Inspection·April 23, 2025

F 0571 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R2's Monthly recorded trust registry dated 11/1/24, documents on 11/1/24 R2's personal trust balance was $1,159.50. This registry documents on 11/12/24, $1086.20 was deducted for R and B (Room and Board) payment. This registry documents three deductions for shopping and one credit of $13.77 for a final balance on 12/1/24 of $32.07. R2's Monthly recorded trust registry, dated 1/1/25, documents R2's account balance was $16.01 and recorded a withdrawal of $16.00 for shopping on 1/7/25. R2's Monthly recorded trust registries, dated 2/1/25, 3/1/25 and 4/1/25 all document R2's trust account balance is $0.01. R2's [NAME] statement, dated 3/31/25, documents R2's account was credited $217.24 on 3/5/25 and R2's total amount due to the facility is $15,413.76. On 4/21/25 at 2:40 PM, V4 (Business Office Manager) confirmed R2's stay is being paid for by Medicaid and R2 has a current trust balance of one cent. V4 stated (R2) has Medicaid for insurance and room and board is also paid from her social security. (R2) has not been getting social security checks or her 60 dollar personal needs allowance each month due to the checks not being delivered here and the facility not being set as her payee. Those checks are just piling up at the social security office. (R2) does have an additional income that is coming to us that is a little over 200 dollars each month. I think that is from an old pension or retirement income. That amount is credited to her bill and does not withhold her 60 dollar monthly allowance. Nothing has been added to (R2's) trust for personal spending from that retirement income. (R2) came here with a check from her past facility and that was all of the money she had in her trust account. (R2) is owed the 60 dollar monthly amount of money for the past year and the over 1000 dollars that we took from her trust in November 2024. That was onetime payment. (R2) has family members (V12 and V12's spouse, V13) who get (R2's) billing accounts and I am sure that viewing large, owed balances is overwhelming. (V13) is (R2's) financial POA (Power of Attorney) and told me to deduct (R2's) room and board from November, out of (R2's) personal trust money. But that money is now all gone because it has not had any deposits since (R2) has lived here. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 2 of 10 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 04/23/2025 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 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to deliver resident mail, unopened and without being read, to one of four residents (R1) reviewed for mail delivery in the sample of seven. Residents Affected - Few Findings include: The facility's Resident Rights policy, dated 12/2024, documents Each resident residing in this community has the right and will be afforded the right to dignified existence, self-determination, and communication with and access to persons and services inside and outside the community without interference, coercion, discrimination or reprisal. It is the responsibility of all who work in this community, including employees of the community and any others who provide services to the residents of the community, to advocate and protect the rights of each resident. This same policy documents Resident rights include but are not limited to: Privacy and confidentiality. Privacy in sending and receiving mail. R1's current Care Plan, dated 4/8/24, documents R1 was admitted to the facility on [DATE]. This Care Plan also documents (R1) has suffered a traumatic life event of husband's death, requiring support and intervention. Triggers include: date of husband's death, approaching holiday's, people talking about his death, church services because husband was a reverend. Date initiated, 12/11/2024. On 4/21/25 at 10:30 AM, R1 was sitting in wheelchair in her room. At this time R1 stated A few weeks ago I was delivered two envelopes that were addressed to me and they were both opened before I got them. The Business Office Manager (V4) brought me the two envelopes and they were both life insurance checks from (V14, R1's late spouse) passing away in November. (V4) said that she opened my letters by accident but if she did that, then why did she open both of them? I have not had any other mail delivered opened, but both of these envelopes were. On 4/21/25 at 11:20 AM, V11 (R1's Family Member) stated We (family members) do all the banking for (R1) and none of it is managed by the facility or (V4). When I called (V4) after the mail was delivered to (R1) already opened, I asked her why she opened it and she said it doesn't matter. The envelope said (company) Life Insurance and only was addressed to (R1), not the facility so (V4) knew these envelopes contained checks. On 4/21/25 at 2:40 PM, V4 (Business Office Manager) confirmed in March 2024, she opened two pieces of mail that were addressed to R1. V4 stated (R1) received life insurance checks and I opened those. I had the envelope upside down, and I opened both envelopes. They were addressed to (R1) and it was just her name, not the facility. I am the one who receives all of the resident