Marquardt Memorial Manor

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are thoroughly investigated for 2 of 3 residents reviewed for abuse (R1 & R3). R1 reported verbally and in writing an allegation of neglect. The facility did not complete a thorough investigation of the allegation. CNA F (Certified Nursing Assistant) and CNA E heard R3 screaming from behind a closed door. When they entered they saw CNA H transferring R3 using a hoyer lift alone, without a second staff member. The facility did not complete a thorough investigation that included an interview by R3, interview with other residents, and skin assessments of non-interviewable residents. Evidenced by:Facility policy, titled Abuse, Neglect, Misappropriation of Resident Property, reviewed 2/11/26, includes: [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure the resident environment remains as free of accidents/hazards as is possible for 2 of 3 sampled residents (R1, R3) reviewed for accidents/hazards. CNA H (Certified Nursing Assistant) transferred R1 and R3 alone using a hoyer lift, while the facility policy is to have 2 staff when using the hoyer lift. Evidenced by:Facility policy titled Full Body Lift, undated, includes: . At all times full body lifts are two staff transfers. CNA D's Witness Statement, dated 4/5/26, includes:. Upon arrival I observed R1 is on the phone talking with her daughter; visibly upset and crying. CNA E was also present in the room. After ending the call, R1 explained the situation regarding an incident involving CNA H, R1 reported that CNA H used a hoyer lift with an incorrect sling size and applied the sling improperly. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to 72 of 73 residents residing in the facility (1 resident was fed via tube). The microwave in the main kitchen was not in a clean condition. Staff did not test the water temperature of the sanitizing solution in the sanitizer buckets or test the sanitization level in the three-compartment sink per manufacturer's recommendations. Staff did not complete appropriate hand hygiene and safe food handling practices while serving food.

Inspectors wroteBased on staff, resident, and resident representative interview and record review, the facility did not ensure 5 residents (R) (R11, R36, R13, R39, and R80) of 6 sampled residents received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, name and address (mailing and email) with telephone number of the office of the state long-term care Ombudsman plus notification of discharge/transfer to the Ombudsman. In addition, the facility did not ensure residents received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R11 was transferred to the hospital on 1/24/26. R11 was not provided with a written bed hold or transfer notice. R36 was transferred to the hospital on 1/27/26. R36 was not provided with a written bed hold or transfer notice. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy. Three of 6 medication carts were observed unlocked and unattended. In addition, 2 of 6 medication carts and 1 of 2 medication storage rooms contained expired medication and medical supplies. This practice had the potential to affect more than 4 of the 73 residents residing in the facility. Medication carts on the 400 and 200 wings were unlocked and unattended. Medication carts and the medication storage room on the 200 and 400 wings contained expired medication and medical supplies.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not incorporate recommendations from a Pre-admission Screening and Resident Review (PASRR) Level II and PASRR evaluation report into the plan of care for 1 resident (R) (R68) of 5 sampled residents . R68's PASRR Level II Screen indicated R68 required specialized services. A PASRR evaluation stated staff should focus on sensory stimulation activities, socialization, and recreational opportunities to benefit R68's social development. An activities note for R68 indicated R68 should be provided with fidget objects and sensory items. On 2/23/26, 2/24/26, and 2/25/26, R68 was observed in R68's room with the lights down and blinds closed. R68 did not have any sensory stimulation objects and was not invited to any activities during that time period.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a comprehensive care plan was developed and implemented for 2 residents (R) (R63 and R12) of 20 sampled residents. R63 had orders 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.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure timely incontinence care was provided for 1 resident (R) (R68) of 4 sampled residents. R68's care plan indicated R68 should be 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.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure a gastrostomy (G)-tube was flushed as ordered for 1 resident (R) (R63) of sampled 2 residents. R63 had a G-tube to provide 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.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring interventions for high-risk medications were in place for 1 resident (R) (R7) of 9 sampled residents. R7 was prescribed morphine sulfate (an opioid medication) for pain and gabapentin (an anticonvulsant medication) for nerve pain. Staff did not monitor R7 for adverse reactions or side effects of the high-risk medications.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R68) of 6 sampled residents. During the provision of incontinence care for R68, 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.

