Regulators focus on Lewiston's Marshwood nursing home as problems mount

Dec. 15--LEWISTON -- The patient was diabetic and arrived at Marshwood Center last April with open sores that were supposed to be cleaned and covered by staff at least once every day. They weren't always.

'Problem' nursing homes in Maine

These Maine nursing homes are currently considered by the Centers for Medicare and Medicaid Services to have serious quality problems:

* The Gregory Wing of St. Andrews Village, Boothbay Harbor

* Marshwood Center, Lewiston*

* Oak Grove Center, Waterville

* Orono Commons, Orono

* Sedgewood Commons, Falmouth

* Designated a "special focus facility" by CMS.

Note: Brewer Center for Health and Rehabilitation had been on the list for several months and was designated a "special focus facility," but it has since improved and was recently removed from the list.

By the numbers: Nursing home problems

42: Complaints lodged against Marshwood Center in Lewiston from fall 2018 to fall 2019

53: Incidents Marshwood self reported to the state in that time

43: Health and safety citations Marshwood received in the past year for violating government rules that protect patients

4.7: Average number of health and safety citations Maine nursing homes received this past year

5: Maine nursing homes on the federal list of "problem" facilities

4: Number of those problem facilities owned by Pennsylvania-based Genesis HealthCare (including Marshwood)

When the patient went home, their spouse noticed the sores "all seemed bigger and deeper." One new wound teemed with maggots.

Another Marshwood patient felt so confused and disoriented one morning in July that his doctor ordered him taken to the emergency room. Staff members called an ambulance that was for some reason later canceled. Marshwood's administrator told investigators, "We do try to reduce readmissions to the hospital."

Angry about the delay, the man's family drove him that night to the hospital, where he was admitted with a list of problems, including dehydration, an inability to urinate, and confusion and delirium due to infection.

Another patient's family found them in bed "covered in dried feces and soaked in urine." It happened multiple times a week.

Another patient lost 7.5% of his body weight in a week. Marshwood staff didn't consider that a reason for concern.

In the past year, people officially lodged 42 complaints against Marshwood, a Lewiston facility for patients who need short-term rehabilitative help after an illness or injury or who need long-term nursing care. Marshwood also self-reported 53 incidents. Those numbers make Marshwood one of the most problematic nursing homes in the state.

Between Nov. 1, 2018 and Oct. 31, 2019, Marshwood was cited 43 times for violating rules that protect patient health and safety. The average for Maine nursing homes is about five.

On Medicare's nursing home comparison website, the federal government recently pinned Marshwood with a special icon -- a red circle with an open hand signaling "stop"-- to warn people that the nursing home has been cited for what investigators consider abuse.

Staff at the Centers for Medicare and Medicaid Services is so concerned about Marshwood that for months the facility has been placed on a special list of problem nursing homes, putting Marshwood and its for-profit owner, Genesis HealthCare, on notice. Because Marshwood failed to improve, CMS last month brightened the spotlight, naming Marshwood a "special focus facility" to be more closely monitored.

If Marshwood doesn't get better fast, Medicaid and Medicare could stop paying for patients to go there.

Five Maine nursing homes are currently on the CMS list of problem facilities. Four of the five are owned by the same national company: Genesis.

A Sun Journal analysis found the other three Maine Genesis facilities on the list -- Sedgewood Commons in Falmouth, Oak Grove Center in Waterville and Orono Commons in Orono have not been named a "special focus facility" like Marshwood, but their problems remain troubling, including drugging patients without their consent and leaving a blind dementia patient in a wheelchair outside in the pouring rain for at least an hour.

Like Marshwood, Sedgewood's online profile also bears the CMS warning about abuse.

"It's a corporate-run place, getting people in, getting people out, collecting the insurance," a Lewiston-area woman told the Sun Journal after her mother-in-law spent about a month in Marshwood. "But what about the patients?"

Maine has 93 nursing homes and their safety is handled by both the state and federal governments. Facilities in Maine are generally considered safe and well run, in part because Maine requires lower staff-to-patient ratios than some other states.

"Historically, Maine nursing homes have had fewer deficiencies and fewer serious deficiencies," said Brenda Gallant, executive director for the Maine Long-Term Care Ombudsman Program.

To land on the CMS list of problem facilities, a nursing home must have more issues than the average, have issues that are more serious than others and have shown a pattern of those serious issues over a long period of time.

Five nursing homes in Maine are on that list. Marshwood is the only one of the five deemed a "special focus facility," which means it will get more scrutiny.

Marshwood has 108 beds and offers, according to its website, hospice care, physical rehab, transitional care, short stays and long-term stays.