mail and see that it gets delivered. (V7, Activity Director) gives the mail to residents once it is sorted by me. On 4/22/25 at 9:35 AM, V7 stated I deliver mail for all of the residents. I get the mail from (V4). If something is addressed to the facility sometimes, I have had to open it only due the fact that there is no resident name on the outside. In which case I then take it to the resident and will show them that the outside of the envelope does not have a name on it. When I get the mail from (V4) it is sealed. V7 confirmed resident mail should be delivered to the residents still sealed and only opened if requested by the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 3 of 10 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 04/23/2025 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. 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 provide a resident with state funded payment transfer assistance and social services to ensure medical and personal state aid payments were accurately delivered for over eleven months and ensure residents currently receiving Medicaid are applying for financial services to allow an opportunity for a monthly personal needs allowance to be provided for four of seven residents (R2, R5, R6, R7) reviewed for Personal Funds and [NAME] in the sample of seven. Residents Affected - Some Findings include: The facility's Social Services Assistant job description (undated), documents Responsible to assist Social Service Coordinator and Social Workers in providing medically related social services so that each resident may attain or maintain the highest practicable level of physical, mental, and psychosocial well-being. Promotes a climate, policies and routines that enable residents to maximize their individuality, independence and dignity. Services will be provided in accordance with Federal, State and Local regulations and governing agencies. Responsibilities: Makes appropriate referrals to other consultants, community agencies, or center departments in order to facilitate the resident/resident's optimal use of resources, and to promote increased level of psycho-social functioning as planned by the Social Service Coordinator or Social Worker. Aids with the resident/resident's admission to assure a smooth transition; meets with resident/resident's and families as needed to provide information and facilitate adjustment. The facility's Admissions Coordinator job description (undated), documents Responsibilities: Ensure financial verification is accurate and complete before the resident is admitted to the facility thus assisting in reducing accounts receivable. Conducts admission process of signing in and explaining admission policies to residents and their families. Ensures a smooth transition is achieved and that all paperwork is complete upon admission. Emphasizes financial arrangements and responsibilities. The facility's Business Office Coordinator job description (undated), documents Responsible for the overall management of business office activities in accordance with current applicable federal, state, and local standard guidelines and regulations, and as directed by the administrator. Responsible for coordinating with the Central [NAME] Office on managing insurance payments, including private, Medicare, Medicaid and other managed care; managing refunds for accounts receivable, and maintaining appropriate logs and reports, not limited to, resident funds, census records, and case accounts. Responsibilities: Manages all business functions including but not limited to accounts receivable, accounts payable, resident trust finds and other assigned duties. Ensures the financial systems are accurate, efficient, and in accordance with professional accounting practices and governmental regulations. Manages insurance payments of Medicare, Medicaid, private insurance, HMOs (Health Maintenance Organizations) and hospice billing; verifies payor source; posting payments to various systems; ensures critical deadlines are met. Ensures timely receipts of all payments. Makes monthly phone calls to responsible parties regarding missing payments; submits Medicaid applications and completes timely follow up on pending cases; enters admission packets into the electronic system within seven days of admission. Maintain monthly logs for outstanding admission packets, new admissions, verifications and pending cases; maintains Medicaid pending and pending admission log. Implements and monitors the facility's established system for receiving, depositing, withdrawing and accounting for resident funds and ensures that resident funds are available for the resident or their authorized representative in accordance with established procedures; conducts monthly audit to ensure process is followed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 4 of 10 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 04/23/2025 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 0745 Obtains information from admissions and assures accuracy and completeness. Level of Harm - Minimal harm or potential for actual harm The Medicaid's Personal Needs Allowance (PNA) for Nursing Home Residents article, dated 1/13/25 and located at