Inspection·July 6, 2024

F 0558 larger (mechanical lift) was delivered today around 2:15 PM for staff to help (R1) get out of bed. Level of Harm - Minimal harm or potential for actual harm R1's Behavior Note written by V24/Assistant Director of Nursing/ADON dated 5/9/24 at 2:43 PM, documents Nurses discussed (R1's) refusal to get out of bed and process for getting weighed. (R1) states she was told that the equipment we have is not safe to lift her. Nurse reassured her that the equipment is safe and that (R1) needs to try and get out of bed due to (R1's) health issues and weight gain. Residents Affected - Few R1's Nursing Note written by V2/Director of Nursing/DON dated 6/29/24 at 9:23 AM, documents writer phoned (mechanical lift company) on 6/28/24. New total (mechanical lift) will be delivered this date as well as an in-service presented by (mechanical lift company) at time of delivery pertaining to safety precautions, function buttons, and general use of lift. CP (Care Plan) updated for (R1) to be encouraged to get out of bed every shift as well as orders per (R1's Primary Care Physician). On 6/28/24 at 10:45 AM, V6/CNA and V7/CNA were preparing to transfer R1 out of bed. V1/Administrator was in the room during this time. V6/CNA grabbed the new (mechanical lift) that had a maximum weight transfer of 750 pounds. V6 and V7 placed a (mechanical lift) sling under R1 and hooked the straps to the (mechanical lift) appropriately. V7/CNA started to lift R1 with the electric remote while V6 was helping guide R1. As R1 was being lifted off the bed, the (mechanical lift) stopped raising up any further. R1's bottom was still touching the bed. V6 then attempted to lower R1's bed to the lowest position in an attempt to be able to transfer R1 with the (mechanical lift). With the bed being in the lowest position, R1 was still unable to be lifted high enough to transfer from the bed to the wheelchair. V7 then lowered R1 back down on the bed. V6 went and got the blue (mechanical lift) that was for a maximum weight of 500 pounds. V6 stated, We (the staff) don't like to use this one because it gets stuck and won't lift (R1) up once we have her transferred. Then we are unable to get (R1) back in bed. V6 and V7 proceeded to hook R1's sling to the blue (mechanical lift). V6 and V7 were able to lift R1 off the bed and transfer R1 to her wheelchair. On 6/28/24 at 1:30 PM, R1 was sitting in her wheelchair. V6/CNA and V7/CNA were preparing to transfer R1 back to bed using the blue (mechanical lift). V6 and V7 hooked the sling to the blue (mechanical) lift and V6 started to raise R1 up using the electric remote. R1 was lifted up slightly off her wheelchair when the blue (mechanical lift) stopped working. V6 and V7 both tried three different batteries on the (mechanical lift) with no success. V7 stated, This is why we don't use this one. (R1) has got stuck before and we had to call an ambulance to come transfer her back to bed. None of these (mechanical lifts) have worked for her since April 2024. V1/Administrator came to R1's room and verified the blue (mechanical lift) stopped working even with three different battery changes. On 6/28/24 at 8:55 AM V5/LPN stated, We (the facility) have not been able to get (R1) out of bed for a while due to the (mechanical lift). (R1) is around 500 pounds and our (mechanical lift) is for 750 pounds but it will not lift (R1), we have tried. We let (V2/DON) know, and (V2) stated it was the sling. (V2) ordered a new sling but it still doesn't work. (R1) does refuse to get out of bed at times, but she is not happy about not being able to get up when she wants to. On 6/28/24 at 9:50 AM, R1 stated, (V1/Administrator) and (V2/DON) won't do anything about the (mechanical lift) not being able to transfer me out of bed. I don't want to get up every day or all of the time, but when I want to get up, I should be able to. They just say I refuse anyway so they won't do anything about it. (V2) ordered a new (mechanical lift) a couple of months ago and I have told (V1) and (V2) it does not lift me out of the bed. (V2) said it was the sling and finally ordered a new sling a couple of weeks ago. The new (mechanical lift) still won't lift me off the bed. (V1) has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 2 of 16 Printed: 05/15/2026 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 145446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2024 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 - Minimal harm or potential for actual harm Residents Affected - Few been aware of it, but (V1) wants me to go somewhere else that deals with bariatric patients, and I don't want to go anywhere else. I feel like they should be able to take care of me here. I don't feel safe when transferring when the (mechanical lifts) have has almost tipped in the past or it won't lift me up all the way. (V1) or (V2) have never come to my room to observe what the (mechanical lifts) is doing. On 6/28/24 a 12:00 PM, V9/CNA stated, (R1) does refuse to get up at times, but we also do have a problem with the (mechanical lift). The new (mechanical lift) the facility told us to use won't lift (R1) up off the bed, and the blue (mechanical lift) goes dead too quickly. (V2/DON) and (V1/Administrator) are aware. On 6/28/24 at 12:05 PM, V8/CNA stated, (R1) has begged me to get her up multiple times while I was working with her. I have tried to use the new (mechanical) lift and the sling would not lift (R1) all the way up off the bed. We tried it on another resident, and it did the same thing. Then the blue (mechanical lift) tipped forward with (R1) in it one time when we were transferring (R1). It didn't tip all of the way over, but it scared us, and we put her right back down. I don't think the blue (mechanical lift) is safe for (R1) and we have let (V2/DON) know several times. On 6/29/24 at 11:57 AM, V2/DON stated, Around April of this year we (the facility) started having trouble with the (mechanical lift) that lifted (R1). They (facility staff) told me that it would lift (R1) up then would stop, but if they took the battery out and put it back in, it would work. I wasn't here when the staff attempted to transfer (R1) to bed with the blue (mechanical lift) and it stopped. I know they (facility staff) had