Inspection·August 19, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to obtain the proper equipment to ensure a resident received showers at least once weekly and was weighed at least once monthly for one of three residents (R2) reviewed for accommodation of needs in the sample of three. These failures resulted in a resident with the diagnoses of Morbid Obesity not receiving a shower for over two years, resulting in R2 having increasing depression and feeling disgusting, smelly, and dirty.Findings include:The Facility Assessment Tool dated 3/19/25 documents, Diseases/Conditions: Morbid Obesity. Services and care we offer based on our resident's needs. The facility provides services for the residents we care for. The residents' care is based on their individual needs and preferences and is reflected in the individual's care plan. The cares and services are distributed by category. Activities of daily living bathing: Bathing and Showers. Physical Environment and building plant needs: Ensure adequate supplies and to ensure equipment is maintained to protect and promote the health and safety of residents. Physical Equipment: Bath benches, shower chairs, bathroom safety bars, bathing tubs, scales, bed scales.The facility's Weight Assessment and Intervention policy dated 12/2024, The nursing staff will measure resident weights on admission and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly. Weights will be recorded in the individual's medical record.The facility's Activities of Daily Living Policy, undated, documents, This facility provides each resident with care, treatment, and services according to the resident's individualized care plan. Based on the resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrates that the decline was unavoidable, including Bathing, dressing, grooming, transferring, locomotion, ambulation, toileting, eating, and communication.R2's admission Record documents R2 is a [AGE] year-old admitted to the facility 10/20/22 with the diagnoses of Depression, Morbid Obesity, Adult Failure to Thrive, Hoarding Disorder, and Attention-Deficit Hyperactivity Disorder.R2's Current Care Plan documents, Behavior Problem: Has signs/symptoms of depression. Withdrawn. BATHING/SHOWERING: Provide sponge bath when a full bath or shower cannot be tolerated. Date Initiated: 04/13/2023 BATHING/SHOWERING: (R2) requires extensive assistance by one staff with bathing/showering (bathing/showering on scheduled days and as necessary. (Mechanical Lift) and two assist for transfers to shower chair. Encourage (R2) to wash upper body. Date Initiated: 04/13/2023.R2's MDS (Minimum Data Set) dated 6/19/25 documents R2 is dependent on staff for showers/bathing and needs partial/moderate assistance of staff for personal hygiene. This same Assessment documents R2's Mood Score at a 10 indicating R2 suffers moderate depression.R2's BIMS (Brief Interview for Mental Status) dated 8/18/25 documents R2 is cognitively intact.R2's Weights and Vitals Summary dated 1/2025 documents R2's most recent weight obtained was 293 pounds.R2's Grievance dated 5/8/25 documents, I (R2) have had difficulty with my bath/hair and getting (a) head to toe bath plus my hair shampooed since the CNAs (Certified Nursing Assistants) have been switched halls. I am not consistently getting a full bath and my hair shampooed. I would like to discuss a shower plan at a care plan meeting with (V14/Ombudsman) to support me (R2). Please let me (R2) know a date and time that we (the facility) can meet, and I will coordinate with the ombudsman.On 8/18/25 at 10:30 AM R2 was lying in a bariatric bed. R2 was morbidly obese and had stringy, oily hair. R2 stated, I feel very disgusting, smelly, and dirty. I have lived here over two years and have never been able to take a shower. The staff tried once, and I could not fit through the shower room door while on the shower chair, and my wheelchair will not fit through the shower room doorway. I am getting further and further depressed from being in this room every day and Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145446 If continuation sheet Page 2 of 3 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 08/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marigold Rehabilitation and Health Care Center 275 East Carl Sandburg Drive Galesburg, IL 61401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete never getting a shower. I get bed baths, and my hair only gets washed maybe six out of the 12 times I get a bed bath. How would you (this surveyor) feel if you never could get a shower? I have asked over and over and filled out a grievance about at least getting my hair washed and nobody ever gets back to me. I do not get weighed monthly because the scale on the (mechanical lift) broke.On 8/18/25 at 10:10 AM V3 (LPN/Licensed Practical Nurse) stated, We (the facility) do not have a shower room that can accommodate (R2). (R2) requires a large shower bench and cannot fit through the shower doorways. Anytime the staff try, (R2's) legs scrape on the doorway of the shower room. The doorway to the shower rooms needs to be wider in order to fit (R2), or (R2) needs a different shower chair.On 8/18/25 at 10:20 AM V4 (CNA/Certified Nursing Assistant) stated, I have worked here four years and have always taken care of (R2). (R2) cannot fit through the shower room doors, so we have to give (R2's) bed baths. We used to not have a (mechanical lift) that would work for (R2's) weight. We have a lift that works for (R2) now. (R2) has never been able to get a shower. The last time we tried to wheel (R2) into the shower room, (R2's) legs scraped on the doorway. The shower chair with (R2) sitting on it does not fit through the shower doorway. Over two years ago there was a shower chair that worked for (R2), but it broke, and we (the facility) have never gotten a new shower chair that would work for (R2). I have never tried to use a (mechanical lift) to get (R2) into the shower room. I did not think about using a (mechanical lift).On 8/18/25 at 10:30 AM V5 (CNA) was providing personal cares to (R2). V5 stated, I always give (R2) bed baths because (R2) cannot fit through the shower room doorways. I have never tried to give (R2) a shower and have never tried a (mechanical lift) to get (R2) into the shower rooms. I just always assumed I was supposed to give (R2) bed baths since (R2) cannot fit into the shower rooms.On 8/18/25 at 2:10 PM V11 (CNA) and V12 (CNA) verified R2 does not get showers due to having no way to get R2 into the shower room.On 8/19/25 at 9:30 AM V14 (Ombudsman) stated, After (R2) wrote the grievance on 5/8/25, I immediately handed it to (V15/Prior Administrator) who was in (V16's/Director of Nurse's) office at the time. I discussed with (V15) and (V16) the need to have a care plan meeting with (R2) to discuss (R2's) concerns. At that time (V15) told me that the care plan coordinator was out of the building, and he would get back to (R2) and myself with a day and time for a care plan meeting. I have never heard anything back. I have been dealing with all different managers for the last two years about (R2) not being able to get a shower. (R2) is very upset that she cannot even get a shower and not get her hair washed. The staff cannot get (R2) into the shower room as the doorway is not big enough and the facility does not have a shower chair that will fit threw the shower room doorway. On 8/19/25 at 11:15 AM V1 (Administrator) stated, I was not made aware about (R2's) grievance from 5/8/25. (R2) should be offered a shower at least once a week and the facility should have the proper equipment and shower rooms to accommodate (R2) being able to get a shower at least once a week or whenever she wants. (R2) not receiving a shower for over two years is ridiculous and unacceptable. The staff have not been weighing (R2) monthly. I guess because the (mechanical lift) scale is broke.On 8/19/25 at 12:15 PM V2 (Director of Nursing) stated, The facility does not have a scale that can weigh (R2). I just found this out yesterday. All residents should be weighed at least once monthly unless a physician's order indicates a resident should be weighed more than monthly. (R2) has not had a monthly weight since January 2025. Event ID: Facility ID: 145446 If continuation sheet Page 3 of 3