Marquette

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 10, 2025

  Based on observation, interview and record review, the facility failed to ensure hospital recommendations related to transfers were followed to ensure a resident was free of accidents for 1 of 2 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B sustaining an acute distal tibia fracture (a break in the lower end of the tibia, often near the ankle joint). Findings include: During an observation, on 6/10/25 at 10:43 a.m., Resident B was sitting in a wheelchair, her right lower extremity was noted to be in a cast, and she was wearing a brace around her mid-section. A facility reported incident (FRI) indicated, on 5/21/25, the CNA assisted Resident B with ambulating to the toilet. […]

• Actual harm, isolatedF689Jan 18, 2024

  Based on observation, interview and record review, the facility failed to ensure dependent residents who required staff assistance with mobility and assistive devices, received adequate supervision and assistance to prevent falls and failed to ensure staff used a mechanical lift with assistance for 3 of 3 residents reviewed for accidents. (Resident C, B and H) This deficient practice resulted in Resident C being hospitalized for treatment of a blunt carotid artery occlusion injury and fractures of the neck, spine, left femur, and two fractures of the right foot. This deficient practice resulted in Resident B receiving a laceration with sutures to the right top of his head and to the right elbow. Findings include: 1. […]

• Actual harm, isolatedF689Nov 29, 2022

  Based on observation, interview and record review, the facility failed to report a fall on the date of the fall, failed to document assessments and neurological checks after a fall and failed to transfer a resident using the correct transfer equipment after a fall for 1 of 3 residents reviewed for accidents. (Resident C) Resident C did not receive fall follow up monitoring for side effects related to a fall and was found to have a fracture to the right clavicle six (6) days after the fall. Finding includes: On 11/28/22 at 11:36 a.m., Resident C was observed in a Broda chair, slightly reclined, alone in her room. She appeared clean and dry, with her call light in reach. The resident did not respond to conversation. The record for Resident C was reviewed on 11/28/22 at 2:04 p.m. […]

• Actual harm, isolatedF686Nov 3, 2022

  Based on observation, interview and record review, the facility failed to ensure residents at risk for development of pressure ulcers received the necessary care, treatment and services, consistent with professional standards of practice, to prevent worsening of a pressure ulcer and promote healing for 1 of 3 residents reviewed for pressure ulcers. (Resident 73) Resident 73 had developed a pressure ulcer at the facility and wound was discovered as a stage 2. Finding includes: During the initial tour of the facility, on 10/27/2022 at 1:00 p.m., Resident 73 was observed sitting, in a reclining Broda chair, in her room. A pressure reducing cushion was in the seat of the chair and a low air mattress was on the resident's empty bed. […]

• No harm, potential for more than minimal, patternF695Jan 18, 2024

  Based on observation, interview and record review, the facility failed to ensure oxygen tubing was dated and a physician's order for oxygen was obtained for 4 of 5 residents reviewed for respiratory care. (Residents 6, 41, 206 and 10). Findings include: 1. During an observation, on 1/11/24 at 1:53 p.m., the oxygen tubing and humidifier bottle for Resident 6 was not dated. The record for Resident 6 was reviewed on 1/16/24 at 10:23 a.m. Diagnoses included, but were not limited to, shortness of breath, history of acute respiratory failure with hypoxia, and unspecified congestive heart failure. […]