to call an ambulance to get (R1) back in bed. I contacted our medical supply company and ordered the new (mechanical lift) to rent. The (mechanical lift) I ordered was for residents that weighed up to 750 pounds. When the (mechanical lift) was delivered the staff came and told me the sling wasn't working with that (mechanical lift). The staff stated the straps from the mechanical lift sling were too long, so it wouldn't lift (R1) up high enough to transfer (R1) out of bed. I then ordered a new sling for that (mechanical lift), but I ordered the wrong one. I ordered one with the same problem. I reached back out to our supply company and asked them to send the same sling that goes with that particular (mechanical lift). The new sling came in and has been here for a couple of weeks. No one let me know the new sling still wasn't working and the (mechanical lift) was still not lifting (R1) up high enough until yesterday. Staff were instructed to use the new (mechanical lift), but I did not know at the time the new (mechanical lift) wasn't working. I did not want them to use the blue (mechanical lift) if it wasn't working properly. I am going to send that (mechanical lift) back and order a new one to see if it will work. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 3 of 16 Printed: 05/15/2026 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 145446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent abuse for four of seven residents (R9, R10, R11, and R12) from resident-to-resident physical abuse and failed to prevent resident-to-resident sexual abuse for one resident (R3) reviewed for abuse in the sample of 26. These failures resulted in R3 physically assaulting R11 by hitting R11 in the left arm, R3 physically assaulting R10 by shoving R10 down to the ground resulting in R10 having a contusion of the scalp and severe pain requiring an emergency room visit, R3 punching R9 in the face, and R3 throwing water on R12. These failures also resulted in R4 sexually assaulting R3 by putting his left hand down R3's pants and briefs when R3 went into R4's room. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 7/6/24 the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: The Abuse, Prevention and Prohibition Policy dated 1/24 documents Statement of Intent Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Policy This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The resident must not be subjected to abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. Annually, the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement. Prevention: The resident has the right to be free from verbal, mental, sexual, exploitation, or physical abuse; corporal punishment and involuntary seclusion. The owner, licensee, Administrator, employee, or agent of the facility shall not abuse or neglect a resident and must prohibit the misappropriation of resident property. Resident behaviors will be monitored for changes, which trigger abusive behaviors. The facility will reassess care plan interventions on a regular basis. Intervention strategies based on resident screenings will be implemented to prevent occurrences of abuse. 1. R3's Face Sheet documents R3 was admitted to the facility on [DATE]. This same form documents the following, but not limited to, diagnoses: Unspecified Dementia and Major Depressive Disorder. R3's MDS (Minimum Data Set) assessment dated [DATE], documents, R3 is severely cognitively impaired, has delusions and behaviors of physical and verbal aggression that impacts others, wanders and significantly intrudes on the privacy or activities of others, wanders and is at significant risk of getting to a potentially dangerous place, is at significant risk for physical illness or injury, puts others at significant risk of physical injury, and significantly intrudes on the privacy or activity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 4 of 16 Printed: 05/15/2026 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 145446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2024 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 0600 of others. Level of Harm - Immediate jeopardy to resident health or safety R3's Care Plan dated 6/25/24, documents R3 has behaviors of being verbally aggressive towards staff, being physically aggressive with others, and is known to wander into other residents' rooms. This same care plan does not include interventions addressing R3 shoving down R11. Residents Affected - Some R3's Behavior Note written by V4/Licensed Practical Nurse/LPN dated 3/30/24 at 1:26 PM, documents (R3) was in the room when CNA (Certified Nursing Assistant) attempted to redirect (R3) out of the room. (R3) became agitated/verbally aggressive and started swinging at CNA. (R3) told CNA to get out. (R3) then came out of the room and went down the hall and asked another resident (R11) to help (R3) and (R3) then punched and shook another resident (R11) on left arm. R3's AIMs (Assessment Intercommunicate Management) dated 3/30/24 documents that R3 appears to have been involved in an altercation with a peer (R11). Just prior to the time of the event R3 appears to have been in another resident's room. V32/CNA stated R3 was in another room and V32 attempted to redirect R3 and R3 became aggressive. The incident happened in the hallway. R3 has a history of physical aggression towards staff and other residents at other nursing (facilities). R11's current computerized medical record, documents R11 is an [AGE] year old female that admitted to the facility on [DATE] with diagnoses which included Dementia, with Psychotic Disturbance, Depressive Disorder, and Chronic Obstructive Pulmonary Disease. R11's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 4/15, indicating (severe cognitive impairment). R11's Nursing Note written by V4/LPN dated 3/30/24 at 1:41 PM, documents, CNA reported that another resident (R3) came up to (R11) and asked (R11) to help (R3) then proceeded to hit (R11) in the left arm and shake (R11's) arm. CNA was able to intervene. Voice mail left for administrator at 1:11 PM d/t (due to) no answer. On 7/2/2024 at 9:04 AM, V32/Agency CNA stated, I haven't worked at (the facility) for a few months. When I was working at (the facility) there was a resident (R3) who was swinging on everyone that day. (R3) punched and shook (R11's) left arm. (R3) was swinging her arms so hard, she even swung herself to the floor. (R3) was being very aggressive and trying to punch everyone. On 6/30/24 at 3:15 PM, V25/R11's Power of Attorney/POA stated that earlier this year she was notified that R11 was hit in the back of the head and shook by another resident (unidentified). V25 asked if R11 had done anything to the resident to provoke the incident. V25 was told No, (R11) did not do anything to the other resident. 