Marigold Rehabilitation And Health Care Center
Marigold Rehabilitation and Health Care Center in GALESBURG, IL — inspection on August 19, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on observation, record review, and interview the facility failed to honor a resident's request to conduct a care plan meeting with the ombudsman present for one of three residents (R2) reviewed for resident rights in the sample of three.Findings include:The Facility Assessment Tool dated 3/19/25 documents, The residents' care is based on their individual needs and preferences and is reflected in the individual's care plan.
Provide person-centered/directed care: Psycho/social/spiritual support: Build relationship with resident/get to know him/her/engage resident in conversation, offer and assist resident and family caregivers (or other proxy as appropriate) to be involved in person-centered care planning and advance care planning.R2's BIMS (Brief Interview for Mental Status) dated 8/18/25 documents R2 is cognitively intact.R2's Grievance dated 5/8/25 documents, I (R2) have had difficulty with (my) bath/hair and getting (a) head to toe bath plus my hair shampooed since the CNAs (Certified Nursing Assistant) have been switched halls. 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 (V14/Ombudsman) to support me (R2).
Please let me (R2) know a date and time that we (the facility) can meet, and I will coordinate with the ombudsman.R2's Electronic Health Record dated 5/8/25 (date of grievance) through 8/19/25 does not include documentation of a care plan meeting being conducted with R2, the facility staff, and the ombudsman.On 8/18/25 at 10:30 AM R2 was lying in a bariatric bed. R2's hair appeared oily and stringy. R2 stated, Nobody listens to me around here. I am trying to find somewhere else to accept me. I asked (V15/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. I have told almost all the staff here that I want a meeting with the ombudsman so I can have a witness and be heard.On 8/19/25 at 9:30 AM V14 (Ombudsman) stated, After (R2) wrote the grievance on 5/8/25, I immediately handed it to (V15/Prior Administrator) who was in (V16's/Director of Nurse's) office at the time.
I discussed with (V15) and (V16) the need to have a care plan meeting with (R2) to discuss (R2's) concerns. At that time (V15) 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. I have never heard anything back.On 8/19/25 at 11:00 AM V1 (Administrator) verified R2 has not had a care plan meeting with the ombudsman present.On 8/18/25 at 11:38 AM V9 (Social Service Director) stated, I have worked here for two years and have never been told that (R2) would like a care plan meeting with the Ombudsman present.
I am responsible for scheduling care plan meetings.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Marigold Rehabilitation and Health Care Center
275 East Carl Sandburg Drive Galesburg, IL 61401
SUMMARY STATEMENT OF DEFICIENCIES
never getting a shower. I get bed baths, and my hair only gets washed maybe six out of the 12 times I get a bed bath.
How would you (this surveyor) feel if you never could get a shower? 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. I do not get weighed monthly because the scale on the (mechanical lift) broke.On 8/18/25 at 10:10 AM V3 (LPN/Licensed Practical Nurse) stated, We (the facility) do not have a shower room that can accommodate (R2). (R2) requires a large shower bench and cannot fit through the shower doorways.
Anytime the staff try, (R2's) legs scrape on the doorway of the shower room.
The doorway to the shower rooms needs to be wider in order to fit (R2), or (R2) needs a different shower chair.On 8/18/25 at 10:20 AM V4 (CNA/Certified Nursing Assistant) stated, I have worked here four years and have always taken care of (R2). (R2) cannot fit through the shower room doors, so we have to give (R2's) bed baths. We used to not have a (mechanical lift) that would work for (R2's) weight. We have a lift that works for (R2) now. (R2) has never been able to get a shower.
The last time we tried to wheel (R2) into the shower room, (R2's) legs scraped on the doorway.
The shower chair with (R2) sitting on it does not fit through the shower doorway.
Over two years ago there was a shower chair that worked for (R2), but it broke, and we (the facility) have never gotten a new shower chair that would work for (R2). I have never tried to use a (mechanical lift) to get (R2) into the shower room.
I did not think about using a (mechanical lift).On 8/18/25 at 10:30 AM V5 (CNA) was providing personal cares to (R2). V5 stated, I always give (R2) bed baths because (R2) cannot fit through the shower room doorways. I have never tried to give (R2) a shower and have never tried a (mechanical lift) to get (R2) into the shower rooms. I just always assumed I was supposed to give (R2) bed baths since (R2) cannot fit into the shower rooms.On 8/18/25 at 2:10 PM V11 (CNA) and V12 (CNA) verified R2 does not get showers due to having no way to get R2 into the shower room.On 8/19/25 at 9:30 AM V14 (Ombudsman) stated, After (R2) wrote the grievance on 5/8/25, I immediately handed it to (V15/Prior Administrator) who was in (V16's/Director of Nurse's) office at the time. I discussed with (V15) and (V16) the need to have a care plan meeting with (R2) to discuss (R2's) concerns. At that time (V15) 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. I have never heard anything back. I have been dealing with all different managers for the last two years about (R2) not being able to get a shower. (R2) is very upset that she cannot even get a shower and not get her hair washed.
The staff cannot get (R2) into the shower room as the doorway is not big enough and the facility does not have a shower chair that will fit threw the shower room doorway. On 8/19/25 at 11:15 AM V1 (Administrator) stated, I was not made aware about (R2's) grievance from 5/8/25. (R2) should be offered a shower at least once a week and the facility should have the proper equipment and shower rooms to accommodate (R2) being able to get a shower at least once a week or whenever she wants. (R2) not receiving a shower for over two years is ridiculous and unacceptable.
The staff have not been weighing (R2) monthly. I guess because the (mechanical lift) scale is broke.On 8/19/25 at 12:15 PM V2 (Director of Nursing) stated, The facility does not have a scale that can weigh (R2). I just found this out yesterday.
All residents should be weighed at least once monthly unless a physician's order indicates a resident should be weighed more than monthly. (R2) has not had a monthly weight since January 2025.
Facility ID: