Marigold Rehab: Ignored Care Meeting Request - IL
The resident, identified as R2 in the inspection report, filed a formal grievance on May 8 requesting the meeting. She wanted to discuss inconsistent bathing care after certified nursing assistants were switched between halls.
"I have had difficulty with my bath/hair and getting head to toe bath plus my hair shampooed since the CNAs have been switched halls," R2 wrote in her grievance. "I am not consistently getting a full bath and my hair shampooed. I would like to discuss a shower plan at a care plan meeting with the ombudsman to support me."
She asked administrators to coordinate with the ombudsman and provide a meeting date.
Nobody ever scheduled it.
When inspectors arrived in August, R2 was lying in a bariatric bed with hair that appeared oily and stringy. Her frustration had reached a breaking point.
"Nobody listens to me around here," she told inspectors on August 18. "I am trying to find somewhere else to accept me. I asked the prior administrator over and over to have a care plan meeting with the ombudsman present and no one has ever set up a meeting for me."
R2 said she had told "almost all the staff here" about wanting the ombudsman meeting "so I can have a witness and be heard."
The ombudsman confirmed R2's account. After receiving the May grievance, the ombudsman immediately delivered it to the prior administrator, who was meeting with the director of nursing at the time.
"I discussed with them the need to have a care plan meeting with R2 to discuss R2's concerns," the ombudsman told inspectors. "At that time the prior administrator told me that the care plan coordinator was out of the building, and he would get back to R2 and myself with a day and time for a care plan meeting."
The ombudsman never heard back.
Electronic health records show no care plan meeting was ever conducted with R2, facility staff, and the ombudsman between May 8 and the August inspection date. The current administrator confirmed R2 never received her requested meeting.
The breakdown in communication extended to key staff responsible for care planning. The social service director, who schedules care plan meetings, told inspectors she had worked at the facility for two years but was never informed about R2's request.
"I have never been told that R2 would like a care plan meeting with the ombudsman present," the social service director said. "I am responsible for scheduling care plan meetings."
Federal regulations require nursing homes to allow residents to participate in developing their person-centered care plans. The facility's own assessment tool, dated March 19, states that "residents' care is based on their individual needs and preferences and is reflected in the individual's care plan."
The document emphasizes providing "person-centered/directed care" and instructs staff to "assist resident and family caregivers to be involved in person-centered care planning."
R2's mental status evaluation from August 18 confirmed she was cognitively intact and capable of participating in care decisions. Her grievance demonstrated she understood the care planning process and knew her rights to ombudsman support.
The facility's failure violated federal requirements for resident participation in care planning. Inspectors cited the violation as causing minimal harm or potential for actual harm, affecting few residents.
But for R2, the impact was deeply personal. After months of advocacy for basic bathing care and proper hair washing, she remained unheard by the staff responsible for her daily needs.
The resident who wanted a witness to ensure she would be heard was left talking to inspectors about finding somewhere else to live.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marigold Rehabilitation and Health Care Center from 2025-08-19 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: June 20, 2026 · Our methodology
Marigold Rehabilitation and Health Care Center in GALESBURG, IL was cited for violations during a health inspection on August 19, 2025.
The resident, identified as R2 in the inspection report, filed a formal grievance on May 8 requesting the meeting.
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.