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:
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.