Marshall Nursing and Rehab: Falsified Records, UTI Hospitalization - MI
The resident, identified in inspection records only as R2, arrived at the ER on June 25, 2025, with altered mental status. A urine test performed in the emergency room came back positive for a urinary tract infection. She was admitted to the hospital, placed on intravenous antibiotics, and stayed for six days. She did not return to the facility until July 1.
A nurse had signed her initials on R2's treatment administration record indicating the urine test had been collected. It had not been.
Licensed Practical Nurse D, interviewed by inspectors on August 19, said she and two CNAs had tried three times on June 5 to obtain the urine sample but could not. She said she did not call R2's physician to report that. Asked the following morning about her initials on the record, LPN D said she did not recall signing them. Shown the record, she confirmed the initials were hers. She acknowledged the urine test was never performed and that she had not notified the physician.
"There was no process that was followed with transcribing physician's orders," LPN D told inspectors. She said physician orders were not being transcribed correctly.
That failure went back further than June. RN C, interviewed on August 20, said she could recall the order for R2's urine test in June but could not recall one from May. When she reviewed R2's electronic medical record with inspectors, she said she did not see any record of anyone calling the physician about the failed June collection attempt. She also said she found no urine test results for an order that had been placed on May 20.
"The practice/process at the facility for transcribing orders was not very good," RN C said.
CNA E described watching R2 decline. She told inspectors that R2 had become more confused in the days before the hospitalization, that she would stare and not react. By June 25, R2 was more confused and sleepier than she had been. That had been going on, CNA E said, for about three days before R2 was sent to the hospital.
A urinary tract infection in an elderly person often does not present the way it does in younger patients. Fever and burning may be absent. What appears instead is confusion, lethargy, a person who seems suddenly somewhere else. The family member in the ER knew what it was. She had been trying to get the facility to check for two weeks.
The inspection, conducted August 20, 2025, was triggered by a complaint. Inspectors cited the facility under F0684, which covers the standard of care residents are entitled to receive. The level of harm was classified as minimal harm or potential for actual harm, affecting few residents.
That classification reflects regulatory language. What it describes is a woman who grew more confused and harder to reach over the course of weeks while a test her doctor ordered went uncollected, a record was falsified to show otherwise, and no one called the physician to say what had actually happened. Her family eventually got her to the emergency room. The hospital got her the IV antibiotics she needed. She was gone from the facility for nearly a week.
The family member's account to the ER physician, recorded in the hospital's history and physical report, is the clearest documentation in the record of what those two weeks looked like from outside the facility's walls.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marshall Nursing and Rehabilitation Community from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
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: July 3, 2026 · Our methodology
Marshall Nursing and Rehabilitation Community in Marshall, MI was cited for violations during a health inspection on August 20, 2025.
The resident, identified in inspection records only as R2, arrived at the ER on June 25, 2025, with altered mental status.
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.