Inspectors wroteBased on staff, resident, and resident representative interview and record review, the facility did not ensure grievances were thoroughly investigated and resolved for 3 residents (R) (R1, R4, and R5) of 4 sampled residents. Family Member (FM)-I filed a grievance on behalf of R1 on 1/7/26 that included concerns about a missed appointment, wound care, and assistance with cares. The facility did not investigate or provide resolution for the grievance. R4 reported in September 2025 that R4 did not receive scheduled showers. The facility did not document, investigate, or provide resolution for the grienvance. R5 reported to staff that Registered Nurse (RN)-R swore at R5. Staff reported to the concern to a supervisor; however, the facility did not file a grievance or follow-up on the concern.

Inspectors wroteBased on staff, resident, and resident representative interview and record review, the facility did not ensure scheduled showers/baths were provided for 3 residents (R) (R4, R1, and R3) of 13 sampled residents. R4 was scheduled for a weekly shower on Tuesday evening. R4 did not receive showers as scheduled. R1 did not receive a shower while at the facility because the facility did not have a functioning bariatric shower chair. R3 did not receive weekly showers as scheduled. In addition, R3's preference to receive a shower instead of a bed bath was not consistently honored. The facility's undated Standard Activities of Daily Living (ADL) Protocol indicates: ADLS: .bathing .Individual will perform ADLs .with or without staff assist. Certified Nursing Assistant (CNA): Offer individual choices with care routines .Offer weekly bath or shower per individual preference . 1. [...]

Inspectors wroteBased on staff interview and record review, the facility did not provide the necessary care and services to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R1) of 3 sampled residents. R1 had an unstageable deep tissue injury that was treated without a physician order. In addition, R1 had a stage 2 pressure injury that was not identified in the facility and was discovered while R1 was at a medical appointment.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R1) of 1 sampled resident received timely placement of a suprapubic catheter (a tube inserted through a small incision in the lower abdomen directly into the bladder to drain urine). R1 did not have transportation from the facility to a medical appointment on 12/31/25 that was scheduled to remove R1's indwelling urinary catheter (a flexible tube inserted through the urethra into the bladder to continuously drain urine into an external bag) and replace it with a suprapubic catheter. R1 scheduled a new appointment for 1/5/26 for placement of the suprapubic catheter.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R5) of 3 sampled residents received oxygen therapy. R5's oxygen tubing was changed on 1/9/26. Following the change, staff did not turn R5's oxygen back on. As a result, R5 was without supplemental oxygen for approximately 6 hours.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure an opportunity to create a Power of Attorney (POA) document or a document that designated an alternate decision maker in the case of incapacity was provided for 1 resident (R) (R1) of 5 sampled residents. The facility did not offer R1 an opportunity to create a POA document or any document to designate a decision maker if R1 became incapacitated.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) for 1 resident (R) (R1) of 1 sampled resident. R1 reported to staff that another staff call R1 stupid. The allegation of abuse was not reported to the SA.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R1) of 1 sampled resident observed during the provision of care. Licensed Practical Nurse (LPN)-C and Certified Nursing Assistant (CNA)-D did not wear appropriate personal protective equipment (PPE) during wound care for R1. In addition, LPN-C did not complete proper hand hygiene or ensure a treatment cart and supplies were free from infectious agents during and after the provision of wound care.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 2 of 3 residents (R3 and R1) reviewed for accidents received adequate supervision and assistance devices to prevent accidents. R3 is being cited at severity level 3 (actual harm). R3 experienced a fall with major injury. Surveyor observed fall interventions not in place. The facility did not complete a root cause analysis for 12 falls and did not implement appropriate interventions for R1's falls. Evidenced by: The facility policy, Falls, reviewed 12/5/24, states, in part; .Prevention measures are put in place to reduce the occurrence of falls and risk of injury from falls .c. A licensed nurse will determine the individuals' risk for falls and individualized care needs. If the individual is at risk for falls, then create a falls care plan .b. The care plan will be updated with an identified intervention . [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 1 resident (R4) reviewed for transmission-based precautions. R4 had a sign posted on his door that he was under isolation for droplet precautions; however, a staff member entered R4's room without following the droplet precaution protocol, wearing the appropriate PPE (Personal Protective Equipment) or performing hand hygiene per standards of practice. This is evidenced by: Facility policy, titled Infection Prevention and Control Program dated 6/14/17, with last review date of 5/8/25, states, in part: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the facility wide assessment developed by the facility included all relevant details to ensure the facility provided care and services to residents to meet their individual needs within the facility's identified resources. This has the potential to affect 9 residents (R5, R6, R7, R8, R9, R10, R11, R12, and R13) currently residing in the facility with a substance use disorder (SUD) diagnosis. The facility assessment must reflect the resident population and resources needed to care for this population. Nine residents had a diagnosis of SUD however the facility did not address the resources needed to care for these residents. R5 has a diagnosis of alcohol abuse. R6 has a diagnosis of alochol dependence with alcohol induced persisting dementia. R7 has a diagnosis of alochol abuse. R8 has a diagnosis of alcohol dependence. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide behavioral health services to ensure a resident received the highest practicable mental and psychosocial well-being. The facility did not create a comprehensive assessment and plan of care to address substance use disorder (SUD) for 3 of 3 residents (R1, R4, and R5) reviewed for SUDs. R1 had cocaine use, regularly drank alcohol while in the facility and had a history of cannabis use. R1 did not have an assessment or comprehensive person-centered care plan for R1's SUD and did not have timely interventions for R1's SUD. R5 regularly drank alcohol while in the facility and did not have a care plan with interventions for SUD. R4 did not have a care plan in place for his diagnosis of alcohol use. This is evidenced by: [...]

