Marshwood Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF584Mar 18, 2026

  Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 6 of 7 units ([NAME], [NAME], [NAME], [NAME], [NAME] and [NAME]) 2 of 2 facility tours.(3/16/26 and 3/18/26)Findings:On 3/18/26 from 3:00 p.m. to 3:45 p.m., two surveyor conducted an Environmental tour with the Administrator, the Director of Nursing, the Maintenance Director, the Maintenance Assistant and the Housekeeping Supervisor in which the following findings were discussed and/or observed. [NAME] Unit:- There were six(6) cracked/broken floor tiles approximately forty one(41) cracked/broken floor tiles in the dining area. […]

• No harm, potential for more than minimal, patternF657Mar 18, 2026

  Based on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 5 of 28 residents reviewed for care planning (Residents #1, #8, #35, #60, and #63). Findings: 1. Review of Resident #1's medical record contained a Quarterly Minimum Data Set (MDS) version 3.0 dated 1/6/26. The clinical record lacked evidence of his/her IDT meeting being held within 7 days of the quarterly MDS assessment On 3/18/26 at 9:30 a.m., in an interview with the Market Clinical Advisor, who confirmed that Resident #1's IDT meeting was not held within 7 days of the quarterly MDS assessment. 2. […]

• No harm, potential for more than minimal, patternF812Mar 18, 2026

  Based on observations and interviews the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for walls, floors, air conditioner vents, and ceiling tiles for 1 of 1 kitchen tour (3/16/26).Findings:On 3/16/26 from 8:16 a.m. to 8:48 a.m. two surveyors conducted an initial kitchen tour with the Director of Operations for Dietary for Health Care Services in which the following findings were observed and discussed:-The wall behind the stove has missing sheet rock.-The kitchen floor had food debris and trash under tables and equipment.-The floor in the walk-in freezer had chipped/missing paint creating an uncleanable surface.-The air conditioner vents were soiled with dust/dirt.-Approximately 15 ceiling tiles and the ceiling grids above the stove were stained… […]

• No harm, potential for more than minimal, patternF842Mar 18, 2026

  Based on record reviews and interviews, the facility failed to ensure the Medication Administration Records (MAR) and Treatment Administration Records (TAR) were accurately completed for 7 of 28 residents reviewed (Resident #1, #3, #8, #14, #35, #60, and #63).Findings: 1. On 4/2/25 a surveyor reviewed Resident #1's clinical record which showed an active physician order initiated on 12/9/25 for Humalog Solution 100 units/milliliters with instructions to Inject per sliding scale if 0-150= 0 units (if blood glucose is less than 70, call MD (medical doctor); 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-230 = 8 units; 351+ = 10 units and 9 (if blood glucose is greater than 400, call MD immediately for further instruction), subcutaneously before meals for sliding scale insulin… […]

• No harm, potential for more than minimal, patternF578Dec 19, 2024

  Based on record reviews and interview, the facility failed to ensure that the resident and/or resident representative written information, concerning the right to accept or refuse medical or surgical treatment and/or formulate and advanced directive, was completed for 4 of 10 residents reviewed for advanced directives. (Residents #70, #90, #306, and #405) Findings: 1. Resident #70 was admitted to the facility on [DATE]. Review of Resident #70's clinical record lacked evidence that the facility provided/obtained resident and/or resident representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 2. Resident #90 was admitted to the facility on [DATE]. […]