www.medicaidplanningassistance.org/personal-needs-allowance, documents Medicaid's Personal Needs Allowance (PNA) is the amount of monthly income a Medicaid-funded nursing home resident can keep of their personal income. Since room, board, and medical care are covered by Medicaid, the majority of one's income must go towards the cost of nursing home-care as a Share of Cost/Patient Liability. The PNA is intended to cover the nursing home resident's personal expenses, which are not covered by Medicaid. This may include, but is not limited to haircuts, vitamins, clothing, magazines, and vending machine snacks. Under certain circumstances, if a nursing home resident does not have their own monthly income, the Personal Needs Allowance is provided by the state in which one resides. Residents Affected - Some 1. R2's current electronic medical record documents R2's stay is being paid for by Medicaid, since admission. R2's current Care Plan, dated 3/11/25, documents R2 was admitted to the facility on [DATE] with Diagnoses of Bipolar Disorder without Psychotic features and Borderline Intellectual Functioning. This same care plan documents (R2) is alert and oriented. She is able to state wants and needs. (R2) requires training for community living skills. She has impairments with self-maintenance, social functioning, work related skills, and community living skills. Diagnosis: Bipolar. On 4/21/25 at 10:15 AM, R2 stated she moved to the facility close to a year ago. R2 stated On April 28th I will be a year without getting my social security. I am on Medicaid and I think I have some insurance and I have no money to my name. If I want a haircut or shoes, or just to go shopping, I can't because I have no money. The only time I have cash is if I win bingo and I might get a dollar or a dollar and a half, and then I have a friend from church who has given me some money for things like shoes. R2's Monthly recorded trust registries, dated 2/1/25, 3/1/25 and 4/1/25 all document R2's trust account balance is $0.01 with zero transactions or deposits throughout the three month period. R2's [NAME] statement, dated 3/31/25, documents R2's total amount due to the facility is $15,413.76. On 4/21/25 at 2:40 PM, V4 (Business Office Manager) stated (R2) has Medicaid for insurance and room and board is paid from her social security and a small retirement income. When (R2) came here the prior nursing home was her payee for social security. (R2's) not been getting her personal needs allowance of 60 each month. (R2) has a family member (V12) who gets her billing accounts but not the checks because those are piling up at the social security office. They (social security) needs to switch over and list (the facility) as her payee so her checks can be sent here. On 4/22/25 at 10:35, V8 (Corporate Educator) stated We (the facility) can apply for rep (representative) payee and then we are the one receiving the payments from social security. This would be the BOM (Business Office Manager's) job to apply for rep payee. (R2) does have a resident liability. I think this error may have been discovered after the fact, after (new facility ownership) took over from (prior ownership). (R2) should be getting her $60 each month added to her personal funds. 2. The facility's Medicaid list (undated), provided by V3 (Licensed Practical Nurse/Assistant Director of Nursing) on 4/22/25, documents R5 was admitted to the facility on [DATE], R6 was admitted to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 5 of 10 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 04/23/2025 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the facility on [DATE] and R7 was admitted to the facility on [DATE]. This list documents all three residents have a payer source of Medicaid. R5, R6 and R7's current electronic medical records document all three residents are under the age of 65. On 4/22/25 at 10:15 AM, V1 (Administrator) provided blank trust balance forms, dated 2/1/25-4/1/25, for R5, R6, and R7 and V1 stated They (R5, R6, R7) do not have any monthly balance due to having no income, so these residents do not receive a monthly Personal Needs Allowance (PNA). On 4/22/25 at 10:35 AM, V8 (Corporate Educator) stated When residents come to the facility they have to have some kind of income. There are very few cases where they don't have any income at all. It would be the Business Office Manager and Social Services who would be responsible for assisting the residents to get the SSI (Supplemental Security Income) after being admitted . On 4/22/25 at 11:00 AM, V9 (Corporate Medicaid Compliance Manager) stated SSI has to be applied for separately. For Illinois, when a resident applies and under age [AGE], if they are not receiving disability and they have no source of income we (the facility) would pursue disability, and they would make a decision. The resident would be entitled to SSI and then they would get a PNA (Personal Needs Allowance). It's not an automatic when they are admitted on Medicaid. What should be done is that we (the facility) pursue the SSI application. The facility should want to make sure they start the disability process and that is usually started through Social Services. If we