Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marquette during CMS and state inspections, most recent first.
The facility failed to provide required written transfer/discharge notices, appeal rights, and bed-hold information to representatives for three residents who were hospitalized or discharged, and did not consistently notify the LTC ombudsman as required. One resident with multiple cardiopulmonary and oncologic conditions was sent to the ER with only verbal family notification. Another resident with psychiatric and metabolic diagnoses was transferred to the hospital for a psychiatric evaluation, with documentation of verbal notification to the son but no written notice or bed-hold information at the time of transfer. A third resident with respiratory failure, CHF, dementia, and other comorbidities was discharged to memory care without documented written notice or bed-hold information to the representative, and the ombudsman was not notified of the scheduled discharge, despite facility policy requiring written notices to the resident, representative, and ombudsman.
A resident with severe cognitive impairment and multiple vertebral fractures, who was assessed as requiring a two-person assist for transfers, was assisted by a single CNA without a gait belt during ambulation to the bathroom. The resident fell and sustained an acute distal tibia fracture. Facility documentation did not clearly communicate the two-person assist requirement, and the CNA was unfamiliar with the resident's needs.
A facility failed to provide a resident with timely Notice of Medicare Non-Coverage (NOMNOC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) documents. The resident received these notices 13 and 15 days after their Medicare Part A coverage ended, preventing them from appealing the decision. The delay was attributed to therapy staff being out of town, contrary to the facility's policy requiring notices to be given at least two days before benefits end.
A facility failed to ensure privacy during medication administration when a QMA administered eye drops to a resident in a shared room without closing the privacy curtain, allowing a visitor to view the care. The QMA acknowledged the oversight, and the DON confirmed adherence to privacy regulations. The facility's policy guarantees residents' rights to privacy.
The facility failed to schedule care plan meetings with two residents and/or their representatives, as required. One resident had severe dementia and mood disorders, while another had age-related debility and pain. The Social Services Worker did not schedule meetings if families indicated they were unnecessary, contrary to facility policy requiring quarterly care plan conferences.
A facility failed to notify a physician when a resident's blood sugar levels were outside the ordered parameters. The resident, with type 2 diabetes and other conditions, had blood sugar readings that were either too low or too high on several occasions. The Director of Nursing confirmed the lack of documentation for physician notification, which was against the facility's policy.
A facility failed to obtain and document a resident's weekly weights as ordered by a physician for monitoring weight loss. Despite a recommendation from the RD for weekly weights, the facility did not document these weights in several months. Interviews revealed that the order for weekly weights should have been discontinued, but it remained active, leading to a lack of adherence to the facility's policies on weight monitoring and documentation.
A facility failed to ensure a clear and accurate physician's order for a resident's oxygen flow rate, leading to a discrepancy between the ordered 4 liters per minute and the observed 2 liters per minute. Interviews with an LPN and the DON revealed uncertainty about the correct flow rate, highlighting a lack of clarity in the physician's order.
A facility failed to provide a resident with a two-handle insulated cup for coffee, despite the resident's need for adaptive equipment to assist with feeding. The resident was observed using two-handle cups for other beverages, but the facility did not have a suitable cup for hot drinks. The Dietary Manager acknowledged the issue, and the resident's care plan and physician's order specified the need for such equipment to promote independence and reduce spillage.
The facility failed to maintain complete and accurate documentation for two residents. A resident's insomnia medication and vital signs were not documented as per physician's orders. Another resident's monitoring for side effects, pain assessment, and weight-bearing activities were also not documented. The ADON acknowledged the missing documentation, highlighting a need for improved record-checking procedures.