2. The Final Report sent to the (State agency) dated 5/21/24 at 8:06 AM, documents that on 5/16/24 R10 BIMs/Brief Interview of Mental Status of 15 (indicating cognition intact) and R3 BIMs of 0 (indicating severe cognitive impairment) had a verbal altercation. Witness statements stated that they heard R10 yelling at R3 What are you doing. Get out of here. Before staff could intervene, R3 pushed R10 and R10 fell hitting her head. This event happened as R10 was leaving the bathroom. R10 was assessed with no injuries but was sent to the Emergency Department for an evaluation due to hitting her head. R3's Behavior Note written by V18/LPN dated 5/16/24, at 4:27 PM, documents (R3) is agitated. (R3) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 5 of 16 Printed: 05/15/2026 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 145446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety was yelling and pushing (V18). (R3) tried shutting the door on (V18). (R3) is refusing to allow roommate (identified as R10) into (R3's) room. (V18) talked calmly to (R3) and (R3) calmed down. (R10) asked CNA to get something out of room. (R3) placed hands on the CNA and was pushing and yelling at the CNA and trying to shut the door on the CNA. (R3) reached out to scratch CNA on the face. (V18) stepped in and asked (R3) to stop and remove her hands from the CNA. (R3) did. Then (R3) became angry and yelling at (V18). (R3) was raising her hand to scratch or hit (V18). (V18) and CNA left the room. Residents Affected - Some R3's Behavior Note written by V18/LPN dated 5/16/24 at 5:05 PM, documents (R3's) roommate (identified as R10) was in the bathroom. There was an altercation between (R3) and (R10). (R10) ended up on the floor in the adjoining room. (R10) stated she bumped her head on floor. R3's current Care Plan does not include interventions addressing R3 shoving R10 down. R10's current computerized medical record, documents R10 is an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis which Dementia, Depression, Essential (Primary) Hypertension, and End Stage Renal Disease. R10's MDS (Minimum Data Set) assessment dated [DATE], documents a BIMS (Brief Interview for Mental Status) Score of 9/15, indicating moderate cognitive impairment. R10's AIMS dated 5/16/24 and signed by V18/LPN documents that R10 had an unwitnessed change in plane at approximately 5:05 PM on 5/16/24. Just prior to the time of the event R10 appears to have been using the bathroom in her room. R10's account of the event is R10 stated her roommate (identified as R3) was standing in the doorway. The next thing R10 remembered was them arguing and R10 ending up on the floor. Staff responded when R10 was yelling for help. R10 stated her only pain was the bump on the back of her head. V18/LPN sent R10 to the local ED (Emergency Department) because of a golf ball size bump on the back of R10's head. R10's Nursing Note dated 5/16/24 at 5:1 PM written by V18/LPN documents, (R10) sent to the hospital because of golf ball sized bump on back of head from incident and right pupil not responding to light. R10's ED (Emergency Department) discharge note dated 5/16/24 documents, Primary Diagnosis: Contusion of scalp. Reason for Visit: Assault Victim and Neck Pain. (R10) here from (the facility). (R10) was hit by her roommate (R3) causing (R10) to fall to the ground. (R10) hit the back of her head. Originally not complaining of any pain but EMS (Emergency Medical Services) reports that in route (R10) started to complain of head and neck pain. C-collar applied. Trauma: Reports headache and neck pain. Neck Pain: associated symptoms- headache. R10's Statement dated 5/17/24 documents another resident (identified as R3) pushed R10 down. R10 was standing in the bathroom doorway talking to someone in the next room. R10's roommate (R3) came up and pushed R10 down. V4/LPN Written Statement dated 5/20/24 about the incident between R3 and R10 documents that R3 gets upset/agitated upon redirection and/or others raising their voice at R3. R3 is difficult to redirect. R10 raises her voice loudly and will yell out to others Why are you in there? What are you doing? Get out of there. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 6 of 16 Printed: 05/15/2026 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 145446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 6/30/24 at 10:19 AM, R10 stated, I don't remember what exactly happened. I just know someone pushed me down and my neck and head were hurting. I went to the hospital. On 7/1/24 at 10:27 AM, V20/R10's POA stated that she was told R10's roommate (R3) pushed R10 and R10 fell hitting her head and was sent to the hospital. (R3) would take R10's clothes. After R10 was pushed and hit her head R10 was moved to another room. R10 is not able to express herself now. V20 was asked how R10 would have felt about being pushed by someone when R10's cognition was intact. V20 stated that R10 had a rough childhood and R10 would have been aggravated and upset. On 7/1/2024 at 4:08 PM V18/LPN stated, I did not witness the altercation between (R3) and (R10), but (R10) was cognitively intact then. (R10) told me (R3) was trying go in the bathroom where (R10) was, (R10) was telling (R3) to get out and (R3) went up to (R10) and shoved her down. 3. The Final Report sent to the (State agency) dated 6/18/24 at 2:53 PM, documents that V12/Certified Nursing Assistant/CNA alerted nursing staff that R9 reported that R3 Punched (R9) in the face and told R9 to get out of bed. R9 was assessed and there were no apparent injuries. Conclusion: R3 got in roommate R9's bed. R3 wanted R9 to get out of the bed due to R3 thinking it was her bed. Neither resident remembers the event after it