have a resident living (in the facility) long term and they are not getting SSI, they (social services) can start paperwork for disability. On 4/22/25 at 11:11 AM, V5 (Social Services) stated she has been in the job position for about one year. V5 stated I have not done any SSI or Disability assistance applications. I know the Business Office Manager gets asked about those things. I assist on admissions as well and act as the Admissions Coordinator. I make sure residents have a payer source that we can accept. Going over the Medicaid list is also part of my admissions duty. On 4/22/25 at 11:38 AM, V4 (Business Office Manager, BOM) confirmed she has been working in the job position for approximately two years. V4 stated I haven't ever helped a resident apply for SSI or Disability. I do the financial agreement on admission and the contract is done by Social Services. (R5, R6 and R7) have been here a while and all have a zero liability. So, they receive no additional funds or personal allowance monthly. I am not sure how to see if they have ever applied for SSI or Disability. I guess we would need to talk to the Medicaid office case managers, but I haven't done that for anyone. On 4/22/25 at 3:25 PM V1 (Administrator) stated On admission the BOM does the financial checks to ensure payer source, and those things are accurate. The combination of BOM and Social Services would do the assisting residents with SSI and Disability. I have not had to encounter it, so we have done any of that. Residents can come and ask and they would be assisted. If they don't have any liability, then we would need to reach out to them and see if they need signed up for SSI or Disability. I don't have the documentation to show when residents were talked to or that this concern has been addressed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 6 of 10 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 04/23/2025 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. 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 provide effective administrative oversight to ensure residents on Medicaid receive a Personal Needs Allowances, assistance with supplemental income financial applications, transfer payment assistance and ensure a resident's personal funds were not charged for Medicaid covered services. This failure has the potential to affect all 68 residents residing in the facility. Residents Affected - Many Findings include: The facility's Administrator/ Executive Director job description (undated), documents The Administrator oversees the day to day operations of the facility to meet state and federal regulations and supervises all department managers to ensure the facility is in compliance. The Administrator is responsible for the delivery of clinical services integrated with business plans while meeting or exceeding quality, clinical and utilization standards, performance measures, and financial productivity objectives. Ensures premier customer service while facilitates resolutions of resident care issues. Responsibilities: Acts as the compliance office for the facility. Ensures center compliance with all federal, state and company regulations and policies. Ensures that all practices and policies are carried out in the highest ethical manner. Ensures the highest quality in standard of care and services provided. Oversees completion of forms, reports, etcetera, including state licensure reports, monthly financial reports, (state agency) or department of labor surveys, plans of correction, responses to corporate requests, replies to residents' council, and others as needed. Reviews and signs accounting records, incident/ accident reports, resident fund reconciliation, and resident funds approval; provides facility related data/ information responsive to the company needs. The facility's Business Office Coordinator job description (undated), documents Responsible for the overall management of business office activities in accordance with current applicable federal, state, and local standard guidelines and regulations, and as directed by the administrator. Responsible for coordinating with the Central [NAME] Office on managing insurance payments, including private, Medicare, Medicaid and other managed care; managing refunds for accounts receivable, and maintaining appropriate logs and reports, not limited to, resident funds, census records, and case accounts. Responsibilities: Manages all business functions including but not limited to accounts receivable, accounts payable, resident trust finds and other assigned duties. Ensures the financial systems are accurate, efficient, and in accordance with professional accounting practices and governmental regulations. Manages insurance payments of Medicare, Medicaid, private insurance, HMOs (Health Maintenance Organizations) and hospice billing; verifies payor source; posting payments to various systems; ensures critical deadlines are met. Ensures timely receipts of all payments. Makes monthly phone calls to responsible parties regarding missing payments; submits Medicaid applications and completes timely follow up on pending cases; enters admission packets into the electronic system within seven days of