Donald Gunn shows a photo of his wife, Alice. He believes poor care at Marshwood Center in Lewiston contributed to her death earlier this year. Andree Kehn/Sun Journal

LEWISTON — Within hours of publishing a story last Sunday about the 95 complaints and self-reported incidents filed with the state regarding Marshwood Center in Lewiston in the past year, the Sun Journal began hearing from dozens of readers who said they, too, had issues with the rehabilitation and long-term care facility.

While no two experiences were the same, patterns emerged among the allegations: Staff failing to respond to call bells. Staff failing to treat bed sores or other conditions properly. Administrators ignoring complaints. Staff noting on medical records that medications were given when they weren’t, or that patients were treated better than they were.

Many matched much of what has already been seen in written complaints. Some also offered photos or documents as proof. Others had their stories corroborated by family members.

Many families said they filed complaints with the state, only to learn that investigators couldn’t substantiate their claims — a not-uncommon situation. Complaints may be valid, according to the Maine Long-Term Care Ombudsman Program, but they may not be able to be proven.

A spokeswoman for Genesis HealthCare, Marshwood’s owner, said this week that the company can’t comment on the care of specific patients, residents or incidents due to federal privacy rules. But she said Genesis in recent months has “made some changes within the facility that support our goal for quality patient care.”

Among those changes: Partnering with a national organization with extensive experience in wound care, hiring a quality improvement organization to recommend places to improve and hiring a longtime administrator to lead Marshwood.

That administrator, Sara Sylvester, led Oak Grove Center in Waterville for years. Oak Grove is also owned by Genesis and, like Marshwood, is currently on the federal list of problem nursing homes.

The state would have to get court approval if it wanted to pull Marshwood’s license to operate. It has not started that process.

Instead, the Maine Department of Health and Human Services, which oversees nursing homes in Maine, named Marshwood a “special focus facility” in November. That designation means the facility will be more closely monitored and will face penalties if it doesn’t improve over two years. Ultimately, it could lose Medicare and Medicaid payments, a major portion of most nursing homes’ funding.

In a statement released this week, DHHS spokewoman Jackie Farwell said, in part, that Marshwood “is under the highest level of licensing scrutiny, and we continue to closely monitor its operations.”

Many of the former patients and their families believe Marshwood has had problems for years. They said it’s time for that to end.

“I want the world to know about this,” Donald Gunn, 86, said.

DONALD AND ALICE GUNN

They met through a friend in Maine when Donald was a 19-year-old Navy guy and Alice was a 20-year-old local girl. Their first date was at a dance, but they spent most of the evening outside, talking.

“I loved her from the first start,” Gunn said.

He shipped out, returned, brought her back a diamond from Africa. But before they could marry, he was shipped out again, this time to Cuba. Though Alice, it turned out, wasn’t willing to be left behind a second time.

“Five days later she showed up at my airport,” Gunn said. “Took her last dime to get there, hoping I’d have 10 cents more to put her up for the night. We often joked about that.”

They married in 1954. He worked first as a bus driver, then as a manager for a bus company, then owned his own business focused on small engine service. She worked in local shoe factories. They raised three children together.

“We had a heck of a good life,” Gunn said.

As they grew older, Alice started having health problems. She stayed briefly in St. Mary’s d’Youville Pavilion in Lewiston to recuperate after doctors gave her a feeding tube and for physical rehab to regain her strength. But otherwise, Gunn cared for her at their home in Greene with help from family and friends. She was 86. He was just months younger.

Then, one day in January, Gunn fell and cracked his hip. He went home to his wife, but too much pain medication left him feeling drugged, and he passed out. The next thing he knew, he and his wife had been admitted to Marshwood Center.

There were, he said, problems from the beginning. For the first three days he wore the same clothes he’d been admitted in because, he said, staff members didn’t offer an alternative, nor did they offer him a shower. He and his wife were moved into the same room after a day, but he said no one rotated his wife, who was too weak to get up on her own and was at risk for bed sores.

After a few days, Gunn walked out of the facility and took a cab home to think about his situation. He didn’t stay for long.

“I didn’t know what they were doing with her,” he said. “(I said,) ‘I’m going back, see if I can get her bailed out.'”

It would take some time.

“She would holler at me in the hallway, ‘Don! Please, if you’re in the hallway I want to go home to die!'” Gunn said, crying at the memory.

Alice was discharged on Feb. 12, about three weeks after she was admitted to Marshwood.

When she returned home, her caregivers said they discovered a Stage 3 bed sore on her tailbone. The next day, they said, it turned into a Stage 4, classified as a sore so deep that it’s damaged muscle and bone.

“The meat started falling off the bone, her flesh,” Gunn said. “It turned black, black, black. It was rotten. And stink. I don’t see how my wife could stand the smell of it. We could not hide it.”

The family provided the Sun Journal with Alice’s Marshwood records and other documents. One Marshwood patient assessment, dated a week after she was admitted, noted that Alice had a more mild bed sore — a Stage 2 — at that time. Her caregivers are adamant she had no wound at all before she entered Marshwood.

“She had gotten home from d’Youville with one and me and the hospice ladies, we got rid of that one,” said Tina-Marie Beaudet, the couple’s niece and a former nurse who was one of Alice’s caretakers. “We just kept rotating her. We were happy, we were excited that day that we got rid of it. So we know she didn’t have a boo-boo when she went in. We were watching for that.”

Alice’s health continued to decline after she returned home, all stemming from the infected bed sore, her caregivers believe.

“She was going slowly downhill. Although each night I would talk with her and joke with her and try to make her jolly. But she knew she was dying,” Gunn said.

Alice Gunn died on March 20, weeks after she left Marshwood and shortly before their 65th wedding anniversary.

Her death almost killed her husband.

“I wanted to die,” he said. “And I still do. I want to be with my wife.”

Gunn, who has his own health problems, is now a patient at Bolster Heights Residential Care in Auburn. The care there, he said, has saved his life. But now he lives for one thing: Seeing Marshwood held accountable.

“I want them people out of there,” he said. “And I’ll fight to my death to do it.”

LLOYD MORRIS

Tina Crowley had a few experiences with Marshwood, none of them happy.

“It’s devastating, the things I’ve seen,” she said.

Her uncle-in-law was a Marshwood patient for about five years, she said, and she and her husband visited him every day to make sure he got the care he needed. Crowley wasn’t overly pleased with the place, but when her mother became sick, Marshwood still seemed the best option, logistically.

“I only live like a mile away from Marshwood,” Crowley said. “I could go down and see her whenever I want, I could pop in whenever I want. . . I was there all the time.”

And then, Crowley said, her mother developed the symptoms of a blood clot.

“Marshwood, they told me, ‘Your mom should go for an ultrasound to see if it’s a blood clot.’ It’s like, ‘OK, that sounds great,'” Crowley recalled. “Every day for a week I’d say, ‘When are you guys taking my mom for her ultrasound?’ (They said,) ‘Oh, well, we’re going to try to do that today, get her in.’ That went on for a week.”

At the end of that week, it became an emergency. Soon after that, her kidneys shut down. Crowley’s mother died.

Crowley believes the clot led to her mother’s death, and that it could have been prevented if Marshwood’s staff had gotten her evaluated when they first said they would.

“I just sat and cried because I feel like it was my fault because I didn’t push it,” Crowley said.

Three years later, in early 2018, when Crowley’s brother Lloyd Morris needed physical rehab after a life-threatening illness, multiple surgeries and three months in the hospital, Marshwood again came up as an option.

Crowley, the big sister, hesitated. She still felt like the facility was at least partially responsible for her mother’s death. But it was close to her home. And Morris, in his mid-fifties, was capable of speaking up and letting her know if he had a problem.

Maybe this time it would be better.

“I talked to my brother about it. ‘If you have a problem there, you let me know and we’ll take care of it because I know this place can be not right,'” she said.

He lasted less than a day.

By dinnertime the first night, Morris complained to his sister that staff members weren’t responding to his call bell. He said no one would help him get up and walk, a necessity if he was going to get better.

“I called the nurse like four times,” Morris told the Sun Journal this week. “She’d come down to my room and she would say, ‘We’re so busy. All the alarms are going off.'”

