in total fines with 2 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
#2
Complete Care at Jefferson Meadows LLC
Baraboo, WI
3-star overall rating with 2-star inspections with $73,275 in total fines with 14 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Waunakee Valley Senior Living
Waunakee, WI
3-star overall rating with 3-star inspections with $41,501 in total fines with 5 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
Jump out