Marshall Health Care: Failed to Report Injury - ME
The resident, identified in inspection records as R1, approached a staff member on the evening of July 24 saying they had hurt their finger. When the nurse asked what happened, the resident said it came from a fall.
Federal inspectors who reviewed the case in August found the facility violated requirements for reporting injuries of unknown origin to proper authorities. The violation carried a designation of minimal harm or potential for actual harm affecting few residents.
Certified Nurse Assistant #1 told inspectors on August 19 that the resident said the injury happened during a fall but couldn't specify where or when. The aide noted the resident "is not reliable in what he/she says" and has behavior problems that could have led to the finger injury "in a number of different ways."
The facility's own abuse policy explicitly requires immediate reporting in such cases. Under the section titled "Reporting Allegations to the Administrator and Authorities," the policy states that if injury of unknown origin is suspected, "the suspicion must be reported immediately to the Administrator and to other officials according to state law."
The policy further specifies that "the Administrator or the individual making the allegation immediately reports his or her suspicion to" the state licensing and certification agency.
None of that happened.
When inspectors interviewed the Administrator and Assistant Director of Nursing on August 19, both acknowledged the resident has impaired cognition and mental health diagnoses. The Assistant Director of Nursing said when staff notified her of the incident, they described it as the resident saying "she fell out of bed."
The nursing director characterized it as "an unwitnessed fall with injury" and acknowledged uncertainty about what actually occurred. "The resident is a poor historian, and it could have been a fall or something else could have caused the injury," she told inspectors.
The Administrator confirmed the resident's unreliable recall of events made the injury's cause uncertain. Both administrators acknowledged to inspectors that "the injury was of unknown origin and should have been reported to the State Agency."
Federal regulations require nursing homes to immediately report suspected abuse, neglect, theft, and injuries of unknown origin to state authorities and document the results of any investigation. The requirement exists specifically for cases where residents cannot provide reliable accounts of how injuries occurred.
Marshall Health Care's policy mirrors these federal requirements, making the facility's failure to report particularly significant since administrators were aware of their own procedures.
The inspection narrative indicates the resident has multiple diagnoses including mental health issues, dementia, and cognitive impairments. These conditions would make the resident particularly vulnerable and unable to provide consistent accounts of incidents.
Documentation in nursing notes from July 24 captured the initial report of the injury, with the resident telling staff it happened from a fall. But the lack of specifics about when, where, or how the fall occurred should have triggered the reporting requirements.
The Assistant Director of Nursing's acknowledgment that "something else could have caused the injury" underscores why the incident qualified as an injury of unknown origin requiring state notification.
Federal inspectors reviewed four residents who had injuries of unknown origin during their complaint investigation. Marshall Health Care failed to properly report one of the four cases to state authorities.
The violation occurred despite clear facility policies and federal requirements designed to protect vulnerable residents who may be unable to accurately report incidents due to cognitive impairments or other conditions.
Nursing homes must report suspected incidents immediately, not after determining definitively what occurred. The reporting requirement exists precisely because facilities cannot always determine the cause of injuries, particularly among residents with dementia or other cognitive impairments.
The Administrator and Assistant Director of Nursing's acknowledgment during the inspection that the injury should have been reported to the state agency confirms they understood the requirements but failed to follow them.
The resident's description of falling, combined with their inability to provide reliable details and the staff's recognition that "something else could have caused the injury," clearly met the threshold for an injury of unknown origin requiring immediate state notification.
Federal inspectors conducted their review as part of a complaint investigation on August 19, examining the facility's handling of injuries of unknown origin among residents.
The violation highlights the challenges nursing homes face in protecting vulnerable residents with cognitive impairments who may be unable to provide accurate accounts of incidents. Federal reporting requirements exist specifically to ensure proper oversight and investigation of such cases.
Marshall Health Care's failure to follow its own written policies raises questions about staff training and administrative oversight of incident reporting procedures.
The facility's policy explicitly states that suspected injuries of unknown origin must be reported "immediately" to both the Administrator and state authorities. The policy leaves no room for interpretation about timing or circumstances requiring notification.
The resident's finger injury remains documented in clinical records, but the lack of state notification meant regulatory authorities had no opportunity to investigate the incident or determine whether additional protections were needed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marshall Health Care and Rehab from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Marshall Health Care and Rehab
- Browse all ME nursing home inspections
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
MARSHALL HEALTH CARE AND REHAB in MACHIAS, ME was cited for violations during a health inspection on August 19, 2025.
The resident, identified in inspection records as R1, approached a staff member on the evening of July 24 saying they had hurt their finger.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at MARSHALL HEALTH CARE AND REHAB?
- The resident, identified in inspection records as R1, approached a staff member on the evening of July 24 saying they had hurt their finger.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in MACHIAS, ME, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from MARSHALL HEALTH CARE AND REHAB or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 205109.
- Has this facility had violations before?
- To check MARSHALL HEALTH CARE AND REHAB's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.