Marigold Rehab: No Shower in Two Years, Grievance Ignored - IL
The resident, identified in inspection records only as R2, told a federal surveyor on August 18 that she had never been able to get a shower during her stay. "How would you feel if you never could get a shower?" she said. "I have asked over and over and filled out a grievance about at least getting my hair washed and nobody ever gets back to me."
Her hair, she said, gets washed maybe six out of every twelve bed baths she receives. The grievance she filed was dated May 8, 2025. By the time inspectors arrived more than three months later, no care plan meeting had been scheduled. No response had been sent. The prior administrator had told the ombudsman he would follow up. He never did.
The ombudsman, identified as V14, told inspectors she had been raising the shower issue with various managers at the facility for two years. When R2 filed her written grievance in May, the ombudsman hand-delivered it to the prior administrator while he was standing in the director of nursing's office. She told him a care plan meeting needed to happen. He said the care plan coordinator was out of the building and he would get back to her with a date and time. "I have never heard anything back," she said.
The physical problem was straightforward. R2 requires a large shower bench, and the bench with R2 seated on it does not fit through the shower room doorways. A certified nursing assistant who had worked at the facility for four years and had always cared for R2 explained that a shower chair once existed that could accommodate her, but it broke more than two years ago. The facility never replaced it. The CNA said she had never thought to try using the mechanical lift to get R2 into the shower room instead.
A second CNA, who was actively providing care to R2 when inspectors approached her, said she had always given bed baths because R2 couldn't fit through the doorways. She had never tried a mechanical lift either. "I just always assumed I was supposed to give R2 bed baths," she said.
Two other nursing assistants confirmed the same thing later that afternoon. Five staff members, across multiple conversations, all described a situation that had calcified into routine. Nobody had tried an alternative approach. Nobody had escalated it as an unsolved problem requiring a solution. It had simply become the way things were.
The facility's current administrator, V1, told inspectors on August 19 that she had not been informed of R2's May grievance. "R2 not receiving a shower for over two years is ridiculous and unacceptable," she said. She acknowledged that R2 should be offered a shower at least once a week and that the facility was responsible for having equipment and shower rooms that could accommodate her.
The shower access failure was not the only gap inspectors documented. R2 had not been weighed monthly since January 2025. The mechanical lift the facility uses for R2 has a built-in scale, and that scale is broken. The director of nursing told inspectors she had only learned about the missing weights the day before. "The facility does not have a scale that can weigh R2," she said.
Federal inspectors rated the violation as causing actual harm.
R2 told the surveyor she had filled out her grievance hoping someone would at least address getting her hair washed. Three months passed. The ombudsman waited for a phone call that never came. The broken shower chair was never replaced. And the woman who asked, over and over, how anyone would feel going without a shower kept getting bed baths instead.
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: August 4, 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 in inspection records only as R2, told a federal surveyor on August 18 that she had never been able to get a shower during her stay.
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.