occurred. R3's Nursing Note written by V26/LPN dated 6/14/24 at 5:38 AM, documents CNA alerted (V26) that (R3) had punched (R3's) roommate (R9) in the face and told her to get out of bed. CNA separated the residents from each other and (R3) laid down in (R9's) bed. (V26) with another nurse was able to get (R3) to her own bed with no altercation. R3's current Care Plan dated 6/25/24 does not include interventions addressing R3 punching R9. R9's current computerized medical record, documents R9 is a [AGE] year-old female that admitted to the facility on [DATE] with diagnosis which included Osteoarthritis, Depressive Disorder, Recurrent, Severe with Psychotic Symptoms, Dementia, Delusional Disorder, and Alzheimer's Disease. R9's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 4/15, indicating severe cognitive impairment. R9's Progress Note dated 6/14/24 at 5:42 AM written by V26/LPN documents that a CNA alerted V26/LPN that R9 had been punched in the right side of her face. R9 stated that R3 punched R9 in the face and told R9 to get out of bed. The CNA separated the R3 and R9 and R3 then laid down in R9's bed. V12/CNA Written Statement dated 6/14/24 documents that R3 was in her roommate (R9's) bed. R9 wanted R3 to get out of R9's bed. R3 hit R9 in the face. On 6/30/24 at 7:34 PM, V19/R9's POA stated that she was told R9 was hit in the jaw by R9's roommate (identified as R3). The facility moved the roommate (R3) to another room. There were several times before the incident happened when V19 went to visit R9, and the roommate (R3) would be in R9's bed or messing with R9's clothes. V19 also stated I would start to say something to the roommate (R3) and (R9) would say Oh, no, leave (R3) alone its ok. V19 was asked if she thought R9 was afraid of R3. V19 stated That's very possible. I know (R9) never wanted me to say anything to her roommate (R3) and (R9) was not that way with anyone else. On 7/2/24 at 9:06 AM an attempt was made to contact V12/CNA with no answer or return call back. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 7 of 16 Printed: 05/15/2026 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 145446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2024 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 0600 4. R3's Nursing Note written by V4/LPN dated 6/19/24 at 5:22 PM, documents (R3) threw a partial glass of water on another resident (R12). (R3) keeps trying to get more water to throw on staff and other residents. Level of Harm - Immediate jeopardy to resident health or safety R3's current Care Plan dated 6/25/24 does not include interventions addressing R3 throwing water on R12. Residents Affected - Some R12's current computerized medical record, documents R12 is an [AGE] year old male that admitted to the facility on [DATE] with diagnosis which included Alzheimer's, Dementia, and Essential (Primary) Hypertension. R12's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 9/15, indicating moderate cognitive impairment. R12's current computerized medical record, documents no evidence of the incident between R3 and R12 on 6/19/24. On 6/29/24 at 2:00 PM V4 stated, I was here on 6/19/24 when (V13/CNA) came and told me (R3) threw a half glass of water on (R12). I reported it to the (V1/Administrator) immediately. (V1) told me it was not abuse and it was just a behavior and to document on it. I received an order for Haldol (antipsychotic) because (R3) was throwing on staff as well and trying to take the water pitcher off my nursing cart. (R3) kept getting water other places as well and was trying to throw it on everyone. We (the staff) were having a hard time re-directing and getting (R3's) behavior to stop. 5. The Final Report sent to the (State agency) dated 6/10/24 at 3:16 PM, documents Incident Description CNA walking by (R4's) room and saw (R4) sitting in recliner leaning over toward (R3), (R3) was laying in (R4's) bed) CNA went into (R4's) room to remove (R4's) hand from inside (R3's) pants. (R3) and (R4) were immediately separated. Resident and staff interviews completed. (R3) wanders and had gone into (R4's) room to lay in (R4's) bed. (R3) was laying on her side with her back to the door talking to (R4) when the staff went into separate them. (R3) was upset and didn't want to leave the room. (R3's) Care Plan updated to reflect aggression when trying to re-direct and wanders in rooms. (R3) to be monitored closely while wandering. (R4) to be monitored for inappropriate sexual behaviors. Medication for (R3) was adjusted to assist with agitation. R4's current computerized medical record, documents R4 is a [AGE] year-old male that admitted to the facility on [DATE] with diagnosis which included Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, and Major Depressive Disorder. R4's MDS (Minimum Data Set) dated 4/22/24 documents a BIMS (Brief Interview for Mental Status) Score of 00/15, indicating (severe cognitive impairment). This same MDS documents R4 has no upper or lower extremity impairment, uses a wheelchair or walker for mobility, and requires supervision for ADL's (Activities of Daily Living). R4's Progress Note written V18/Agency LPN dated 6/4/24 at 3:00 PM, documents, CNA's stated (R4) was in the chair next to the bed. A female resident (R3) was lying in the bed next to the chair. (R4) leaned over and had his hand down the front of the female resident (R3) pants. R3's Behavior Note dated written by V4/ LPN dated 6/4/24 at 6:33 AM, documents (R3) is wandering (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 8 of 16 Printed: 05/15/2026 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 145446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2024 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 0600 and rummaging in others (other residents) rooms. Level of Harm - Immediate jeopardy to resident health or safety R3's Nursing Note written by V18/LPN dated 6/4/24 at 3:00 PM, documents CNAs stated (R3) was lying in another resident's bed. A male resident (R4) was sitting in the chair next to the bed. (R4) leaned over and had his hand down the front of (R3's) pants. V18 notified V1/Administrator and V29/Unit Manager. Residents Affected - Some Written Witness Statement by V16/Agency CNA dated 6/4/24, documents At 2:40 PM while doing