F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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 ensure a resident was assessed following an
alleged fall for 1 of 3 residents (R1) reviewed for fall assessments in the sample of 3.
Residents Affected - Few
The findings include:
R1's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including
severe dementia without behavioral disturbance, anxiety and depression.
R1's 4/18/25 Resident Assessment and Care Screening documents R1 to have moderate cognitive
impairment.
On 6/13/25 at 9:50 AM, R1 was observed lying in bed, alert and confused. She was unable to answer
questions with any clear answers. She was wearing a hospital gown, and had an indwelling urinary
catheter. Her room was located on the dementia unit.
The facility's 5/9/25 final incident investigation report documents on 4/29/25 R1 was observed sitting on the
floor in her room leaning against her bed. R1 stated she had fallen, and was unable to recall how she fell.
The report shows V4 and V5 Certified Nursing Assistants (CNA's) reported to V6 Licensed Practical Nurse
(LPN) R1 had fallen out of bed. The report shows V6 sent R1 to the emergency room for evaluation.
On 6/13/25 at 12:15 PM, V4 said she was working on the west wing when V5 came out of the dementia unit
asking for help with R1, because she was on the floor. V4 said V5 notified V6 of the incident at same time.
She said V6 asked what had happened, and then told them to get R1 up and put her back into bed. V6 did
not go to assess R1 at that time. V4 said R1 was moved from the floor to the bed, but could not recall what
time this had occurred. Then just before the end of the shift at 6:00 AM, V6 said R1 was being sent out to
the emergency room.
The ED (Emergency Department) record for R1 shows the date and time of service to be 4/29/25 at 7:18
AM. The chief complaint was a fall, and R1 had complaints of mid back pain and right rib pain. The
discharge assessment and clinical impression shows closed fractures of the 8th and 9th ribs on the right
side.
R1's 4/29/25 Nursing Progress Notes show she was transported back from the emergency department
(ED) at 11:16 AM, and was received by V12 LPN. The progress notes do not show evidence of a fall
incident, resident assessment, or documentation of notifications or what time R1 was sent out to the ED.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145446
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
06/13/2025
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 0684
Level of Harm - Minimal harm
or potential for actual harm
On 6/13/25 at 11:30 AM, V12 LPN said on the morning of 4/29/25, she relieved V6 and received in report
R1 had been sent out for evaluation due to behaviors. She was not given report of any fall. V12 said when
she reviewed R1's notes, there was nothing charted. She said V6 should have charted the fall, and an
assessment with vital signs. She should have noted if there was any head injury and range of motion. V12
said she found out about the fall when the emergency room called to let her know R1 had fractured ribs.
Residents Affected - Few
On 6/13/25 at 10:37 AM, V3 Assistant Director of Nursing (ADON) said when a resident has a fall, the
nurse should immediately assess the resident for any injury or possibility of injury and if the resident needs
to be sent out to the ED. She said the nurse should document in the progress notes the assessment, what
occurred, and what immediate interventions should be put in place to prevent further falls. She said the
importance of the documentation is for staff to know what is going on with the residents.
The facility's 4/29/25 policy for Post Fall Procedure documents Post Fall: After a resident fall, they must be
stabilized by the nursing staff. A fall risk evaluation must be completed by the charge nurse. A detailed
progress note must be documented in the resident's record, including root cause analysis, resident provider
notification, resident representative notification, details of injury if present, new intervention, pertinent
statement, and any other details surrounding the resident fall.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145446
If continuation sheet
Page 2 of 2
