Marigold Rehabilitation And Health Care Center

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

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 (Resident 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.Resident R2's BIMS (Brief Interview for Mental Status) dated 8/18/25 documents Resident R2 is cognitively intact.Resident R2's Grievance dated 5/8/25 documents, I (Resident 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 (Resident R2). Please let me (Resident R2) know

a date and time that we (the facility) can meet, and I will coordinate with the ombudsman.Resident 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 Resident R2, the facility staff, and the ombudsman.On 8/18/25 at 10:30 AM Resident R2 was lying in a bariatric bed. Resident R2's hair appeared oily and stringy. Resident 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 (Resident 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 (Resident R2) to discuss (Resident 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 (Resident 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 Resident 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 (Resident 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

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Marigold Rehabilitation and Health Care Center

275 East Carl Sandburg Drive Galesburg, IL 61401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 (Resident R2). (Resident R2) requires a large shower bench and cannot fit through the shower doorways. Anytime the staff try, (Resident 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 (Resident R2), or (Resident 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 (Resident R2). (Resident R2) cannot fit through the shower room doors, so we have to give (Resident R2's) bed baths. We used to not have a (mechanical lift) that would work for (Resident R2's) weight. We have a lift that works for (Resident R2) now. (Resident R2) has never been able to get

a shower. The last time we tried to wheel (Resident R2) into the shower room, (Resident R2's) legs scraped on the doorway.

The shower chair with (Resident R2) sitting on it does not fit through the shower doorway. Over two years ago there was a shower chair that worked for (Resident R2), but it broke, and we (the facility) have never gotten a new shower chair that would work for (Resident R2). I have never tried to use a (mechanical lift) to get (Resident 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 (Resident R2). V5 stated, I always give (Resident R2) bed baths because (Resident R2) cannot fit through the shower room doorways. I have never tried to give (Resident R2) a shower and have never tried a (mechanical lift) to get (Resident R2) into

the shower rooms. I just always assumed I was supposed to give (Resident R2) bed baths since (Resident R2) cannot fit into

the shower rooms.On 8/18/25 at 2:10 PM V11 (CNA) and V12 (CNA) verified Resident R2 does not get showers due to having no way to get Resident R2 into the shower room.On 8/19/25 at 9:30 AM V14 (Ombudsman) stated, After (Resident 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 (Resident R2) to discuss (Resident 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 (Resident 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 (Resident R2) not being able to get a shower. (Resident R2) is very upset that she cannot even get a shower and not get her hair washed. The staff cannot get (Resident 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 (Resident R2's) grievance from 5/8/25. (Resident R2) should be offered

a shower at least once a week and the facility should have the proper equipment and shower rooms to accommodate (Resident R2) being able to get a shower at least once a week or whenever she wants. (Resident R2) not receiving a shower for over two years is ridiculous and unacceptable. The staff have not been weighing (Resident 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 (Resident 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. (Resident R2) has not had a monthly weight since January 2025.

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