Inspectors wroteBased on the comprehensive assessment of a resident, the facility must ensure that residents receive care, consistent with professional standards of practice, to prevent pressure injuries and do not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable for 1 of 3 (R24) residents reviewed for pressure injuries. R24 had a Controlled Ankle Movement (CAM) boot applied for an ankle fracture. The facility did not implement interventions to remove the boot and assess her skin. R24 developed unstageable pressure injuries to her left heel and top of foot.

Inspectors wroteBased on interview, and record review the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 (R10 and R222) of 5 residents reviewed. *R10 had an unwitnessed fall on 11/25/2023 and did not have neurological checks completed as scheduled per the facility policy. R10's Fall Risk Care Plan was not updated after R10's fall on 11/25/2023. On 1/19/2024, R10 was transferred by Certified Nursing Assistant (CNA)-W with a Sara Steady (an assistive device used for transferring residents). CNA-W did not have assistance from another staff member when R10's care plan documented 2 assist should be used with transferring R10. R10 fell from the Sara Steady and fractured R10's left tibia. R10 was hospitalized from [DATE] through 1/22/2024 and required a Closed reduction of R10's left leg while under sedation. [...]

Inspectors wroteBased on observation, interview, and record review, the Facility did not ensure food was prepared and served in a sanitary manner. -Proper dishwashing rinse cycle temperatures were not obtained on the dish washing machine gauge or the manual gauge that was run though the dishwashing machine. There was no evidence or observations that sanitizing temperature was reached by the dishmachine and the dishmachine was observed to not properly sanitize the dishware through the high temperature cycle. -Cook-R was observed grabbing ready to eat food with gloved hands, after touching non-sanitized food surfaces, and placing the ready to eat food on plates for residents to eat. [NAME] was observed not changing gloves and washing hands after touching non-sanitized food surfaces. This practice has the potential to affect 76 of 76 residents residing in the facility.

