Marquardt Memorial Manor
Marquardt Memorial Manor in Watertown, WI — inspection on October 6, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
denied asking if APS-F was aware that R1 requested an advocate or representative. NHA-A stated APS-F made it clear that R1 was R1's own decision maker. SW-E and NHA-A indicated no further action had been taken to fulfill R1's request to complete a new POA document.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Marquardt Memorial Manor
1020 Hill St Watertown, WI 53098
SUMMARY STATEMENT OF DEFICIENCIES
10/6/25 and stated if the allegation was reported sooner, DON-B would have initiated an investigation.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Marquardt Memorial Manor
1020 Hill St Watertown, WI 53098
SUMMARY STATEMENT OF DEFICIENCIES
During the provision of wound care, LPN-C and CNA-D's clothing was in contact with R1's environment, including R1's bed linens.
During the observation, LPN-C removed gloves and did not sanitize hands after completing the soiled portion of wound care. LPN-C then put a clean dressing on R1's wound and donned a glove on the left hand. LPN-C's bare right hand was in contact with R1's skin, linens, and environment while using a roll of tape. LPN-C put two dressing packages on R1's bedside table that were not used. LPN-C retrieved clean gloves from the treatment cart and did not complete hand hygiene after removing the left glove. LPN-C placed clean gloves on R1's bedside table, donned a glove on the right hand, and assisted R1 onto the left side. LPN-C removed a used absorbent pad, removed the right glove, unrolled tape, and stuck the tape to a second bedside table. LPN-C donned a clean glove, put a dressing on R1's wound, and taped the dressing in place. LPN-C then moved R1's electronic tablet, put a clean brief on R1, assisted R1 onto the right side, taped the dressing in place, and fastened R1's brief. LPN-C then removed the glove, sanitized hands, and put a clean sheet over R1. On 10/6/25 at 10:59 AM, LPN-C rolled the treatment cart from R1's room to the nurses' station. LPN-C donned gloves and disinfected the bandage scissors, wound cleanser, and top of the cart with hydrogen peroxide-based wipes.On 10/6/25 at 11:03 AM, Surveyor interviewed LPN-C who thought gowns were worn during wound care and stated LPN-C was nervous. LPN-C verified the treatment cart is used for all residents and stated LPN-C sanitizes the cart after it leaves each room. LPN-C was not aware of the sanitizing product's dwell time (amount of time that a disinfecting product needs to stay wet on an item in order to properly disinfect) of one minute. LPN-C verified LPN-C put the bandage scissors and wound cleanser in the cart before ensuring a minute had passed. LPN-C verified R1's wound care items were in the treatment cart and stated LPN-C should have put the items in a treatment bag.
Surveyor and LPN-C verified the EBP sign outside R1's door indicated staff shoud wear a gown and gloves during high-contact resident care, including wound care. LPN-C stated LPN-C should have worn a gown because R1 had an open wound and a Foley catheter.On 10/6/25 at approximately 11:30 AM, Surveyor interviewed CNA-D.
When asked if CNA-D wears a gown during cares for R1, CNA-D stated, Sometimes, sometimes not. CNA-D then stated, We just forgot to put one on, I think.
On 10/6/25 at 3:00 PM, Surveyor interviewed Director of Nursing (DON)-B who veriifed LPN-C and CNA-D should have worn gowns during wound care for R1. DON-B also indicated LPN-C should have taken the amount of gauze needed and placed the gauze on a clean surface with a barrier.
When Surveyor informed DON-B of missed hand hygiene opportunities and cross-contamination of wound care products, clothing, and the environment, DON-B stated DON-B had educated staff on infection control. DON-B verified items used in R1's room should not be used on other residents, including the tape or gauze.
Facility ID: