LEWISTON — Too few staff to care for patients. Still.

Rooms and equipment in disrepair. Still.

Care plans not followed. Still.

Months after Marshwood Center was named a “special focus facility” and put on notice, the nursing home’s problems remain so serious that the state has asked the Centers for Medicare and Medicaid Services to stop paying for new patients to stay there if the issues don’t quickly improve.

Most nursing homes find it difficult, if not impossible, to operate without Medicare and Medicaid payments.

But with COVID-19 wreaking havoc across the country, the federal government has placed nearly all such sanctions on hold. The Maine Department of Health and Human Services expects the government to visit the issue of Marshwood when that suspension is lifted.

In the meantime, those who have been keeping an eye on the facility remain concerned.

“I am appalled with the level of neglect that this facility is foisting on their residents,” state Rep. Margaret Craven, D-Lewiston, said. “It is not that Marshwood has not had time to get their plan of correction in place, it seems that safety and doctors’ orders are being completely ignored. I am worried about the people who live at Marshwood, especially now that families are not able to visit and supervise ongoing care because of COVID-19.”

Marshwood is owned by Pennsylvania-based for-profit Genesis HealthCare. It has 108 beds and offers hospice care, physical rehab, transitional care, short stays and long-term stays. The facility has a Veterans Affairs contract, according to its website, which means it is approved and paid by the Veterans Affairs to care for military vets. Marshwood also cares for patients who use MaineCare, Maine’s Medicaid program for people who are poor, disabled or elderly. It received just about $4 million from MaineCare in fiscal year 2018 and $4.3 million in 2019, according to the state.

Marshwood’s problems have gotten progressively worse since 2016-2017, when it was cited for eight health and safety violations, according to Nursing Home Compare, a website maintained by the Centers for Medicare and Medicaid Services, or CMS. The following year, Marshwood had 18 violations.

In mid-December, the CMS site listed 28 violations for 2019, a number that was expected to climb as months-old cases were closed, processed and added to the list. Maine’s 93 nursing homes average just under five violations each. Nationally, nursing homes average about eight.

On the nursing home compare site, the federal government 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 considered abuse.

A Sun Journal story in December listed some of the problems investigators reported at Marshwood, including a lack of medical or personal care, patients left to soil themselves in their beds, too few staff on shift, broken equipment, unsanitary conditions and multiple parts of the facility dirty or in disrepair.

In November, the state named Marshwood a “special focus facility,” subjecting it to a regular on-site inspection twice a year rather than the once-a-year visits required of others. Without improvement over those two years, Marshwood 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.

So far, according to the state, Marshwood has not improved.

State inspectors visited the facility in February and in March issued a 76-page report detailing new and continuing problems there, including:

• Patients unkempt from lack of care, including one who was left undressed from the waist down, covered in a sheet but with their right hip and incontinence brief exposed. Another was seen with dry lips, eyes dirty with a “crusty substance” and hair uncombed.

• Care plans not followed, including staff failing to give residents special cups or utensils needed to safely eat. In one case, a resident was supposed to be supervised while eating but was left alone.

• Written therapy recommendations thrown out by the nurse executive rather than added to patients’ files as required.

• Not enough staff to care for patients. In one case, an inspector saw an unshaven patient in a wheelchair call out “hey” several times from the doorway to their room. The inspector didn’t see any staff respond and later noticed the patient had fallen asleep in the chair, still in the doorway. The patient’s room had a strong urine smell, the inspector said.

• Prescribed medications not kept on hand as required. In one case, a patient missed doses of their antibiotic, bladder medication, urinary tract infection medication, migraine medication and insulin because the facility said they weren’t available.

• Doctor’s orders not processed correctly, leading a new patient to miss two doses of anti-seizure medication. That resident had a seizure and was taken to the hospital. A family member told investigators that the resident kept asking for their medication and Marshwood staff responded, “We’re waiting for them.” The family member pulled the resident from Marshwood against medical advice.

• Parts of the facility and items left soiled or in disrepair, including holes in walls, peeling paint and dirty wheelchairs.

• Patients sent to medical appointments alone, including one who was sent on public transportation even though that patient required nursing care and got confused or couldn’t talk.

• Poor discharge planning for one patient who had been diagnosed with alcohol use disorder, major depression, weakness and impaired coordination, neuropathy, seizures and a broken left clavicle. Even though the patient was considered to be a very high fall risk, they were discharged to a homeless shelter that required them to climb stairs to get to the sleeping area. When the patient called the shelter, they told investigators, the shelter was full anyway.

Maine Department of Health and Human Services spokeswoman Jackie Farwell said Marshwood submitted a plan to correct the problems, but that plan “has not yet been determined to be acceptable and remains under review by CMS.”

Genesis spokeswoman Lori Mayer declined to release that plan of correction, saying it would be “inappropriate” to do so before DHHS accepts and publishes it.

In a cover letter accompanying the 76-page report, DHHS said it is recommending that CMS stop paying for all new Medicaid and Medicare patients to go to Marshwood and impose daily fines if Marshwood doesn’t fix its problems within weeks.

But 10 days after that letter, CMS suspended what it calls “enforcement actions” in the wake of the pandemic. The declaration placed nearly all fines and sanctions on hold.

CMS has put off its consideration of Marshwood until after that suspension has been lifted.

Meanwhile, inspectors found more issues in mid-March.

That 17-page report again detailed a number of problems, including:

• Failure of the facility to report sexual abuse as required after a resident said another resident was following them around and grabbing at their breasts. Investigators learned of the situation when Adult Protective Services got involved. That state agency was concerned that Marshwood was unresponsive after the resident complained and the resident was now “not eating and not sleeping and has been suffering.” The Marshwood social worker who took the resident’s complaint told investigators the situation wasn’t reported because they didn’t know it had to be and that “we couldn’t prove that it happened.”

• Failure to keep patients’ medical orders updated.

• Failure to properly clean CPAP and BiPAP machines used by residents to help their breathing during sleep. In one case, a resident’s face piece was found “visibly dirty with food and debris.” According to machine manufacturers, dirty hoses, tubing and masks can lead to the growth of bacteria or mold, which can cause health problems.

Mayer said Genesis has not yet received that March report.

Maine’s long-term care ombudsman, state legislators and residents’ family members have been trying to keep an eye on problems at the facility, though that effort has been hampered by a ban on visitors in the wake of COVID-19. Still, the ombudsman’s office has been working remotely, reaching out to family members and advocating for residents at Marshwood — and all Maine long-term care facilities — from afar.

“Any problems that are brought to our attention in any manner, we can respond. It’s just more challenging because you can’t be on site,” said Brenda Gallant, executive director for the Maine Long-Term Care Ombudsman Program.

Five months after Marshwood was named a special focus facility, Gallant said she’s concerned about the place.

“I want to see them succeed in providing a high standard of care for residents,” she said. “That’s the goal. You just want to see that. I want the staff to feel a sense of pride in what they do and for families to be reassured. You want that for everybody.”

While regular on-site inspections have been suspended, the state is continuing to respond to complaints. Investigators are working remotely, but they will go to Marshwood, or any Maine facility, if they fear someone’s health or safety is in immediate jeopardy.

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