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Complaint Investigation

Marquardt Memorial Manor

October 6, 2025 · Watertown, WI · 1020 Hill St
Citations 3
CMS Rating 1/5
Beds 140
Provider ID 525543
Healthcare Facility
Marquardt Memorial Manor
Watertown, WI  ·  View full profile →
Inspection Summary

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.

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Inspection Findings

FF0578
Resident Rights Deficiencies
Potential for More Than Minimal Harm

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:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Watertown, WI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Marquardt Memorial Manor or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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