rounds, we enter (R4's) room to find (R4) leaning over (R3) while (R3) was laying on bed. (R4) drew his hand back and sat up and closed his eyes. We instructed (R3) to get up and come out for snack. (R3) resisted. We stepped outside door. We peeked back in room to find (R4) leaned over again with his hands down (R3's) pants. At that point we helped (R3) put her shoes on and guided (R3) to the TV (television) room. Written Witness Statement by V13/CNA dated 6/4/24, documents that at 2:40 PM while doing afternoon rounds V13 entered R4's room to find R4 leaning over R3 while R3 was lying in a bed. As R4 set up R4 drew his hand back and closed his eyes. R3 was asked to please get up and R3 resisted. V13 stepped outside R4's room to figure a plan to get R3 out of R4's room. V13 looked back in the room to find R4 leaned over again with his hand down R3's pants. R3's shoes were put on her and R3 was taken out of R4's room. The incident was reported to the unit nurse immediately. Written Witness Statement by V4/LPN dated 6/10/24 documents that R3 wanders and roams in and out of multiple rooms. R3 is difficult to redirect and come can become verbally and physically aggressive. On 6/28/24 at 3:00 PM V13/CNA stated, (R3) wandered into (R4's) room and laid down in (R4's) roommate's bed. I had noticed (R3) in (R4's) room so (V16/Agency CNA) and I entered (R4's) room. When (V16) and I entered the room was in the recliner leaning over to the bed (R3) was lying in. I immediately noticed (R4) jerk his hand away from (R3) and sat up in the recliner. (V16) and I attempted to re-direct (R3) out of the room. (R3) started kicking and slapping us, so I just said let's leave (R3) alone because we are not going to be able to get (R3) out when she is agitated. When (V16) and I got past the doorway to (R4's) room we turned around in the doorway and noticed (R4) was leaning over the bed (from the recliner) where (R3) was laying and had his left hand underneath her pants touching (R3's) private area. (V16) and I then immediately entered the room and was able to immediately separate them and get (R3) out of the room. On 6/30/24 at 10:00, V16/Agency CNA stated, (V13/CNA) was training me the night the incident occurred between (R3) and (R4). That was my first night working at the facility and it was just us two for CNA's back on the unit. We walked into the room because we saw (R3) laying in (R4's) roommates' bed, and it was not her room. When I walked in the room (R4) was in the recliner leaning over by (R3). (R4) immediately pulled his hand back from (R3) when we walked into the room. I did not see where (R4's) hand was at that time. (V13) and I tried to remove (R3), but she was being aggressive. (V13) and I decided to leave the room to figure out a plan because (R3) was being aggressive. When (V13) and I got past the doorway we turned around and (V13) and I saw (R4's) left hand down (R3's) pants and underpants. (V13) and I went back in the room and (R4) removed his hand from her underpants again. We then removed (R3) from the room. On 6/29/24 at 4:06 PM, V14/R4's POA stated she was told something about R3 pants but did not remember exactly what it was about. V14 also stated We (R4's Family) have had to run (R3) out of (R4's) room several times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 9 of 16 Printed: 05/15/2026 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 145446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 6/29/24 at 1:57 PM, V13/R3's POA was asked if he had been notified about R3 being in R4's room and R4 had his hands in R3's pants. V13 stated I was not. V13 was asked if he had any idea how R3 would feel about the incident happening and V13 stated I have no idea. V13 also stated I feel bad that it happened, but I don't know what can be done to prevent it. On 6/28/2024 at 3:35 PM, R3 was ambulating independently down the hallway on the locked unit towards the double doors that go out to the other hallways. R3 was exit seeking and observed to be agitated. R3 was kicking and punching at the doors. R3 then turned around and was ambulating down the hallways past other residents. No CNA or Nurses were observed in the hallway during that time. On 6/29/2024 at 1:00 PM, R3 was in her room asleep in her roommate's bed. On 6/30/24 at 11:00 AM V2/Director of Nursing/DON verified no new interventions were put in place to prevent R3 from abusing residents. V2/DON stated, I do not see where (R3's) care plan addresses her resident-to-resident altercations with (R9, R10, R11, or R12) or interventions. On 6/30/24 at 12:00 PM, V1/Administrator stated, The facility staff should not leave someone alone if they are experiencing aggression but should remove other resident's away from that person during that time to prevent abuse from happening. The Immediate Jeopardy started on 3-30-24 at 1:26 PM when R3 physically assaulted R11 by punching and shaking R11's left arm. V1/Administrator, V2/Director of Nursing, and V34/Regional Director of Operations were notified of the Immediate Jeopardy on 7-2-24 at 12:43 PM. This surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 7/2/24 V34/Regional Director of Operations in-serviced V1/Administrator on the facility's Abuse Policy on what constitutes abuse, how to prevent it and providing adequate supervision to prevent abuse 2. On 7/2/24 V34/Regional Director of Operations in-serviced V1/Administrator was in-serviced on Dementia care. 3. On 7/2/24 all residents were reviewed by the Interdisciplinary Team to assess their potential to be abusive towards other residents. 4. On 7/2/24 All residents' care plans were reviewed by the Interdisciplinary Team to ensure that all abusive behaviors are addressed, and interventions are reflected to prevent further abusive behaviors. 5. R3's electronic medical record documents R3 has been on 1:1 supervision 24 hours per day from 7/2/24 to 7/6/24. 