Marquardt Memorial Manor

blinds closed. R68 did not have any sensory objects. R68's TV was on the facility's informational

sensory objects. R68's TV was on the facility's informational channel.

Surveyor noted several staff

Surveyor observed Certified Nursing Assistant (CNA)-F provide incontinence care for R68. CNA-F did not interact with R68 aside from providing care. CNA-F left R68's room without providing R68 with any sensory items.On 2/24/26 at 2:10 PM, Surveyor observed R68 in bed with the lights turned down and the blinds closed. R68 did not have any sensory objects. R68's TV was on the facility's informational channel.On 2/24/26 at 1:44 PM, Surveyor interviewed CNA-F who stated staff get R68 up depending on the day. CNA-F indicated R68 had not been getting out of bed recently due to having loose stools.On 2/24/26, Surveyor reviewed the facility's activity calendar for 2/24/26 and noted the following scheduled activities: 9:15 AM Daily chronicles and current events; 9:45 AM Greet your neighbor; 10:00 AM Chips and salsa; 10:30 AM Dice; 1:15 PM Music videos; 1:30 PM Happy hour/birthday party; 3:00 PM Cards; 3:30 PM Mail pass; 7:00 PM Bucks basketball.Surveyor did not observe R68 participate in any activities. R68's medical record did not indicate R68 was invited to any activities.On 2/25/26 at 8:47 AM, Surveyor observed R68 in bed fidgeting with the bed sheet and pulling it over R68's face. R68 did not have any sensory items. R68's TV was on the facility's informational channel.On 2/25/26 at 9:02 AM, Surveyor interviewed CNA-Q who stated staff use a lift to get R68 out of bed. CNA-Q was not sure when R68 had last gotten out of bed.On 2/25/26 at 10:02 AM, Surveyor observed R68 in bed. A fidget toy was on the floor next to the bed.

The lights were turned down and the blinds were closed. R68 did not have any other sensory items. R68's TV was on the facility's informational channel.On 2/25/26, Surveyor reviewed the facility's activity calendar and noted the following scheduled activities: 9:45 AM Music videos; 10:00 AM [NAME] basketball/monopoly exercises; 10:30 AM Bocce ball; 11:15 AM Activity talk; 1:15 PM Trivia; and 1:30 PM Beanbag fishing.

Surveyor did not observe R68 go to any activities. R68's medical record did not indicate R68 was invited to any activities. On 2/25/26 at 12:04 PM, Surveyor interviewed Life Enrichment Assistant (LEA)-P who stated staff typically invite/bring R68 to activities, even to passively participate, when R68 is in R68's wheelchair. LEA-P stated nursing staff are responsible for getting R68 into the wheelchair. LEA-P reviewed R68's activity attendance for the last 6 months and indicated R68 had attended only 12 activities. LEA-P verified R68 did not attend any activities from 2/23/26 to 2/25/26.On 2/25/26 at 11:20 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B regarding R68's specialized services. NHA-A verified staff should get R68 out of bed to provide opportunities for socialization and confirmed staff should be provide R68 with sensory items throughout the day when R68 is in bed.

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actions that can be measured.

staff interview and record review, the facility did not ensure a comprehensive care plan was

for gastrostomy (G)-tube management for seizure rescue medication administration. R63's care plan did not include G-tube care. R12 had an order for the use of continuous oxygen to maintain optimal oxygen saturation rates. R12's care plan did not indicate R12 used continuous oxygen.

Findings include: The facility's policy and procedure for Individual Care Plan Conferences, dated 2/21/24, indicates: A written care plan is developed and maintained directing a course of comprehensive care specific to the individual's needs from all appropriate disciplines and the individual's primary care provider . 1. On 2/24/26, Surveyor reviewed R63's medical record. R63 was admitted to the facility on [DATE] and had diagnoses including hemiplegia, Arnold Chiari Syndrome, epilepsy, dysphagia, and depression. R63's Minimum Data Set (MDS) assessment, dated 1/15/26, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R63 had significant cognitive impairment.

R63 had a Guardian for healthcare decisions. R63's medical record indicated R63 had a G-tube to provide rescue medication for seizures and contained the following orders: ~ Exchange Mic-Key button G-tube every 3 months.

Size 16 French, 3.5 centimeter (cm) length with 5 milliliter (ml) balloon.

Every day shift every 3 months starting on the 14th for 1 day for G-tube (dated 1/14/26) ~ G-tube care: Cleanse skin with gentle soap and water.

Pat dry.

Apply a thin strip of Silvercel antimicrobial alginate around insertion site.

Apply drain sponge over Silvercel in evening, every day (dated 4/11/25) ~ Flush G-tube with 30 cubic centimeters (ccs) free water flush twice daily (dated 4/11/25) R63's care plan did not contain goals or interventions to address maintenance of the G-tube or the potential for impaired skin integrity. On 2/25/26 at 12:27 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who indicated LPN-D followed the Medication Administration Record (MAR) for R63's G-tube orders. LPN-D verified R63's care plan should address G-tube maintenance. On 2/25/26 at 1:06 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff are expected to develop a care plan intervention for skin integrity to address R63's G-tube placement and maintenance. 2. On 2/24/26, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including quadriplegia, dysarthria, hypoxemia, dependence on supplemental oxygen, and epilepsy. R12's MDS assessment, dated 1/28/26, had a BIMS score of 10 out of 15 which indicated R12 had moderate cognitive impairment. R12 had an activated Power of Attorney for Healthcare (POAHC) to assist with healthcare decisions. R12's medical record contained the following oxygen orders: ~ Change humified air canister as needed (dated 2/11/25) ~ Change oxygen tubing - Date tubing every night shift every 7 days (dated 2/11/25) ~ Cleanse top of left ear/crease behind ear with soap and water.

Pat dry.

Apply non-sting skin prep to area.

Ensure foam is intact to nasal cannula to prevent further skin injury two times daily (dated 10/20/25) ~ Oxygen at 1-5 liters per nasal cannula to keep oxygen saturation greater or equal to 90% every shift (dated 5/12/25) R12's care plan did not contain goals or interventions to address R12's dependence on oxygen and potential for airway disturbance. On 2/25/26 at 12:24 PM, Surveyor interviewed Medication Technician (MT)-E who indicated MT-E would ask the nurse or refer to R12's care plan for information regarding oxygen use. On 2/25/26 at 1:04 PM, Surveyor interviewed DON-B who indicated staff should refer to a resident's MAR and Treatment Administration Record (TAR) for oxygen orders and confirmed residents who use oxygen should have a care plan to address airway needs.

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Marquardt Memorial Manor 1020 Hill St Watertown, WI 53098

catheter care, and appropriate care to prevent urinary tract infections.

observation, staff interview, and record review, the facility did not ensure timely incontinence care

checked and changed every 2 to 3 hours or as needed. On 2/24/26, staff did not check and change R68 for 3 hours and 21 minutes. R68 was in a brief that had soaked through to a Chux pad underneath R68 and R68's room smelled of urine.

Findings include: The facility's undated Activities of Daily Living (ADL) Protocol indicates: Toileting should be offered every 2 to 3 hours and incontinence care should be provided as needed. On 2/24/26, Surveyor reviewed R68's medical record. R68 was admitted to the facility on [DATE] and had diagnoses including spastic quadriplegia cerebral palsy, epilepsy, severe intellectual disability, cachexia, and weakness. R68's most recent Minimum Data Set (MDS) assessment, dated 2/13/26, indicated R68 had severe cognitive impairment, was always incontinent of bladder and bowel, and required staff assistance for incontinence cares. A care plan, revised 2/14/26, indicated R68 had a history of urinary tract infections (UTIs) and should be checked and changed every 2 to 3 hours and as needed. On 2/24/26 at 10:03 AM, Surveyor observed R68 in bed.

Surveyor noted a strong urine odor in the room.

Surveyor continuously observed R68 from 10:03 AM to 1:24 PM (3 hours and 21 minutes) and noted several staff walked past R68's room but did not enter to see if R68 was incontinent and needed to be changed. On 2/24/26 at 1:24 PM, Surveyor observed Certified Nursing Assistant (CNA)-F enter R68's room and provide incontinence care. CNA-F verified R68 was incontinent of urine and stated urine had soaked into a washable Chux pad beneath R68. CNA-F provided R68 with a clean brief and Chux pad. On 2/24/26 at 1:38 PM, Surveyor interviewed CNA-F who stated CNA-F tries to check and change R68 every two hours, however, it does not happen at times. CNA-F stated CNA-F last checked R68 at approximately 10:00 AM and R68 was dry. CNA-F stated R68 did not routinely use the call light to make R68's needs known. On 2/24/26, Surveyor reviewed R68's CNA charting and noted R68 was provided incontinence care at 8:49 AM. On 2/25/26 at 11:08 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R68 should be checked and changed every two to three hours and should not have been left in a wet brief for over three hours.