Failure to Provide Required Written Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notices of transfer or discharge, appeal rights, and bed-hold information to resident representatives, and to notify the LTC ombudsman, for multiple residents who were hospitalized or discharged. For one resident with diagnoses including pneumonia, atrial flutter, acute respiratory failure with hypoxia, malignant neoplasm of the colon, and obstructive and reflux uropathy, nursing documentation showed the resident was transferred to the ER and the daughter was notified verbally, but there was no indication that a written notice of transfer or discharge was provided. For another resident with anxiety disorder, major depressive disorder, catatonic disorder due to a known physiological condition, mood affective disorder, type 2 DM, edema, and metabolic encephalopathy, the record showed a physician ordered transfer to the hospital for psychiatric evaluation, and a progress note documented a Zoom visit with a psychiatric physician followed by transport by family. The transfer/discharge report indicated the son was notified of the transfer but did not show that a written notice or bed-hold policy was provided at the time of transfer. A third resident, with diagnoses including metabolic encephalopathy, contusion of the right thigh, acute and chronic respiratory failure with hypoxia, pulmonary fibrosis, bronchiectasis, acute on chronic diastolic CHF, anxiety disorder, and moderate dementia with mood disturbance, was discharged to an assisted living memory care apartment. Progress notes documented the planned discharge and the actual discharge, but there was no documentation that the resident representative received a written notice of transfer or discharge or the bed-hold policy. Interviews with the Executive Director and Social Services Director confirmed that the facility had been providing only verbal notifications to resident representatives and had not consistently issuing written transfer/discharge notices, bed-hold information, or notifying the ombudsman for both emergent hospital transfers and scheduled discharges, contrary to the facility’s own “Transfer Emergency Discharge” policy requiring written notices to the resident, representative, and ombudsman.
Failure to Follow Transfer Recommendations Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to follow hospital recommendations regarding transfer assistance for a resident with significant mobility and cognitive impairments, resulting in an accident. The resident, who had a history of multiple vertebral compression fractures and severe cognitive impairment, was assessed by hospital occupational and physical therapists as requiring a two-person assist for transfers and ambulation, with the use of a gait belt and rolling walker. These recommendations were documented in the preadmission records and communicated to the facility prior to the resident's admission. On the day of the incident, a CNA assisted the resident with ambulation to the bathroom using a walker, but did so alone and without a gait belt. The CNA reported that she intended to get additional assistance but proceeded to assist the resident when the resident stood up independently. During the return from the bathroom, the resident's ankle gave way, resulting in a fall and an acute distal tibia fracture. Documentation and interviews confirmed that only one staff member was present during the transfer, contrary to the two-person assist requirement outlined in the hospital's recommendations. Further review revealed that the facility's documentation did not clearly indicate the need for two-person assistance for this resident, and the CNA was unfamiliar with the resident's specific transfer needs. The facility's policies required the use of appropriate techniques and devices for resident safety, but these were not followed in this instance. The incident resulted in the resident sustaining a significant injury due to inadequate supervision and failure to implement recommended safety precautions.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNOC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to a resident prior to the end of their Medicare Part A coverage. The NOMNOC document indicated that the resident's Medicare Part A coverage would end on a specific date, and the resident had the right to request an appeal by noon the day before the coverage ended. However, the resident received the NOMNOC document 13 days after the end of service date, which was too late for them to exercise their right to appeal. Similarly, the SNF ABN document, which informed the resident that their Medicare Part A Skilled coverage would end and that subsequent services would be out-of-pocket, was also provided 15 days after the end of service date. The Social Service Director explained that the delay was due to therapy staff being out of town when the notices were due. According to the facility's policy, these notices should have been provided at least two calendar days before the benefits ended to allow the resident time to appeal the decision.
Failure to Ensure Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure privacy during a medication administration for a resident in a shared room. During an observation, a Qualified Medication Aide (QMA) administered eye drops to a resident without pulling the privacy curtain, allowing a visitor on the other side of the room to have an unobstructed view of the care being provided. The QMA acknowledged that the privacy curtain should have been closed during the care. The Director of Nursing later confirmed that the facility follows state and federal regulations regarding resident privacy and confidentiality. The facility's policy on Resident Rights, revised in February 2021, guarantees residents' rights to privacy and confidentiality.
Failure to Schedule Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were scheduled with the residents and/or their representatives for two residents. A family member of one resident reported not attending a care plan meeting for a year, and the clinical record confirmed that the last documented meetings were held several months prior. This resident had diagnoses including severe dementia with mood disturbance, major depressive disorder, and mood disorder. Similarly, a family member of another resident also indicated not having a care plan meeting in a year, with the last documented meeting occurring several months earlier. This resident's diagnoses included age-related physical debility, constipation, and pain. The Social Services Worker acknowledged that care plan conferences were supposed to be completed quarterly and documented, but admitted to not scheduling meetings if families indicated everything was okay or did not want a meeting. The facility's policy required the interdisciplinary team to develop resident care plans, but this was not adhered to in these cases.