It's unclear who Marshwood's typical patients are or how much the nursing home makes each year. Neither Marshwood staff nor Genesis officials would speak to the specific problems recorded in CMS reports. But the facility has a Veterans Affairs contract, according to its website, which means it is approved and paid by the VA to care for military vets. And Marshwood received just about $4 million from MaineCare in fiscal year 2018 and $4.3 million in 2019, according to the state. MaineCare covers Mainers who are poor, disabled or elderly.

Advocates note that the incident numbers in the CMS reports are lower than the actual numbers because patients and their families sometimes let issues go without protest.

"Families are very fearful about making complaints because a loved one is vulnerable," Gallant said.

CMS maintains nursing home inspection records online for three years through its Nursing Home Compare site. Those records show Marshwood's problems have gotten progressively worse since 2016-2017, when it was cited for eight health and safety violations. The following year it had 18 violations.

This year, the CMS site lists 28 violations, a number that continues to climb as months-old cases are closed, processed and added to the list.

Maine's 93 nursing homes average just under 5 violations each. Nationally, nursing homes average about 8.

Investigators issue reports when they look into complaints. Those reports are publicly available through both the federal Nursing Home Compare site and through the Maine Department of Health and Human Services' licensing site. The Sun Journal reviewed all Marshwood reports from fall 2018 to fall 2019.

Patients, family members and staff are not named in the reports. Generally, even their gender is not identified.

Not every complaint is substantiated by investigators. In fact, most aren't. But those that were substantiated resulted in 43 citations for Marshwood from Nov. 1, 2018 to Oct. 31, 2019, according to the state.

January 2019 was a particularly bad month for Marshwood. That's when investigators issued two reports, one of them 35 pages long, detailing a host of problems at the facility going back to the previous summer. Those problems included:

* Being short staffed 26 out of 65 days, or 40% of the time. One family complained there was so little nursing staff to help patients that they found their loved one lying in feces and urine multiple times a week. A patient told investigators that "I've had to wait for someone to answer the call light too long and have wet myself. The wait for help is worst on the day shift."

* Staff members not respecting patients' rights. One patient said they had been required to use a bed pan rather than be helped to the toilet and had been given daily "bed baths" rather than the showers they preferred and that had been scheduled.

* A strong urine odor pervading a section of the nursing home. It was so powerful that a new patient cried and had to be consoled by family who tried to assure them that, "No, no, it's OK, they just changed someone's diaper, that's what that smell is."

* Multiple areas in disrepair, with exposed sheetrock, holes in the wall, soiled walls and curtains and embedded grime in kitchenette drawers.

* A patient not assessed after a fall.

* A patient's weight dropping from 148.2 pounds to 137 pounds in a week, a 7.5% decrease, but staff members didn't make note of the weight loss and didn't consider it significant.

* Staff failing to follow or update care plans and leaving patients and their representatives out of meetings that discussed their care.

* Bed sores not being properly cared for.

* Medications and cleansers left available and unattended.

* Patients forced to go without food for more than 14 hours between dinner and breakfast. While nourishing snacks are required to be available -- a necessity for some people with diabetes or other medical needs -- little food was accessible, and in many cases involved ice cream, saltine crackers and bread. One section's kitchenette had no food at all.

* Unsanitary conditions in the kitchen, including floors soiled with dirt and debris in the walk-in cooler, walk-in freezer, dry food storage area and "in all corners and along walls."

* Open and expired food, including bottles of Boost nutritional drink a month past the expiration date and a half-gallon of milk a week past its expiration date.

* A patient's medical record not updated to reflect they'd gotten a gastric tube the month before and no longer swallowed medication.

As the year went on, more investigations followed. None resulted in a report as long as January's, but the findings were just as serious.

On July 22, investigators found one patient was in Marshwood for nearly a week and their medical record still didn't have the basic instructions necessary for staff to properly care for them. They'd been admitted with a heart problem requiring a blood thinner and end-stage renal disease requiring dialysis.

Investigators also found a patient, who'd recently had their leg amputated, moving through the facility in a wheelchair with their leg incision uncovered and draining. The patient said their dressing had fallen off in the night and they had asked that it be replaced at 6:50 a.m. Staff did nothing until almost two hours later, when a nurse came around the corner and noticed the problem. The nurse dressed the wound but did not follow the surgeon's instructions.

A little more than a week later, on July 31, investigators returned. They found more problems.

An ambulance was somehow canceled for a confused, disoriented patient who needed to go to the emergency room. Marshwood staff told investigators the ambulance attendants didn't think it was an emergency and they refused to take him -- a claim the United Ambulance attendants and their supervisor said wasn't true, according to the report. Those with the ambulance service said Marshwood staff had balked at the cost.