6. On 7/2/24 R3's care plan was updated with new intervention to address pain, overstimulation aggression towards peers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 10 of 16 Printed: 05/15/2026 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 145446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2024 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 0600 7. On 7-2-24 R4's care plan was reviewed by the Interdisciplinary Team and interventions were updated to address inappropriate sexual behavior. Level of Harm - Immediate jeopardy to resident health or safety 8. Agency staff verified they have been given access to the electric health care record since 7/2/24. Residents Affected - Some 9. On 7/5/24 V1/Administrator interviewed five staff members to audit their understanding on the abuse policy of what constitutes abuse, preventing abuse, providing adequate supervision to prevent abuse and Dementia Care. 10. On 7/5/24 V1/Administrator audited three resident care plans for interventions in place to prevent abuse. 11. On 7/3/24 the Interdisciplinary Team documented on a QA (Quality Assurance) form their review of residents with new abusive behaviors and interventions to prevent abuse. No residents were identified as having new abusive behaviors. On 7/5/24 at 10:00 AM V35/Agency Registered Nurse (RN) stated she has not been in-serviced regarding abuse or dementia from (the facility). V35/RN sated, I would report abuse to the state or Director of Nursing. On 7/5/24 at 10:07 AM V1/Administrator verified that V35/Agency RN had not been in-serviced on the Abuse and Dementia policies. Due to all staff not being in-serviced on Abuse and Dementia policies prior to their shift the facility's abatement plan was not completely executed on 7/2/24 as documented by the facility. Therefor the immediacy could not be removed on 7/2/24. On 7/6/24 the facility completed all measures on the abatement plan, including providing in-servicing all of the staff on abuse and dementia policies. Therefor the abatement plan could be approved on 7/6/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 11 of 16 Printed: 05/15/2026 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 145446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2024 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a thorough investigation of two resident-to-resident altercations of physical abuse for three of seven residents (R3, R11, and R12) reviewed for abuse in the sample of 26. Residents Affected - Few Findings include: The Abuse, Prevention and Prohibition Policy dated 1/24 documents Statement of Intent Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Policy This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The resident must not be subjected to abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. Annually, the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement. This same policy states, Investigation: Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Implement steps to prevent further potential abuse. (See section on Protection: Resident to Resident Altercations, Employee Allegations or Other Potential Perpetrators) If sexual assault has been alleged, the physician will be contacted for an order to transfer to the emergency room for examination. Social Services (designee) will complete a Trauma Informed Care assessment and provide follow-up care regardless if allegation is substantiated. 1. R3's Face Sheet documents R3 was admitted to the facility on [DATE]. This same form documents the following, but not limited to, diagnoses: Unspecified Dementia and Major Depressive Disorder. R3's MDS (Minimum Data Set) assessment dated [DATE] documents R3 is severely cognitively impaired, has delusions and behaviors of physical and verbal aggression that impacts others, wanders and significantly intrudes on the privacy or activities of others, wanders and is at significant risk of getting to a potentially dangerous place, is at significant risk for physical illness or injury, puts others at significant risk of physical injury, and significantly intrudes on the privacy or activity of others. R3's Care Plan dated 6/25/24 documents R3 has behaviors of being verbally aggressive towards staff, being physically aggressive with others, and is known to wander into other residents' rooms. R3's Behavior Note written by V4/Licensed Practical Nurse/LPN dated 3/30/24 at 1:26 PM, documents (R3) was in room [ROOM NUMBER] when CNA (Certified Nursing Assistant) attempted to redirect (R3) out of the room. (R3) became agitated/verbally aggressive and started swinging at CNA. (R3) told CNA to get out. (R3) then came out of the room and went down the hall and asked another resident (R11) to help her and (R3) then punched and shook (R11) on left arm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 12 of 16 Printed: 05/15/2026 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 145446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm R3's AIM (Assessment Intercommunicate Management) for Wellness form dated 3/30/24 documents that R3 appears to have been involved in an altercation with a peer (R11). Just prior to the time of the event R3 appears to have been in another resident's room. V32/CNA stated R3 was in another room and V32 attempted to redirect R3 and R3 became aggressive. The incident happened in the hallway. R3 has a history of physical aggression towards staff and other residents at other nursing (facilities). Residents Affected - Few R11's current computerized medical record, documents R11 is an [AGE] year old female that admitted to the facility on [DATE] with diagnosis which included Dementia, with Psychotic Disturbance, Depressive Disorder, and Chronic Obstructive Pulmonary Disease. R11's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 4/15, indicating severe cognitive impairment. R11's Nursing Note written by V4/LPN dated 3/30/24 at 1:41 PM documents, CNA reported that another resident (R3) came up to (R11) and asked (R11) to help (R3) then proceeded to hit (R11) in the left arm and shake (R11's) arm. On 7/2/2024 at 9:04 AM, V32/Agency CNA stated, I haven't worked at (the facility) for a few months. When I was working at (the facility) there was a resident (R3) who was swinging on everyone that day. (R3) punched and shook (R11's) left arm. (R3) was swinging her arms so hard, she even swung herself to the floor. (R3) was being very aggressive and trying to punch everyone. 