But Morris said he noticed the alarm board was beside his room and he didn’t hear any other alarms.

By mid-morning the next day, Crowley found her brother still in bed, without breakfast, without having gotten up since the day before. His bed was soaked in urine, she said. A medical bag that collected his feces was unsecured, and feces leaked down his leg and across his surgical incision.

Tina Crowley said she found her brother with his bed soaked in urine a day after he was admitted to Marshwood Center in Lewiston. She said she took this picture as proof. Submitted photo

“I’m crying. I’m crying along with my brother,” Crowley said.

At her behest, she said, a therapist helped Morris get up and walk. When they returned, the therapist set him back in the soiled bed.

When administration didn’t seem receptive to her complaint, Crowley said, she called 911 to get ambulance help moving her brother out of Marshwood and back to the hospital.

Soon after, he moved to another rehab facility. This one he liked.

That was almost two years ago. Morris is now home and feeling better, but time hasn’t softened his disdain for Marshwood.

“I wouldn’t take a dead cat there,” he said.

BEVERLY LaPLANTE

Barbara Gordon’s mother, Beverly LaPlante, was a patient at Marshwood for about three years. Most of the issues she saw there, Gordon believes, were caused by administration.

“I feel bad for the staff because all the problems there start higher up,” she said.

Among those problems, she said: a lack of essential basics.

“I had to buy my mom’s briefs, her Depends, because there weren’t any in the building,” she said. “There wasn’t any toilet paper in the building because whoever was doing the ordering wasn’t doing it.”

On many weekends, she said, just one aide was assigned to her mother’s unit. The problem was, her mother needed two aides to help her out of bed.

“So she couldn’t get to the bathroom. Or she couldn’t get out to breakfast because no one was able to get her up,” Gordon said. “And then she would call me crying, upset, because she soiled herself. Because her mind was solid. Her body wasn’t, but her mind was. So that would just totally upset her that she soiled herself.”

Once, Gordon said, an aide offered to try helping her mother alone. The aide, though, was pregnant, and Gordon said her mom didn’t want the baby put at risk.

“I don’t want the aides and the nurses to take any heat for what’s going on in Marshwood because it’s not their fault that things aren’t getting done,” Gordon said. “When you’ve got 14 people in your unit and just one aide, it just can’t be done. It can’t be.”

So, she said, she did what she could herself. She cleaned and dusted her mother’s room. She cleaned her wheelchair. She made sure her mother had baby wipes for her sensitive skin and a cabinet stocked with alternative meals and snacks.

“Everything she needed, I supplied,” Gordon said.

Time after time, Gordon found herself speaking up on her mother’s behalf. But, she said, “the people in the office they just don’t care.”

Once, she said, two directors loudly “came down on” her mother as a result of Gordon’s complaints.

“So she called me crying,” Gordon said. “I went right back the next day and said if you ever have another issue, you call me. You do not take it out on my mother.”

LaPlante died in February at 82. Gordon said doctors told her that her mother was septic, which means she was dealing with a severe infection.

Gordon still wonders whether Marshwood could have caught the problem earlier.

“For her to be OK on a Thursday and to be septic and pass on a Saturday, there must have been something there that no one picked up on,” she said.

LANETTE GODDARD

Last April, Lanette Goddard, 57, didn’t know where to go. After having both of her knees replaced, the Auburn woman needed a place to recuperate and she needed rehab to walk again.

So when someone from Marshwood pitched the facility to her, she said, she decided Marshwood it would be.

She would last about 16 hours, she said, before calling both 911 and her husband to come get her.

“I just can’t figure out why someone would treat somebody like that,” Goddard said.

Everything seemed fine at first, she said. She arrived in the afternoon, was given her pain medication a few hours later, her family said goodbye for the night around 8 p.m.

By about 9:30 p.m., she said, she started to hurt again. She rang for a staff member.

“I was told that we don’t have a nurse available to give you any meds. We’ll let her know if I see her in the hall,” she said. “I thought, ‘OK, that’s messed up.’ I’m just not one to complain, so I thought, ‘Well, maybe they really are busy.’ So I sat on it for another hour. Rang again. Same answer”

She made her third call, she said, around midnight.