"There is never a time to deny transfer . . . only if it's refused," a United Ambulance supervisor told investigators. "If the nursing home indicated he/she needed to go, we would transport."

Investigators also found that staff failed to properly care for a diabetic patient who had been admitted with open sores on their leg and foot. When the patient was discharged home, their spouse told investigators, the sores seemed bigger and deeper, and there was a new one "about the size of your palm. . . . That was the one with the maggots."

"They were all squirming around. There were 15 to 20 of them. I should've thought to take a picture, but I did not," the spouse told investigators. "I just wanted to get it cleaned up. I sent (my spouse) to the hospital. I was so distressed, I couldn't deal with that. The smell was terrible, horrible."

Investigators found that staff also failed to provide wound care instructions to that patient and their spouse when the patient was discharged. Staff did give the couple the name of the home-care agency that would be providing follow-up treatment, but staff did not give a telephone number or address for the organization, and the name of the home-care agency was wrong. That agency said it didn't receive wound care instructions for the patient, either.

Investigators also found that staff failed to assess two patients with bladder problems. One patient complained of pain for three days. On the third day, staff members said they would get a urine sample to test for problems, like infection. They did not.

The other patient was the same person whose ambulance to the ER was canceled and who was ultimately taken to the hospital by family and admitted with dehydration, an inability to urinate, and confusion and delirium due to infection. The nurse manager told the patient's family that Marshwood's bladder scanner was broken but that staff members would monitor how much the patient drank and urinated. They did not, according to the report.

Marshwood's nursing director told investigators the facility's bladder scanner -- a non-invasive ultrasound device that can help evaluate the bladder -- had been out of service for two months and had not been re-calibrated due to the cost. However, Marshwood's maintenance director told investigators that cost wasn't a factor at all; the maintenance request had never been made.

Marshwood's head administrator declined to answer any Sun Journal questions. A Genesis spokeswoman also declined to answer questions or make anyone from the company available for an interview, but she emailed a statement that said, in part, "The health and safety of our patients and residents are always our primary concern."

While they declined to answer questions from the Sun Journal, Marshwood's leadership did respond to investigators and did create plans of correction for each problem raised.

Almost every plan included the education or re-education of staff. Many plans called for Marshwood's leadership to check in regularly to make sure situations were being handled correctly.

When Marshwood leaders said a problem was fixed or soon would be, Maine DHHS officials -- following federal regulations -- took them at their word.

Every time Marshwood submitted a plan of correction, the state responded with a letter that said, in part: "We are accepting your allegation of compliance and presume that you achieved substantial compliance by (date named)."

State officials may later follow up with another visit, document review or interview, on a case-by-case basis. At least once, in that 35-page January report, investigators found that Marshwood hadn't done what it said it was going to do. The facility didn't fix the problems it had with patient care plans the year before and it had even more problems now.

Marshwood's response: It would educate employees. Leadership would check in regularly.

It was essentially the same answer Marshwood had given the year before.

Many of Marshwood's problems can be traced back to too few or untrained staff. One local family told the Sun Journal they experienced that problem firsthand recently when their 74-year-old mother was in Marshwood for a month for physical rehab.

The woman and her family asked to remain anonymous to protect her privacy.

"When I saw the way they were treating the old people down there, it just blew my mind," the woman's son said.

Among the problems, they said: She wasn't helped out of bed for meals because staff said they didn't have time; staff left her lying for hours in her own feces; staff wouldn't respond to call bells or loud patient pleas, even when the woman's roommate needed help getting to the toilet.

While rehab itself was good, "the nursing part of it is the pits," said the woman's daughter-in-law, a former certified nurse's aide. "There's a few good ones that are really into what they do and are really nice and helpful, but there are some of them who don't seem to care."

The family said one staff member warned them early on they were going to have to be "the squeaky wheel" in order to get care.

"When someone (who) works there tells a patient this, that's kind of a red flag," the daughter-in-law said.

The family filed an official complaint. In November, the state said it could not prove their allegations. That's not uncommon.

"The complaint may be valid, but it isn't always able to be substantiated," said Gallant with the ombudsman program.

Staffing-related issues are also not uncommon, experts say, particularly among for-profit companies with locations across the country.

"What we know is that everything goes back to staffing," said Lori Smetanka, executive director of National Consumer Voice for Quality Long-Term Care. "If you don't have adequate numbers and if they're not appropriately trained, if they're not appropriately monitored, that just leads to all kinds of problems in long-term care facilities. The decisions really should be made at the level where the people are receiving the care. That's one of the problems we're seeing right now with these big corporations."

Genesis runs nearly 400 nursing centers and senior living communities in 26 states, according to its website. It has 11 in Maine, four of which have been named to the CMS list of problem nursing homes.