Failure to Notify Physician of Out-of-Range Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician when a resident's blood sugar levels were outside the parameters set by the physician's orders. The clinical record for a resident with diagnoses including type 2 diabetes, edema, and chronic kidney disease showed blood sugar levels that were either below 70 or above 400 on multiple occasions. Specifically, the resident's blood sugar was recorded as 69, 65, 425, and 51 on different dates, but there was no documentation indicating that the physician was notified of these out-of-range results. Interviews with the Director of Nursing confirmed the absence of notifications in the resident's record, which was contrary to the facility's policy on charting and documentation that required notification of the physician when indicated.
Failure to Monitor and Document Resident's Weight as Ordered
Penalty
Summary
The facility failed to ensure that staff obtained a resident's weight weekly as per the physician's order and correctly documented these weights in the medical record for a resident diagnosed with Barrette's esophagus, anorexia, and nutritional deficiency. The Registered Dietitian (RD) had recommended weekly weights for closer monitoring of weight loss, and a physician's order was placed to weigh the resident every Monday morning starting in September. However, the resident's medical record was missing documentation for the weekly weights in several months, including September, November, January, and February. A weight summary review confirmed that the facility did not obtain weekly weights during these months. Interviews with facility staff revealed a breakdown in communication and procedure adherence. The Licensed Practical Nurse indicated that weights were documented on a form at the nurse's station and given to the unit manager, but the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) noted that the order for weekly weights should have been discontinued as the resident was no longer followed by the RD. Despite this, the order remained active, and the RD acknowledged documenting to continue the weekly weights due to the active order. The facility's policy on Nutrition Risk and Weight Loss Management required residents to be weighed at least monthly unless otherwise ordered, and the Charting and Documentation policy required complete and accurate documentation in the medical record.
Oxygen Flow Rate Discrepancy for Resident
Penalty
Summary
The facility failed to ensure a clear and accurate physician's order for the correct oxygen liter flow rate for a resident requiring respiratory care. During an observation, the resident's oxygen flow rate was set at 2 liters per minute, while the physician's order dated earlier indicated it should be at 4 liters per minute via nasal cannula. However, the order summary also indicated a flow rate of 2 liters per minute, leading to a discrepancy. Interviews with an LPN and the Director of Nursing revealed uncertainty about the correct flow rate, with the LPN unaware of the 2-liter order and the DON needing to verify the correct rate. The facility's policy on oxygen administration requires adherence to the physician's order, which was not clearly followed in this instance.
Failure to Provide Adaptive Equipment for Coffee Consumption
Penalty
Summary
The facility failed to provide a two-handle insulated cup for a resident who required adaptive equipment to assist with feeding. During observations, the resident was seen using two-handle cups for milk, juice, and water, but only had a one-handle insulated cup for coffee. The Dietary Manager acknowledged the need for a two-handle cup for coffee but indicated that the facility did not have such a cup available and would need to order it. As a result, the resident did not receive coffee during meals because the regular two-handle cups were not suitable for hot beverages. The resident's clinical record indicated diagnoses of weakness, heart failure, and a need for assistance with personal care. A care plan and physician's order specified the use of two-handle mugs with lids to promote independence and reduce spillage. The Therapy Manager confirmed the resident's use of two-handle cups to support independence in daily living activities. Despite these documented needs and orders, the facility's lack of appropriate equipment led to the deficiency in providing necessary adaptive equipment for the resident's coffee consumption.
Incomplete Documentation of Resident Care
Penalty
Summary
The facility failed to ensure complete and accurate documentation of care provided to two residents. For Resident 46, the clinical record review revealed missing documentation for the administration of Dayvigo, a medication for insomnia, on two separate dates. Additionally, there was a lack of documentation for monitoring the resident's vital signs during a specific shift. These omissions indicate a failure to adhere to physician's orders and maintain accurate medical records. Similarly, for Resident 1, the facility did not document the monitoring of side effects from psychoactive drugs, anti-coagulant medications, and pain assessment during several evening shifts. Furthermore, there was no documentation of the resident's weight-bearing activities as ordered by the physician. The Assistant Director of Nursing acknowledged the missing documentation and indicated a need for improved record-checking procedures. The facility's policy on charting and documentation, last revised in 2017, requires documentation of medications administered and treatments performed, which was not followed in these cases.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Augustine Home For The Aged | 0.5 mi | ★★★★★ | 0 | 0 |
| Harcourt Terrace Nursing And Rehabilitation | 0.5 mi | ★★★★★ | 27 | 0 |
| Spring Mill Meadows | 0.5 mi | ★★★★★ | 4 | 0 |
| Brickyard Healthcare - Willow Springs Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Hooverwood | 2.2 mi | ★★★★★ | 12 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.