Inspectors wroteBased on observation, record review and staff interviews, the facility did not ensure 1 out of 1 residents ( R27) reviewed for the use of a physical restraint, conducted a comprehensive assessment and developed a plan of care for the continued use of the physical restraint. R27 has an abdominal binder in place at all times which cannot be removed easily by R27 and restricts R27's freedom of movement or normal access to her body. The facility did not provide evidence that the use of the abdominal restraint is the least restrictive alternative and did not ensure that it was used for the least amount of time and did not document on-going re-evaluation of the need for the abdominal binder.

Inspectors wrote2.) R35 was admitted to the facility on [DATE] from the hospital with a primary diagnosis of alcohol dependence with alcohol-induced persisting dementia; and other diagnoses which include, in part, encounter for palliative care, epilepsy, and anxiety disorder. R35's quarterly Minimum Data Set (MDS) with an assessment reference date of 9/9/24 indicated R35 had a Brief Interview for Mental Status score of 13 (fully intact memory). R35 makes self understood and understands others. No behaviors were noted during the look back period. R35's upper extremity has an impairment on one side, the lower extremities have no impairment. R35 is always continent of bowel and bladder. R35 has the following care plan for falls: The resident is Moderate risk for falls r/t Deconditioning, Gait/balance problems, Dementia, Hx falls. Date Initiated: 05/01/2023 Revision on: 07/24/2023 Goal: [...]

Inspectors wroteBased on interviews and record review the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, including the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility for 1 of 1 (R24) residents reviewed for dialysis. The facility did not implement interventions to assess and document care of R24's Arteriorvenous (AV) fistula including auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow.

Inspectors wroteBased on interview and record review, the facility did not ensure medical records contained documentation related to Pneumococcal immunizations for 1 (R67) of 5 residents reviewed for immunizations. R67's medical record does not contain any documentation as to whether R67 was offered, received, or declined the Pneumococcal immunization.

Inspectors wroteBased on interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunizations for 1 (R67) of 5 residents reviewed for immunizations. R67's medical record does not contain any documentation as to whether R67 was offered, received, or declined the COVID-19 immunization.

Inspectors wroteBased on interview, review of facility food temperature logs, and facility policy review, the facility failed to ensure potentially hazardous foods (PHF) such as meat, eggs and dairy were tested for safe food temperatures prior to distribution to the residents. Specifically, hot, and cold food temperatures were not taken on 69 meals during a 90-day period. This deficient practice had the potential to affect the health of 80 of 83 residents at the facility.

Inspectors wroteBased on interview, record review and review of the facility's incident investigation report, the facility failed to protect one of 16 sampled residents' (Resident (R) 1) right to be free from neglect when the facility failed to provide timely and appropriate toileting services. Specifically, R1 was told to urinate in her brief and was left on the bedpan for one hour which resulted in R1 being neglected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 86 residents. Surveyor observed dishwasher temperature logs not meeting manufacture requirement for sanitation. The facility did not have a practice to monitor and report findings of the dishwasher temperature logs. Surveyor observed the kitchen sink, dishwashing sink, and floors to be not cleaned properly; in addition to cobwebs with dead bugs and peeling paint, therefore causing an unsanitary environment. Surveyor observed staff without hairnets and hairnets not worn properly. This is evidenced by: Example 1 The Wisconsin Food Code 2022 documents at section 4-501.110 Mechanical Ware washing Equipment, Wash Solution Temperature. [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 Residents (R2) of 11 residents reviewed. R2 reported an allegation of abuse on 9/21/23 and 9/22/23. The facility did not thoroughly investigate the allegations reported to rule out abuse.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 4 residents reviewed (R7) for 2 assist with full body lifts and 1 of 3 (R4) reviewed for wandering. R7 transfer status is care planned as two-assist with full body lift. R7 reported to surveyor that when she is transferred it is completed by Family Member J and a Certified Nursing Assistant (CNA). R4 entered R6's room while she was awake in bed and was touching her legs below the knee and shin area. R6 stated R4 would not leave her room and he made her feel creepy. R4 has a history of wandering and was wandering repeatedly prior to this incident. R4's care plan does not reflect wandering and interventions. This is evidenced by the facility policy Safe Individual Handling Program, with a review date of 6/13/23, indicates, in part: [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 78 of 80 residents who resided in the facility (two residents received nutrition exclusively via tube feeding). Staff did not test Quaternary sanitizing solution per manufacturer's instructions. The facility did not ensure food-contact and non-food contact equipment was clean and dry for storage or use. The facility did not have a practice to monitor and document dishwashing wash and rinse cycle temperatures