2. R3's Nursing Note written by V4/LPN dated 6/19/24 at 5:22 PM, documents (R3) threw a partial glass of water on another resident (R12). (R3) keeps trying to get more water to throw on staff and other residents. R12's current computerized medical record, documents R12 is an [AGE] year-old male that admitted to the facility on [DATE] with diagnosis which included Alzheimer's, Dementia, and Essential (Primary) Hypertension. R12's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 9/15, indicating moderate cognitive impairment. R12's current computerized medical record, documents no evidence of the incident between R3 and R12 on 6/19/24. On 6/29/24 at 2:00 PM, V4 stated, I was here on 6/19/24 when (V13/CNA) came and told me (R3) threw a half glass of water on (R12). I reported it to (V1/Administrator) immediately. (V1) told me it was not abuse and it was just a behavior and to monitor (R3's) behaviors. I received an order for Haldol (antipsychotic) because (R3) was throwing water on staff as well and trying to take the water pitcher off my nursing cart. (R3) kept getting water other places as well and was trying to throw it on everyone. We (the staff) were having a hard time re-directing and getting (R3's) behavior to stop. On 7/1/2024 at 10:15 AM, V1/Administrator verified she did not investigate the alleged incident between R3 and R12 on 3/30/24 or the incident between R3 and R11 on 6/19/24. V1 stated, I don't remember if I was aware of the two alleged incidents or not, but I will start an investigation now. (There was not a facility reported incident sent to the (State agency) when R3 abused R11 or R12). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 13 of 16 Printed: 05/15/2026 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 145446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's antidepressant and diabetic medications were available for 1 (R1) of 3 residents reviewed for medication in the sample of 26. Findings include: The Nursing Job Description (not dated) documents Registered Nurse: Position Description Responsible for ensuring the delivery of efficient and effective nursing care while achieving positive clinical outcomes and resident/family satisfaction in accordance with accepted standards of practice, state and federal regulations and licensing requirements. Operates within the scope of practice defined by the state Nurse Practice Act. Responsible for resident care and direction of nursing care during assigned shift; includes staff assignments, mentoring and educating nursing personnel, working with physicians and other medical professionals. Principal Responsibilities Conduct the daily nursing functions in accordance with Company, State, Federal and local rules, regulations, and guidelines. Ability to administer medications and treatment timely and according to facility policy; Demonstrates ability to receive, transcribe, and carry out physician orders, if allowed by Nurse Practice Act. Ensures that physician orders are followed as prescribed. Effectively carries out medication management to ensure adequate supplies and that all medications are handled in accordance with company policy. Direct Care Responsibilities Follows Pharmacy policy and procedures for ordering and delivering medications. Licensed Vocational Nurse License Qualification: Position Description Responsible for ensuring the delivery of efficient and effective nursing care while achieving positive clinical outcomes and resident/family satisfaction in accordance with accepted standards of practice, state and federal regulations and licensing requirements. Operates within the scope of practice defined by the state Nurse Practice Act. Responsible for resident care and direction of nursing care during assigned shift; includes staff assignments, mentoring and educating nursing personnel, working with physicians and other medical professionals. Principal Responsibilities Conduct the daily nursing functions in accordance with Company, State, Federal and local rules, regulations, and guidelines. Ability to administer medications and treatment timely and according to facility policy; Demonstrates ability to receive, transcribe, and carry out physician orders, if allowed by Nurse Practice Act. Ensures that physician orders are followed as prescribed. Effectively carries out medication management to ensure adequate supplies and that all medications are handled in accordance with company policy. Direct Care Responsibilities Follows Pharmacy policy and procedures for ordering and delivering medications. The Ombudsman Residents' Rights Booklet dated 11/18, documents Your facility must provide services to keep your physical and mental health, at their highest practical levels. R1's admission Record documents R1 was admitted to the facility on [DATE] with the following diagnosis Depression, Morbid (Severe Obesity Due to Excess Calories), Type 2 Diabetes Mellitus Without Complications and Adult Failure to Thrive. R2's MDS (Minimum Data Set) assessment dated documents R2 is cognitively intact. R1's Care Plan documents (R1) has Diabetes Mellitus and is at risk for Hyperglycemia and Hypoglycemia. Date Initiated 9/20/23. Interventions Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. (R1) takes antidepressant medications r/t (related to) Depression. Date Initiated 4/17/23. Interventions: Administer antidepressant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 14 of 16 Printed: 05/15/2026 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 145446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2024 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 0755 medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Level of Harm - Minimal harm or potential for actual harm R1's Order Summary Report dated 6/28/24 documents, Effexor XR (Extended Release) Oral Capsule Extended Release 24 Hour 150 MG (milligrams) (Venlafaxine HCI/Hydrochloride) Give 1 (one) capsule by mouth in the morning related to Depression. Order Date 9/22/23. Venlafaxine HCI ER (Extended Release) Oral Capsule Extended Release 24 Hour 75 MG (Venlafaxine HCI) Give 1 capsule by mouth in the morning for depression to be given with Venlafaxine ER 150 mg capsule to equal 225 mg. Order date 1/17/24. Victoza Subcutaneous Solution Pen-injector 18 MG/3ML (milliliter) (Liraglutide) Inject 1.2 mg subcutaneously one time a day for DM2 related to type 2 Diabetes Mellitus Without Complications. Administer 1.2 mg (0.2 ml) subcutaneously