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provide appropriate care for a resident with a feeding tube.

observation, staff interview, and record review, the facility did not ensure a gastrostomy (G)-tube

rescue medication for seizures. R63 had an order to flush the G-tube for patency. R63's G-tube was not flushed in accordance with the order.

Findings include: The facility's General Guidelines for Administering Medication via Enteral Tube policy, dated 5/2018, indicates: The facility assures the safe and effective administration of enteral formula and medication via enteral tubes .D.

Enteral tubes are flushed with at least 15 milliliters (ml) of purified or sterile water before administering medication, between each medication, and after all medications have been administered . On 2/24/26, Surveyor reviewed R63's medical record. R63 was admitted to the facility on [DATE] and had diagnoses including hemiplegia, Arnold Chiari Syndrome, epilepsy, dysphagia, and depression. R63's Minimum Data Set (MDS) assessment, dated 1/15/26, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R63 had severe cognitive impairment. R63 had a Guardian for healthcare decisionsR63's medical record indicated R63 had a G-tube to provide rescue medication for seizures.

R63 had the following orders: ~ Exchange Mic-Key button G-tube every 3 months.

Size 16 French, 3.5 centimeters (cm) length with 5 milliliter (ml) balloon.

Every day shift every 3 months starting on the 14th for 1 day for G-tube (dated 1/14/26) ~ G-tube care: Cleanse skin with gentle soap and water.

Pat dry.

Apply a thin strip of Silvercel antimicrobial alginate around the insertion site.

Apply drain sponge over Silvercel in evening, every day (dated 4/11/25) ~ Flush G-tube with 30 cubic centimeters (ccs) of free water twice daily (dated 4/11/25) R68's Medication Administration Record (MAR) indicated R68's G-tube was not flushed on the 1/25/26, 2/22/26, 2/23/26, and 2/24/26 AM shifts. On 2/25/26 at 1:06 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should provide flushes as ordered.

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medications were in place for 1 resident (R) (R7) of 9 sampled residents.R7 was prescribed morphine

Staff did not monitor R7 for adverse reactions or side effects of the high-risk medications.Findings include: The facility's Miscellaneous Special Situations policy, dated May 2018, indicates: Box warning medications - Many medications used by residents in the nursing home may carry a Food and Drug Administration (FDA)-issued box warning.

The box warning is a serious type of warning the FDA can require on medication labeling and is important to the health and safety of prescription drug consumers.

Nursing facility staff, prescribers, and pharmacists should be familiar with box warnings for any medication used for a nursing home resident and assure the medications are used and monitored appropriately .C.

The attending physician should assure and document .2.

Ongoing monitoring for any adverse events. 3.

Evaluation and management of any experienced adverse events .E.

Nursing staff must be informed by the attending physician or via in-service or clinical protocol of symptoms, side effects, and special monitoring to monitor and report associated with medications with box warnings.From 2/23/26 to 2/25/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including dementia, fibromyalgia, and osteoarthritis. R7's Minimum Data Set (MDS) assessment, dated 1/24/26, had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R7 had severe cognitive impairment. R7 received Hospice services and had an activated Power of Attorney (POA).R7's medical record contained the following orders: ~ Morphine sulfate solution 20 milligrams (mg)/milliliter (ml), give 0.5 ml by mouth every hour as needed for moderate pain/dyspnea.~ Gabapentin capsule 100 mg, give 3 capsules by mouth every morning and at bedtime for pain.R7's plan of care did not contain monitoring interventions for the use of opioid or anticonvulsant medication, including side effects for opioid use of sedation, dizziness, nausea, vomiting, constipation, and respiratory depression or side effects for anticonvulsant use of fatigue, tremors, rash, blurred vision, and weight gain.On 2/24/26 at 1:34 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who reviewed R7's medical record and confirmed R7 did not have monitoring interventions for opioid or anticonvulsant use. LPN-D stated LPN-D updates the provider if there is anything unusual with a resident. LPN-D indicated the facility does not schedule daily monitoring for adverse reactions or side effects.On 2/25/26 at 12:20 PM, Surveyor interviewed Regional Nurse Consultant (RNC)-C who verified R7's plan of care did not contain adverse reaction/side effect monitoring for opioid or anticonvulsant use.

