Marquardt Memorial Manor

In the surveyor’s words

From the most serious findings on record at Marquardt Memorial Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 22, 2021

  Based on observation, interview and record review, the facility did not ensure that 1 R (Resident) (R12) of 6 residents reviewed for accidents had adequate supervision to prevent accidents. On 3/13/21, R12 eloped from the facility on foot and was found on the ground by the side of the road approximately 0.1 miles from the facility by citizens driving on the road who witnessed R12 fall. R12 was transported to the hospital and diagnosed with a fracture to right ankle. On 4/19/21 at 10:57 AM, Surveyor observed R12 elope from the facility again on foot through the 100 wing end door. R12 was outside approximately three minutes before staff responded to the alarm that had been set off. […]

• Actual harm, isolatedF689Apr 10, 2025

  Based 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. […]

• Actual harm, isolatedF686Sep 26, 2024

  Based 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. […]

• Actual harm, isolatedF689Sep 26, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Feb 25, 2026

  Based 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. […]