once daily for type 2 DM. (May increase dose to 1.8 mg (0.3 ml) as tolerated). Order date 5/22/24. Residents Affected - Few R1's Medication Administration Record dated 6/1/24-6/30/24 documents Victoza Subcutaneous Solution Pen-Injector 18 MG/3ML(Liraglutide) inject 1.2 mg subcutaneously one time a day for DM2 related to Type 2 Diabetes Mellitus Without Complications. Administer 1.2 mg (0.2 ml) subcutaneously once daily for type 2 DM. (May increase dose to 1.8 mg (0.3 ml) as tolerated. Start Date 5/23/24 at 8:00 AM. (R1 did not receive this medication on (6/23-6/27/24) Venlafaxine HCI ER Oral Capsule Extended Release 24-hour 75 MG (Venlafaxine HCI) Give 1 capsule by mouth in the morning for depression to be given with Venlafaxine ER 150 mg capsule to equal 225 mg. Start date 1/18/24 (R1 did not receive this medication on 6/15 -6/17/24). R1's EMAR (Electronic Medication Administration Record) notes dated 6/14, 6/15, and 6/16/24 all document, Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 75 MG (milligram), give one capsule by mouth in the morning for depression to be given with Venlafaxine ER 150 mg capsule to equal 225 mg. On order. R1's Orders Note written by V5/LPN dated 6/15/24 at 8:13 AM, documents Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 75 MG. Give 1 capsule by mouth in the morning for depression to be given with Venlafaxine ER 150 mg capsule to equal 225 mg. On order. R1's Orders Note written by V23/Registered Nurse/RN dated 6/16/24 at 7:33 AM, documents Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 75 MG. Give 1 capsule by mouth in the morning for depression to be given with Venlafaxine ER 150 mg capsule to equal 225 mg. On order. R1's Orders Note written by V5/LPN dated 6/17/24 at 8:57 AM, documents Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 75 MG. Give 1 capsule by mouth in the morning for depression to be given with Venlafaxine ER 150 mg capsule to equal 225 mg. On order. R1's Orders Note written by V10/LPN dated 6/23/24 at 7:38 AM, documents Victoza Subcutaneous Solution Pen-injector 18 MG/3ML Inject 1.2 mg subcutaneously one time a day for DM 2 related to Type 2 Diabetes Mellitus Without Complications. Administer 1.2 mg (0.2 ml) subcutaneously once daily for type 2 DM. (May increase dose to 1.8 mg (0.3 ml) as tolerated) On order. R1's Orders Note written by V5/LPN dated 6/24/24 at 8:43 AM, documents Victoza Subcutaneous Solution Pen-injector 18 MG/3ML Inject 1.2 mg subcutaneously one time a day for DM 2 related to Type 2 Diabetes Mellitus Without Complications. Administer 1.2 mg (0.2 ml) subcutaneously once daily for type 2 DM. (May increase dose to 1.8 mg (0.3 ml) as tolerated) On order. R1's Orders Note written by V5/LPN dated 6/25/24 at 8:49 AM, documents Victoza Subcutaneous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 15 of 16 Printed: 05/15/2026 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 145446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Solution Pen-injector 18 MG/3ML Inject 1.2 mg subcutaneously one time a day for DM 2 related to Type 2 Diabetes Mellitus Without Complications. Administer 1.2 mg (0.2 ml) subcutaneously once daily for type 2 DM. (May increase dose to 1.8 mg (0.3 ml) as tolerated) On order. R1's Orders Note written by V5/LPN dated 6/26/24 at 8:44 AM, documents Victoza Subcutaneous Solution Pen-injector 18 MG/3ML Inject 1.2 mg subcutaneously one time a day for DM 2 related to Type 2 Diabetes Mellitus Without Complications. Administer 1.2 mg (0.2 ml) subcutaneously once daily for type 2 DM. (May increase dose to 1.8 mg (0.3 ml) as tolerated) On order. R1's Orders Note written by V22/LPN dated 6/27/24 at 8:47 AM, documents Victoza Subcutaneous Solution Pen-injector 18 MG/3ML Inject 1.2 mg subcutaneously one time a day for DM 2 related to Type 2 Diabetes Mellitus Without Complications. Administer 1.2 mg (0.2 ml) subcutaneously once daily for type 2 DM. (May increase dose to 1.8 mg (0.3 ml) as tolerated) On order. R1's clinic record lacked any implemented interventions related to the unavailable medications. On 6/28/24 at 8:55 AM V5/LPN (Licensed Practical Nurse/LPN) stated R1 has been out of Victoza (Diabetes Medication) for approximately a week because it's on back order. V5/LPN stated, I don't see where (R1's) doctor has been notified of (R1) being out of Victoza. I don't see a doctor's order to hold the Victoza or change the medication to something different. We (the facility) should have called (R3's) Doctor to see if they wanted to order something else for (R3) in place of Victoza. On 6/28/24 at 9:50 AM (R1) was lying in her bed with the head of the bed up. R1 stated, The facility ran out of my Effexor 75 mg for three days (6/15, 6/16, and 6/17/24). It made me have a severe headache, depressed, and I didn't feel good. I have also not received my Victoza for the past week. I have been so tired and weak feeling since I have been out of my Victoza. On 6/28/24 at 1:35 PM V10/Agency LPN Agency stated, I was taking care of (R3) on one of the day's her Effexor 75 mg (Depression Medication) was out. I tried to re-order the Effexor 75 mg from pharmacy, but it stated through online ordering it had already been re-ordered. I did not call the doctor when the medication was out or the pharmacy to see what was going on. When we don't have a medication, we don't have it. Usually if we are out of a medication, it will come in from pharmacy within a day or two. On 6-29-24 at 11:57 AM V2/Director of Nursing/DON stated, If we (the facility) run out of a medication then the nurse should check the emergency medication box for non-controlled medications. If the medication is not in there, then the nurse should reach out to pharmacy to see why the medication has not been sent and to get it sent right away. The resident's doctor should also be notified if a resident is out of a medication to get further orders. They (the nursing staff) should be putting progress notes in regarding being out of medications and calling the doctor. V2/DON verified there was no evidence in R1's medical record of the nurses notifying R1's doctor regarding (R1) being out of Effexor 75 mg on 6/15, 6/16, and 6/17/24 as well as Victoza on 6/23, 6/24, 6/25, 6/26, and 6/27/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 16 of 16