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Marquardt Memorial Manor 1020 Hill St Watertown, WI 53098

opening. On 2/25/26 at 1:16 PM, Surveyor interviewed DON-B who stated staff should monitor

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Marquardt Memorial Manor 1020 Hill St Watertown, WI 53098

During tray line service, Surveyor observed Dietary Aide (DA)-N change gloves five times without completing hand hygiene. DA-N touched toasted garlic bread and noodles with gloved hands, and touched utensils, countertops, and meal slips without completing hand hygiene.

Surveyor also observed DA-O open cooler doors with gloved hands and grab ready-to-eat food, including cheese, lettuce, and bacon, and put the ready-to-eat food on residents' plates. DA-O did not change gloves or complete hand hygiene.

Surveyor observed DA-O repeat the process two more times. On 2/24/26 at 11:31 AM, Surveyor interviewed FSD-L and DM-M who stated it is ideal for staff to use tongs when working with ready-to-eat food; however, staff can touch ready-to-eat food with gloved hands provided they complete appropriate hand hygiene. FSD-L stated staff should complete hand hygiene prior to donning gloves and between glove changes. FSD-L stated glove should be changed if they are contaminated, visibly soiled, or between tasks.

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Marquardt Memorial Manor 1020 Hill St Watertown, WI 53098

and control program designed to prevent the transmission of communicable disease and infection for

Certified Nursing Assistant (CNA)-F did not complete hand hygiene after removing soiled gloves.During the provision of incontinence care for R68, CNA-G did not wear a gown, appropriately change gloves, or complete hand hygiene after removing soiled gloves.

Findings include: The facility's Hand Hygiene policy, revised 12/5/24, indicates: Hand hygiene should be completed before moving from work on a soiled body site to a clean body site on the same resident, after contact with bodily fluids, and immediately after glove removal.

The facility's Enhanced Barrier Precautions (EBP) policy, revised 2/6/25, indicates: For residents for whom EBP is indicated, a gown and gloves should be worn when completing high-contact resident cares such as dressing, bathing, providing hygiene, changing linens, and changing briefs. On 2/24/26, Surveyor reviewed R68's medical record. R68 was admitted to the facility on [DATE] and had diagnoses including spastic quadraplegic cerebral palsy, epilepsy, severe intellectual disability, cachexia, and weakness. R68's most recent Minimum Data Set (MDS) assessment, dated 2/13/26, indicated R68 had severe cognitive impairment, had a feeding tube, and was always incontinent of bowel and bladder. A care plan, revised 2/14/26, indicated R68 had a history of urinary tract infections (UTIs) and was on EBP related to a feeding tube. On 2/24/26 at 1:34 PM, Surveyor observed CNA-F provide incontinence care for R68 who was incontinent of urine.

CNA-F provided care, removed gloves, and donned clean gloves before putting a clean brief on R68 and changing R68's linens. CNA-F did not complete hand hygiene after removing soiled gloves. On 2/24/26 at 2:02 PM, Surveyor interviewed CNA-F who verified CNA-F should have completed hand hygiene after removing soiled gloves and prior to donning clean gloves. On 2/25/26 at 8:47 AM, Surveyor observed CNA-G provide incontinence care for R68 who was incontinent of bowel. CNA-G did not wear a gown during cares. CNA-G provided care, changed R68's linens, touched items in R68's closet, and touched soiled linen carts outside R68's room before removing gloves. CNA-G did not complete hand hygiene prior to touching another resident's wheelchair and wheeling the resident to the nurses' station. CNA-G completed hand hygiene at the nurses' station. On 2/25/26 at 9:14 AM, Surveyor interviewed CNA-G who verified CNA-G should have worn a gown during incontinence care and should have changed gloves and washed hands when moving from dirty to clean areas. On 2/25/26 at 11:20 AM, Surveyor interviewed Director of Nursing (DON)-B and Registered Nurse Consultant (RNC)-C regarding proper infection control practices during cares. DON-B verified staff should complete hand hygiene after removing soiled gloves and should change gloves after completing perineal care for an incontinent resident before doing anything else. RNC-C verified staff should wear gloves and a gown during high-contact cares for residents on EBP.