“The nurse, after a while, opened up the curtain, said, ‘Sorry! We don’t have anything available,’ smiles and closes the curtain,” Goddard said.

That’s when, she said, “the panic set in.”

Goddard said she spent the night crying in pain. And because no staff members came in to help her, she said, she struggled to get to the commode that had been placed across the room.

“Half the time I never got there, so I was completely soiled all night long,” she said.

Her cellphone was dead, she said, but just before sunrise the next morning she discovered a facility-owned phone behind her bed. She called 911 and her husband, angry and adamant that she be moved from Marshwood.

At the time, Marshwood staff said Goddard had been given pain medication. In records provided by Goddard, a Marshwood nursing assistant wrote that Goddard had received medication at 11:45 p.m., had not rung her bell for assistance and had been checked on at 1 a.m., 3 a.m. and 5 a.m.

“That’s a crock of shit,” Goddard said. “It’s all lies.”

Genesis spokeswoman Lori Mayer said she could not speak about specific patients or incidents due to federal privacy rules, but she said Genesis is “not aware of any complaints or instances regarding staff making changes to medical records, for example when giving patient medications.”

“We would take any allegation seriously and investigate it,” she added. “In fact, we utilize an Electronic Medical Administration Record (EMAR), which cannot be altered.”

According to DHHS, Marshwood has been cited in the past regarding inaccurate medical records.

Goddard said she filed a complaint against Marshwood but was told that her allegations could not be substantiated.

Several days after her time in Marshwood, Goddard took her story online. She left a scathing review of Marshwood on Yelp.

“DON’T DO IT!” she wrote. “Do not send any one you care about to this place!”

Goddard said an ambulance took her back to the hospital after she demanded to leave Marshwood. She said she stayed there three more days.

Goddard refused to go to another facility and instead recuperated at home with visiting assistance and outpatient therapy.

Eight months later, her knees are better but not as strong as they could be. She wonders how much better they’d be if she’d gone through in-patient rehab.

“This all hurt me in the long run,” she said.

MARY ARCHIBALD

Tim Archibald didn’t like what he saw after his mother, Mary, moved into Marshwood.

Neither did his wife, and she worked there.

“It was always the staffing issue,” Archibald said.

His mother had been living alone in Monmouth, but she was in her 90s and falling more. She couldn’t handle life by herself.

Archibald and his wife didn’t know where to go, but they knew her employer: Marshwood. If Mary lived there, his wife could check on her every day. And Marshwood had an available bed at about $8,500 a month — paid privately at first before MaineCare kicked in.

“They loved that,” Archibald said of Marshwood.

But Archibald quickly became concerned. When he went to visit his mother, he said, there often seemed to be few or no staff members on the unit. His mother wasn’t dressed by midafternoon, he said, even though she’d never liked lounging in her nightclothes. Her lunch was repeatedly left to sit in the hallway, he said, so it was cold and unappetizing by the time someone brought it in to her.

Mary declined to eat those meals, even when her son offered to heat them up in the microwave. It didn’t taste good, she told him.

“You’ve got to remember, this woman is 95, in her 90s at the time, and this woman was brought up and raised her children that we had dinner and meals were served hot,” Archibald said.

He said staff at patient care meetings assured him that his mother would get regular exercise, including walking and work with light weights to help her strength. But while physical therapy was scheduled on her calendar every other day, Achibald said, his mother didn’t get it regularly.

When he complained, he said, “I got the same answer all the time: ‘We’re putting it on the schedule.’ ‘We put it on the schedule.'”

Archibald said everything came to a head one summer day when his wife was working on his mother’s unit. She was the only CNA there, he said, and she refused to leave without a replacement, even though the schedule called her to be elsewhere during that shift.

Soon after, he said, she was fired.

That was in 2015. Archibald said things only got worse for his mother afterward.

“She wasn’t being taken care of,” he said. “I would go out and say, ‘She needs to go to the bathroom.’ She’d ring the bell and no one would come.”

Archibald said he counted staff and patients and found there were too few staff members based on state law. He said he filed complaints with the state about staffing, but his claims were not substantiated.

