Marshall Health Care And Rehab

F-F712 would be recited.

On 8/13/24 at 3:15 p.m., the above concerns were discussed with the Administrator and Director of Nursing.

2. During the annual Long Term Care survey, dated 6/12/24, a deficiency was cited at

F-F812 would be recited.

On 8/13/24 at 3:15 p.m., the above concerns were discussed with the Administrator and Director of Nursing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 205109 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 205109 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Marshall Health Care and Rehab 16 Beal Street MacHias, ME 04654

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35904 potential for actual harm Based on record reviews and interview, the facility failed to ensure residents were offered pneumococcal Residents Affected - Some vaccinations in accordance with the Centers for Disease and Prevention Control (CDC) recommendations for 5 of 6 residents reviewed for immunizations (Resident #5 [R] , Resident R18, Resident R2, Resident R39, and Resident R244).

Findings:

1. Resident R5 was admitted to the facility on [DATE REDACTED]. The CDC recommendation was to review, offer and/or receive one dose of Prevnar 20 which had not been done.

2. Resident R18 was admitted to the facility on [DATE REDACTED]. The CDC recommendation was to administer one dose of Prevnar 20 which had not been done.

3. Resident R2 was admitted to the facility on [DATE REDACTED]. The CDC recommendation was to review, offer and/or receive one dose of Prevnar 20 which had not been done.

4. Resident R39 was admitted to the facility on [DATE REDACTED]. The CDC recommendation was to review, offer and/or receive one dose of Prevnar 20 which had not been done.

5. Resident R244 was admitted to the facility on [DATE REDACTED]. The CDC recommendation was to review, offer and/or receive one dose of Prevnar 20 which had not been done. Resident R244'a pneumococcal vaccination status was reviewed for pneumococcal vaccines that did not include a Prevnar 20 vaccination.

On 6/12/24 at 9:45 a.m. in an interview with the Unit Manager-Infection Preventionist and the Director of Nursing, a surveyor confirmed they are not following CDC recommendations and were unaware of the CDC recommendation to review, offer, and administer the Prevnar 20 vaccination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 205109