While Marshwood is the only one on the list currently designated a "special focus facility," experts say just being on the list is significant.

"All of the facilities really have the same level of problems and concerns," Smetanka said.

According to the state, from October 2018 to October 2019, Marshwood had 95 issues reported to regulators, including self-reported incidents and complaints from patients or family members.

Oak Grove Center had 37.

Sedgewood Commons had 111.

Orono Commons had 127.

The Sun Journal reviewed the past year's investigative reports for Oak Grove Center, Sedgewood Commons and Orono Commons. They contained serious problems substantiated by investigators.

At Oak Grove, a patient wandered off three times in two weeks. Investigators said the front door was locked and alarmed when the patent was brought back inside, but staff hadn't heard an alarm go off when the patient left.

At Orono Commons, during one site visit this fall, investigators found the facility had almost no three-day emergency food supply for its 80 residents, stocking just three of the 45 food items it was supposed to keep on hand. Like Marshwood, it failed to regularly offer evening snacks to patients, including one person who was diabetic and was supposed to eat before bedtime. It did not provide adaptive eating utensils to everyone who needed them so patients could safely feed themselves. Food was not properly stored, including a refrigerated cup that investigators found "filled with a purple substance that was not dated and/or labeled."

During another visit to Orono Commons, investigators found a patient had been medicated with Haldol, an anti-psychotic known for its sedating effects, to calm them down. The medication was given without their consent and without their knowledge after the patient said they didn't want it.

At Sedgewood Commons, investigators this summer found a patient was medicated without their knowledge or consent. That patient was given trazodone, an anti-depressant also known for its sedating effects.

A month later, investigators returned to Sedgewood, where they confirmed a patient had been left outside in a rainstorm for an hour to an hour and a half.

The patient, who is blind, has dementia, uses a wheelchair and has a history of stroke and repeated falls, had gone outside with several others one afternoon in August. When it began to rain and then pour, staff members brought the patients back inside and shut the courtyard doors. No one realized the patient was missing until dinner.

The patient was found on the ground, 20 to 25 feet away from their wheelchair.

The patient was brought inside, cleaned, dried and changed into dry clothes, then brought to dinner. They were not assessed after a fall from their wheelchair. The fall was not noted in their medical record. Staff did not notify the patient's family, their doctor, the charge nurse or the oncoming nursing staff.

"It was a very busy shift, and it just slipped my mind," a staff member told investigators.

Sedgewood was supposed to report possible patient neglect or mistreatment to the state within 24 hours. It reported the incident 13 days later.

The family of another patient told investigators the facility needed more staff.

"Sometimes it's hard to find any staff around the unit," the family member said. "Sometimes nurses are not very attentive."

In her statement to the Sun Journal, Genesis spokeswoman Lori Mayer did not answer any specific questions about the safety of the nursing homes. But she noted that the federal Nursing Home Compare site shows Marshwood has a 5-star rating for quality and Oak Grove, Orono Commons and Sedgewood Commons all have four stars for staffing.

On that site, nursing homes are rated up to five stars in three categories: health inspections, staffing and quality measures. They also receive an overall rating.

Currently, Marshwood is listed as having five stars for quality, and gets two stars overall. Oak Grove, Orono Commons and Sedgewood Commons all have four stars for staffing, and get two stars overall.

Gallant acknowledged that the ratings were confusing.

"People need to really read all the information that's there to get an accurate picture of a facility. Also consider this is one source of information," she said.

Experts say another factor in such a rating discrepancy: Since the Nursing Home Compare site is updated just four times a year, reporting delays may account for how a nursing home can receive four or five stars in some categories on that site but still make a separate CMS list of problem facilities.

Mayer, with Genesis, noted that her company's own customer satisfaction ratings, handled by an outside organization, remain high. On Marshwood's webpage, for example, it received nearly four out of five stars, with comments like "I was very pleased when I was there" and "I would highly recommend them to anybody."

Mayer said Genesis facilities are "committed to providing high-quality care to our patients and residents and are always striving to improve quality and performance at each center."

On independent sites, including Caring.com, Yelp and Google, Marshwood received closer to 2.5 stars.

"Please think twice before you take your loved ones here!" one person wrote on Yelp.

As a "special focus facility," Marshwood will be subject to a regular on-site inspection twice a year rather than the once-a-year visits required of others. If it doesn't improve over two years, it faces increasing penalties, including possible fines and the loss of Medicaid and Medicare payments.

According to CMS, most "special focus facilities" significantly improve within 18 to 24 months. About 10% lose Medicaid and Medicare.

The state received 12 more complaints and self reports for Marshwood since October.

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