admission. Maintain monthly logs for outstanding admission packets, new admissions, verifications and pending cases; maintains Medicaid pending and pending admission log. Implements and monitors the facility's established system for receiving, depositing, withdrawing and accounting for resident funds and ensures that resident funds are available for the resident or their authorized representative in accordance with established procedures; conducts monthly audit to ensure process is followed. Obtains information from admissions and assures accuracy and completeness. The facility's Admissions Coordinator job description (undated), documents Responsibilities: Ensure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 7 of 10 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 04/23/2025 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many financial verification is accurate and complete before the resident is admitted to the facility thus assisting in reducing accounts receivable. Conducts admission process of signing in and explaining admission policies to residents and their families. Ensures a smooth transition is achieved and that all paperwork is complete upon admission. Emphasizes financial arrangements and responsibilities. The Medicaid's Personal Needs Allowance (PNA) for Nursing Home Residents article, dated 1/13/25 and located at www.medicaidplanningassistance.org/personal-needs-allowance, documents Medicaid's Personal Needs Allowance (PNA) is the amount of monthly income a Medicaid-funded nursing home resident can keep of their personal income. Since room, board, and medical care are covered by Medicaid, the majority of one's income must go towards the cost of nursing home-care as a Share of Cost/Patient Liability. The PNA is intended to cover the nursing home resident's personal expenses, which are not covered by Medicaid. This may include, but is not limited to haircuts, vitamins, clothing, magazines, and vending machine snacks. Under certain circumstances, if a nursing home resident does not have their own monthly income, the Personal Needs Allowance is provided by the state in which one resides. The facility's Financial Responsibility Agreement, dated 10/2023, documents Residents who are eligible for Medicaid will not be charged for any medical or personal supplies that are routinely supplied to all residents in accordance to state guidelines. R2's current electronic medical record documents R2 was admitted to the facility on [DATE] and R2's stay is being paid for by Medicaid, since admission. On 4/21/25 at 10:15 AM, R2 stated she moved to the facility close to a year ago. R2 stated On April 28th I will be a year without getting my social security. I am on Medicaid, and I think I have some insurance and I have no money to my name. If I want a haircut or shoes, or just to go shopping, I can't because I have no money. The only time I have cash is if I win bingo and I might get a dollar or a dollar and a half, and then I have a friend from church who has given me some money for things like shoes. R2's Monthly recorded trust registry dated 11/1/24, documents on 11/1/24 R2's personal trust balance was $1,159.50. This registry documents on 11/12/24, $1086.20 was deducted for R and B (Room and Board) payment. This registry documents three deductions for shopping and one credit of $13.77 for a final balance on 12/1/24 of $32.07. R2's Monthly recorded trust registry, dated 1/1/25, documents R2's account balance was $16.01 and recorded a withdrawal of $16.00 for shopping on 1/7/25. R2's Monthly recorded trust registries, dated 2/1/25, 3/1/25 and 4/1/25 all document R2's trust account balance is $0.01. R2's [NAME] statement, dated 3/31/25, documents R2's account was credited $217.24 on 3/5/25 and R2's total amount due to the facility is $15,413.76. On 4/21/25 at 2:40 PM, V4 (Business Office Manager) confirmed R2's stay is being paid for by Medicaid and R2 has a current trust balance of one cent. V4 stated (R2) has Medicaid for insurance and room and board is also paid from her social security. (R2) has not been getting social security checks or her 60 dollar personal needs allowance each month due to the checks not being delivered here and the facility not being set as her payee. Those checks are just piling up at the social security office. (R2) does have an additional income that is coming to us that is a little over 200 dollars each month. I think that is from an old pension or retirement income. That amount is credited to her bill and does not withhold her 60 dollar monthly allowance. Nothing has been added to (R2's) trust for personal spending from that retirement income. (R2) came here with a check from her past facility and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 8 of 10 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 04/23/2025 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many it was the money she had in her trust account. (R2) is owed the 60 dollar monthly amount of money for the past year and the over 1000 dollars that we took from her trust in November 2024. That was onetime payment. (R2) has a family members (V12 and V12's spouse, V13) who get (R2's) billing accounts and I am sure that viewing