North Shore Healthcare at Marshfield

In the surveyor’s words

From the most serious findings on record at North Shore Healthcare at Marshfield, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 7, 2025

  Based on staff interview and record review, the facility did not provide the necessary care and services to prevent the development of pressure injuries and/or promote healing for 1 resident (R) (R1) of 2 sampled residents. R1 developed a stage 3 pressure injury on the sacrum. The facility did not implement interventions to prevent the pressure injury from developing and did not monitor the pressure injury after it was identified. Findings include: The facility's Pressure Injuries and Non-Pressure Injuries policy indicates: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries .For those residents admitted with, or who subsequently… […]

• No harm, potential for more than minimal, isolatedF627Jun 4, 2026

  Based on staff interview and record review, the facility did not ensure proper documentation and communication for discharge was provided for 1 resident (R) (R72) of 4 sampled residents. The facility did not provide sufficient written documentation to ensure a safe and orderly discharge from the facility for R72. Findings include: The facility's Transfer and Discharge (including Against Medical Advice (AMA)) policy, revised 7/15/22, indicates: .The care and services provided to each resident is dependent on the individual resident and circumstances present at the time .6. Non-emergency transfers or discharges initiated by the facility, return not anticipated: a. Document the reason for the transfer or discharge in the resident's medical record. […]

• No harm, potential for more than minimal, isolatedF628Jun 4, 2026

  Based on staff interview and record review, the facility did not ensure Protective Placement Services (PPS) received notification of discharge for 1 resident (R) (R72) of 4 sampled residents. R72 was protectively placed in the facility and had a court-appointed Guardian. The facility failed to obtain written consent from the Guardian prior to R72's discharge. Findings include: The facility's Transfer and Discharge (including Against Medical Advice (AMA)) policy, revised 7/15/22, indicates: The care and services provided to each resident is dependent on the individual resident and circumstances present at the time .6. Non-emergency transfers or discharges initiated by the facility, return not anticipated: a. Document the reason for the .discharge in the resident's medical record .b. […]

• No harm, potential for more than minimal, isolatedF676Jun 4, 2026

  Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R9) of 1 sampled resident was provided restorative services to maintain physical abilities.Therapy developed a restorative program for R9 that indicated R9 shoud walk daily. The restorative program was not implemented. Findings include:The facility's Activities of Daily Living (ADLs) policy, dated 7/26/22, indicates: The facility will provide a maintenance and restorative program as applicable to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment.R9 had diagnoses including osteoarthritis, history of thrombosis and embolism, and mild cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF684Jun 4, 2026

  Based on staff and resident interview and record review, the facility did not ensure treatments were provided as ordered for 1 resident (R) (R7) of 4 sampled residents. R7 had a non-pressure chronic ulcer of the right foot and peripheral artery disease of the right leg. R7's Treatment Administration Record (TAR) contained multiple missing entries for treatments in March and May of 2026. Findings include:The facility's Pressure Injuries and Non-Pressure Injuries policy, revised 7/20/22, indicates: For those residents admitted with, or who subsequently develop a pressure injury or impaired skin integrity, they will receive care, treatment, and services that promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity.R7 was admitted to the… […]