North Shore Healthcare at Marshfield

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R8) of 4 sampled residents received the necessary care and services to prevent pressure injuries from developing and/or promote healing. R8 had a pressure injury on the right heel. During an observation of wound care, Licensed Practical Nurse (LPN)-J used soiled scissors to cut gauze that was directly applied to the pressure injury on R8's right heel.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 3 residents (R) (R3, R7, and R35) of 10 residents observed during medication administration. Medication Technician (MT)-D did not complete hand hygiene prior to or after administering medication to R3, R7, and R35.

Inspectors wroteBased on staff interview and record review, the facility did not ensure influenza vaccines were offered and/or administered for 2 residents (R) (R41 and R5) of 5 sampled residents.

Inspectors wroteBased 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.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Minimum Data Set (MDS) assessment was accurate for 1 resident (R) (R1) of 1 sampled resident. R1 was admitted to the facility with a surgical incision that was not represented to R1's admission MDS assessment. R1 also had a stage 3 pressure injury that was not represented on R1's Discharge MDS assessment.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a complete baseline care plan was developed within 48 hours of admission for 1 resident (R) (R1) of 1 sampled resident. R1 had a surgical incision and was at risk for pressure injury upon admission. The facility did not develop a baseline care plan that indicated R1 had impaired skin integrity or included interventions for treatment and prevention.

Inspectors wroteBased on observation, staff interview and record review, the facility did not assess the risk for entrapment, review the risks and benefits, and obtain consent for the use of side rails for 1 resident (R) (R2) of 3 sampled residents. R2's bed contained side rails. The facility did not complete an assessment or obtain consent for side rails from R2's Power of Attorney (POA).

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection for 1 resident (R) (R8) of 1 resident observed during the provision of care. During the provision of care for R8, Certified Nursing Assistant (CNA)-E did not remove soiled gloves after incontinence care and did not wash or sanitize hands before touching R8 and objects in R8's room.

Inspectors wroteBased on staff interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse for 1 (Registered Nurse (RN)-C) of 8 facility and contracted staff reviewed for caregiver background checks. The facility did not ensure a thorough caregiver background check was completed for RN-C.

Inspectors wroteBased on staff interview and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 1 resident (R) (R42) of 24 sampled residents. R42 had an order for daily weights and to notify the physician if R42's weight increased more then 3 pounds in a day or 5 pounds in a week. R42 was not weighed on 3 occasions between 3/1/25 and 3/22/25. In addition, the physician was not notified on 3 occasions when R42's weight was outside the ordered parameters.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure smoking interventions were followed for 2 residents (R) (R36 and R45) of 3 sampled residents. R36's smoking assessment and care plan indicated R36's smoking materials should be stored at the nurses' station. The smoking assessment and care plan were not consistently followed. R45's care plan contained interventions to sign out when R45 went outside to smoke and to return smoking materials to the nurses' station. The interventions were not consistently followed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide appropriate catheter care and services for 1 resident (R) (R15) of 3 sampled residents. R15 had a history of urinary tract infections (UTIs) and was diagnosed with a UTI on 3/11/25. On 3/25/25, R15's Foley catheter drainage bag and catheter tubing were observed on the floor.

Inspectors wroteBased on staff interview and record review, the facility did not ensure enteral feedings were provided as ordered for 1 resident (R) (R34) of 1 sampled resident. R34 was not administered supplemental feedings via enteral tube as ordered.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the accurate and safe administration of medication for 2 residents (R) (R38 and R156) of 24 sampled residents. On 3/24/25, Surveyor observed medication at R38's bedside. R38 did not have a physician's order for the medication. In addition, R38 did not have a physician's order to self-administer medication and was assessed as not able to self-administer medication. On 3/24/25, Surveyor observed three medications at R156's bedside. R156 did not have a physician's order for one of the medications. In addition, R156 did not have a physician's order to self-administer medication and was assessed as not able to self-administer medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure protective placement was obtained for 3 Residents (R) (R11, R12, and R14) of 3 sampled residents. R11 had a court-ordered guardian and was admitted to the facility on [DATE]. The facility did not petition for protective placement when R11's stay exceeded 60 days. R12 had a court-ordered guardian and was admitted to the facility on [DATE]. The facility did not petition for protective placement when R12's stay exceeded 60 days. R14 had a court-ordered guardian and was admitted to the facility on [DATE]. The facility did not petition for protective placement when R14's stay exceeded 60 days.

Inspectors wroteBased on staff interview and record review, the facility did not ensure smoking assessments were completed for 1 Resident (R) (R42) of 2 residents reviewed. R42 was an active smoker and had a diagnosis of nicotine dependence. The facility did not complete smoking assessment for R42 per their policy.

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, and administered for 3 Residents (R) (R37, R28 and R47) of 5 residents reviewed for vaccines. The facility did not review R37's vaccination history or offer R37 the PCV20 (Prevnar 20®) vaccine. The facility did not review R28's vaccination history or offer R28 the Prevnar 20® vaccine. The facility did not review R47's vaccination history or offer R47 the PPSV23 (Pneumovax23®) or the Prevnar 20® vaccine.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 4 Residents (R) (R11, R40, R56, and R59) of 4 residents received the required information when discharged /transferred from the facility. R11 was transferred to the hospital on [DATE] and 12/12/23 and was not provided a written transfer notice. R40 was transferred to the hospital on 7/6/23 and was not provided a written transfer notice. R56 was transferred to the hospital on 9/21/23, 10/14/23, 11/6/23, and 12/2/23 and was not provided a written transfer notice. R59 was transferred to the hospital on 7/6/23 and 7/30/23 and was not provided a written transfer notice.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 Residents (R) (R11, R40, and R56) of 3 residents who were transferred to the hospital received the required written information of the duration of the facility's bed hold policy, the reserve bed hold payment rate, and the right of the resident to return to the facility. R11 was transferred to the hospital on [DATE] and 12/12/23 and was not provided a bed hold notice that contained the required information. R40 was transferred to the hospital on 7/6/23 and was not provided a bed hold notice that contained the required information. R56 was transferred to the hospital on 9/21/23, 10/14/23, 11/6/23, and 12/2/23 and was not provided a bed hold notice.