He believes the state told Marshwood when investigators would be coming, and Marshwood added staff those days. DHHS said all investigations are unannounced.

Mary died in 2017 after about two years in Marshwood. She was 95.

OLGA DESROSIER

It was 2012 when Linda Desrosier’s 82-year-old mother-in-law, Olga, moved into Marshwood. She needed care and Marshwood had the first open bed.

Desrosier, who’d worked as a geriatric nurse, was uneasy from the beginning.

“When admitted, it took forever for them to log in her doctor’s orders, which meant that her medication was being withheld,” Desrosier said. “Then the falls started to occur.”

Seven falls in 39 days, she said.

“I mean, a lot of time people are confused … so (a fall) can happen,” Desrosier said. “But when it starts happening multiple times, you know, you have to address this. And in my mother-in-law’s case, it wasn’t being addressed.”

Staff didn’t take precautions, like keeping bed rails raised or lowering her mother-in-law’s bed, even though it was possible to do so, she said. Desrosier said she often asked to see Olga’s chart, nurse’s notes, doctor’s orders and care plan.

“I wasn’t seeing what I should have seen for her particular care plan. And so I would always bring it up,” Desrosier  said. “But I think my words pretty much fell on deaf ears.”

The problem was not just that Olga was prone to falls. She also had a bleeding disorder.

Linda Desrosier said her 82-year-old mother-in-law, Olga, has seven falls in 39 days. She said this photo shows some of the bruising. Submitted photo

Her condition was known as gastric antral vascular ectasia or “watermelon stomach.” For patients with the condition, blood vessels in the lining of the stomach become fragile. Desrosier’s mother-in-law bled so much that she was anemic.

With every fall, Desrosier said, the 82-year-old bruised. And that meant she bled even more.

Olga’s last fall was so bad, Desrosier said, that she broke her arm. Desrosier said she rushed to Marshwood from her home in Litchfield to find her alone in a room, her arm in a sling, in pain.

“No one was attending her whatsoever,” she said.

Desrosier said staff declined to send Olga to the hospital because she was a hospice patient. Desrosier insisted.

Her mother-in-law died within weeks, Desrosier said, the bruises from her falls still covering her body.

“I do believe her passing was hastened through the chain of events that took place with those multiple falls,” she said. “I believe that in my heart of hearts.”

Desrosier said Olga’s care lacked in other ways as well. Once when she fell, Desrosier said, staff taped a wound closed without antibiotic ointment or a bandage. After the fall that broke her arm, staff wrote in her chart that they’d given her medication, Desrosier said — but she was in the hospital at that time, not at Marshwood.

Linda Desrosier said her mother-in-law’s care lacked in a number of ways. Once when she fell, Desrosier said, staff taped a wound closed without antibiotic ointment or a bandage. Submitted photo

“It was just ridiculous,” Desrosier said.

After Olga died, Desrosier  said she requested her Marshwood medical records. She noticed charting discrepancies — nursing notes that appeared to have been entered afterward, for example.

“Everything needs to be charted or else it’s a violation. And each time, it’s a violation, whether it’s with the same patient or not. They’re trying to cover their tracks,” Desrosier  said. “They went back. They knew I was ‘trouble’ because I kind of had a background and I could see what was going on.”

Desrosier filed a complaint with the state. She said her complaint was substantiated.

As a geriatric nurse, Desrosier said she’d heard that Marshwood had a poor reputation before her mother-in-law was admitted there. But she’d also heard it had improved.

“This has been an ongoing problem with Marshwood for a really, really long time,” she said. “It’s just now seeing the light of day.”

On Thursday afternoon, Marshwood called a meeting of patients’ family members. When a Sun Journal reporter arrived and asked to attend, Administrator Emily LaVine declined, saying the meeting was only for family members. She asked the reporter to leave.

Representatives from the Maine Long-Term Care Ombudsman Program attended. The head of that program, Brenda Gallant, declined Friday to talk about the meeting or say how many people attended, citing privacy concerns. But she said the ombudsman program will help facilitate a family council that will communicate directly with Marshwood administration.

“I feel strongly that the residents’ and family members’ voices must be heard,” Gallant said. “The facility is agreeable to that. They’re very interested in the conversation.”


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