large, owed balances is overwhelming. (V13) is (R2's) financial POA (Power of Attorney) and told me to deduct (R2's) room and board from November, out of (R2's) personal trust money. But that money is all gone because it has not had any deposits since (R2) has lived here. The facility's Medicaid list (undated), provided by V3 (Licensed Practical Nurse/Assistant Director of Nursing) on 4/22/25, documents R5 was admitted to the facility on [DATE], R6 was admitted to the facility on [DATE] and R7 was admitted to the facility on [DATE]. This list documents all three residents have a payer source of Medicaid. R5, R6 and R7's current electronic medical records document all three residents are under the age of 65. On 4/22/25 at 10:15 AM, V1 (Administrator) provided blank trust balance forms, dated 2/1/25-4/1/25, for R5, R6, and R7 and V1 stated They (R5, R6, R7) do not have any monthly balance due to having no income, so these residents do not receive a monthly Personal Needs Allowance (PNA). On 4/22/25 at 10:35 AM, V8 (Corporate Educator) stated When residents come to the facility they have to have some kind of income. There are very few cases where they don't have any income at all. It would be the Business Office Manager and Social Services who would be responsible for assisting the residents to get the SSI (Supplemental Security Income) after being admitted . On 4/22/25 at 11:00 AM, V9 (Corporate Medicaid Compliance Manager) stated SSI has to be applied for separately. For Illinois, when a resident applies and under age [AGE], if they are not receiving disability and they have no source of income we (the facility) would pursue disability, and they would make a decision. The resident would be entitled to SSI and then they would get a PNA (Personal Needs Allowance). It's not an automatic when they are admitted on Medicaid. What should be done is that we (the facility) pursue the SSI application. The facility should want to make sure they start the disability process and that is usually started through Social Services. If we have a resident living (in the facility) long term and they are not getting SSI, they (social services) can start paperwork for disability. On 4/22/25 at 11:11 AM, V5 (Social Services) stated she has been in the job position for about one year. V5 stated I have not done any SSI or Disability assistance applications. On 4/22/25 at 11:38 AM, V4 (Business Office Manager, BOM) confirmed she has been working in the job position for approximately two years. V4 stated I haven't ever helped a resident apply for SSI or Disability. I do the financial agreement on admission and the contract is done by Social Services. (R5, R6 and R7) have been here a while and all have a zero liability. So, they receive no additional funds or personal allowance monthly. I am not sure how to see if they have ever applied for SSI or Disability. I guess we would need to talk to the Medicaid office case managers, but I haven't done that for anyone. On 4/22/25 at 3:25 PM V1 (Administrator) stated On admission the BOM does the financial checks to ensure payer source, and those things are accurate. There isn't generally anyone else overseeing the payments through corporate. We just do the financial check and see that they have a payer source. We (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 9 of 10 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 04/23/2025 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many (the facility) do have a monthly AR (Accounts Receivable) call with myself, the BOM (V4) and a corporate representative, related to private pay, liability and making sure all of those things are coming through correctly. I can't speak to any time prior to October 2024 when I started. I was not aware that (R2) was receiving income aside from the social security checks (that haven't been delivered). I didn't know (R2) had any trust money transferred here from her (previous nursing home) account or that we deducted room and board from those personal funds account. (R2) came here before I did, and I was not aware that happened. (R2) came to me once, early on (unknown date). She told me she was concerned about her social security not coming here and that's when I was made aware of a possible issue, but only recently realized it is still an issue. The combination of BOM and Social Services would be the people assisting residents with SSI and Disability. I have not had to encounter anyone needing it, so we have not done any of that. I am not aware of anything related to residents needing additional funding or lacking personal needs allowances. If they don't have any liability, then we would need to reach out to them and see if they need signed up for SSI or Disability. I don't have the documentation to show when residents were talked to or that this concern has been addressed. V1 confirmed that the facility has a large population of Medicaid funded residents and that at any time a residents could face a need to be placed on Medicaid services for facility payment. The facility's (undated) Resident Roster provided on 4/21/25 and verified by V1 (Administrator), documents 68 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 10 of 10