Inspectors wroteBased on staff interview and record review, the facility did not ensure 4 Residents (R26, R57, R58 and R67) of 5 residents reviewed for immunizations were offered a pneumococcal vaccine. R26's medical record did not contain documentation that R26 was offered or declined a pneumococcal vaccination. R57's medical record did not contain documentation that R57 was offered or declined the Prevnar 20 vaccine. R58's medical record did not contain documentation that R58 was offered or declined a pneumococcal vaccination. R67's medical record did not contain documentation that R67 was offered or declined the Prevnar 20 vaccine.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 4 residents (R) (R7, R26, R58 and R67) of 5 residents reviewed for immunizations were provided education regarding the risks and benefits of COVID-19 immunization and either received or did not receive the vaccine due to medical contraindications or refusal. R7 did not receive a COVID-19 vaccine. R7's medical record did not indicate the facility provided education regarding the risks and benefits of the vaccine, or that R7 was not immunized due to medical contraindications or refusal. R26 did not receive a COVID-19 vaccine. R26's medical record did not indicate the facility provided education regarding the risks and benefits of the vaccine, or that R26 was not immunized due to medical contraindications or refusal. R58 did not receive a COVID-19 vaccine. [...]

Inspectors wroteBased on staff and resident interview, and record review, the facility did not thoroughly investigate and resolve a grievance for 1 Resident (R) (R180) of 21 sampled residents. On 6/17/23, R180 reported care concerns to staff. Staff did not follow the facility's grievance process. R180's grievance was not thoroughly investigated or resolved.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a resident suspected of having a mental illness and/or intellectual/developmental disability was screened through the Pre-admission Screen and Resident Review (PASRR) Level II process to determine if nursing home placement was appropriate and if specialized services were required for 2 Residents (R) (R26 and R71) of 21 sampled residents. The facility did not complete a PASRR Level II Screen for R26. The facility did not complete a PASRR Level II Screen for R71.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R26) of 4 residents reviewed for activities of daily living (ADLs) was provided AM and PM cares. R26 was not provided AM and PM cares daily which caused discomfort to R26's groin and buttocks.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure care and treatment was provided in accordance with professional standards of practice for 1 Resident (R) (R26) of 4 sampled residents. R26 was admitted to the facility with skin damage and was not provided treatment according to physician orders.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the provision of care and treatment to prevent the development or worsening of pressure injuries for 1 Resident (R) (R35) of 7 sampled residents. R35's had a facility-acquired unstageable pressure injury on the right heel. R35 was observed in bed on multiple occasions with both heels in direct contact with the mattress.

Inspectors wrote3. On 6/28/23, Surveyor reviewed R47's medical record. R47 was admitted to the facility on [DATE] with diagnoses to include history of chronic urinary tract infection, urinary incontinence and indwelling catheter for wound healing. R47's most recent UTI was in May of 2023. On 6/28/23 at 9:15 AM, Surveyor observed CNA-M and CNA-T perform catheter care for R47. Prior to emptying R47's drainage bag, CNA-M placed the drainage bag on the floor without a protective barrier and did not use an alcohol wipe to disinfect the drainage spout before or after emptying the urine into a graduated cylinder. CNA-M then placed the drainage bag in a basin. CNA-M disposed of the urine in the sink and rinsed the cylinder. On 6/28/23, Surveyor interviewed CNA-T who verified R47's drainage bag was placed on the floor without a protective barrier. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R1) of 1 sampled resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding. R1's enteral feed bag was not changed after 24 hours as ordered. In addition, the enteral nutrition (EN) formula was labeled Jevity after R1's tube feeding (TF) order was changed to Glucerna.