Marigold Rehabilitation and Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent physical and verbal abuse from happening for five (R1, R2, R4, R5 and R6) of five residents reviewed for abuse in a sample of six. The physical abuse on 3/9/26 between R1 and R2 resulted in R1getting a black eye and ear laceration, and R2 getting a fat lip.

Inspectors wroteBased on observation, interview, and record review the facility failed to transcribe a residents physician order appropriately for one (R2) of eight residents reviewed for medication administration in a sample of 10. This failure resulted in R2 not receiving his anti-neoplastic medication for three days.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was free from neglect, as evidenced by the failure to provide goods and services necessary to avoid physical harm for one of three residents (R1), reviewed for medications, in a sample of three. The facility failed to administer prescribed medications to R1 in accordance with physician orders. R1's medical record revealed that multiple medications were not administered as prescribed, no timely notification to the physician and no implementation of appropriate interventions. As a result of the facility's failure to provide necessary care and services, R1 experienced a decline in condition and subsequently expired. The failure to administer prescribed medications and to respond appropriately constituted neglect and resulted in actual harm and death to the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident received prescribed medications in accordance with physician orders, resulting in a failure to provide necessary care and services to attain or maintain the resident's highest practicable physical well-being, for 1 of 3 residents (R1) reviewed for medications, in a sample of 3. The facility failed to administer prescribed medications to R1 as ordered over multiple days. R1's medical record review revealed that the medications were ordered to be administered routinely; however, documentation showed missed doses without evidence of physician notification, or appropriate intervention. Staff interviews confirmed that missed medications were not escalated to nursing leadership or the attending physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate medical record for three of three residents (R1, R2 and R3) reviewed for accuracy of medical records, in a sample of 3.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident remained free from physical abuse. This failure affects one of three residents (R1) reviewed for abuse in a total sample of three residents. This failure resulted in R1 being pushed by R2, causing R1 to fall to the floor after losing R1's balance.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review, and interview the facility failed to honor a resident's request to conduct a care plan meeting with the ombudsman present for one of three residents (R2) reviewed for resident rights in the sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect a resident with severely impaired cognition from resident-to-resident sexual abuse and failed to protect a resident from resident-to-resident physical abuse for four of four residents (R26, R35, R42, R62) reviewed for abuse in the sample of 38. This failure resulted in R35 a cognitively intact resident sexually assaulting R42 a cognitively impaired resident, on more than one occasion. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 4/7/25 when R35 entered R42's room and sexually assaulted her within the facility. V2 (Director of Nursing) and V26 (Regional Nurse) were notified of the Immediate Jeopardy on 7/24/25 at 4:10 PM. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to post grievance/complaint procedures in a prominent location throughout the facility and promptly address resident grievances. This has the potential to affect all 67 residents residing in the facility.

Inspectors wroteBased on Interview and Record review the facility failed to report an allegation of resident-to-resident sexual abuse to the local police department and report allegations of sexual abuse and physical abuse timely to the State Agency for four of four residents (R26, R35, R42, R62) reviewed for abuse in the sample of 38.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's personal funds were not charged for covered services while receiving Medicaid benefits for one of seven residents (R2) reviewed for billing in the sample of seven.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review and interview, the facility failed to follow its policy and ensure sanitary handling of food items during mealtimes. This failure has the potential to affect all 75 residents who reside in the facility.

Inspectors wroteBased on record review and interview the facility failed to answer call lights timely for 11 of 11 residents (R8, R20, R26, R38, R40, R54, R59, R60, R63, R64, and R66) reviewed for call light response time in the sample of 33.

Inspectors wroteBased on record review and interview the facility failed to provide bedtime snacks for 11 of 11 residents (R8, R20, R26, R38, R40, R54, R59, R60, R63, R64, and R66) reviewed for bedtime snacks in the sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and indwelling medical devices for four of 12 residents (R2, R19, R54 and R65) reviewed for EBP in a sample of 33.

Inspectors wroteBased on interview and record review the facility failed to provide the Resident and/or Resident Representative with a written notice of hospital transfer for one of one resident (R83) in the sample of 33. Findings Include: R83's Census Profile, dated 6/3/2024, documents that R83 had a hospital unpaid leave from 6/3/24 through 6/5/2024 and 6/22/2024. Evidence of a facility notification to R83 of a written notice of transfer or discharge was not present in R83's chart. On 8/22/2024 at 11:35 am, V20/SSA (Social Service Assistant) stated, I do not see where there is any documentation or evidence that R83 or R83's Representative was given a written notice of the transfer or discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of the Bed Hold Policy for Residents who are discharging to the hospital for one of one resident (R83) reviewed for bed holds in a sample of 33. Findings Include: The facility policy, named Bed Hold Policy and Agreement Form, revised 2/2024, documents the following: It is the policy of the Management Company that the facility will establish a system to notify the Resident/Responsible party/Resident Representative of the facility bed hold policy; Procedure: The Bed Hold Agreement is to be obtained for each/occurrence, hospital, or therapeutic leave. R83's Progress Notes, dated 6/22/2024 at 11:40 am, documents the following: Staff entered R83's room and R83 had a clock in her hands with the glass all broken up. R83 kept saying she needed it to cut herself. [...]

Inspectors wroteBased on record review and interview the facility failed to obtain a level II PASRR (Pre-admission Screening and Resident Review) screening for one of three residents (R67) reviewed for a new diagnosis of mental illness in the sample of 33.

Inspectors wroteBased on record review and interview the facility failed to assess and identify potential triggers and failed to provide specific personalized interventions for one (R44) of three residents reviewed for mood and behavior in a sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to document behaviors to justify the use of antipsychotic medications, obtain a consent prior to the use of an antipsychotic medication, and perform an annual gradual dose reduction of scheduled antipsychotic medications for two of four residents (R10 and R67) reviewed for antipsychotic medication use in the sample of 33.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure a mechanical lift was available and in working order for a bariatric resident dependent on transfers for one of three residents (R1) reviewed for transfers in the sample of 26.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interview, the facility failed to prevent a misappropriation of medications for one of three residents (R1) reviewed for missing narcotics on the sample list of three. Findings Include: The facility policy named, Missing Controlled Substance, dated 11/6/2018, documents the following: It is the policy of this facility to prevent the loss of controlled substances and vigorously investigate incorrect inventory of controlled drugs, medications or pharmaceuticals reported by Pharmacists, Physicians or Licensed Nurses. R1's Delivery Receipt, dated 11/3/2023, documents the following: R1's Tramadol 50MG (pain reliever) (milligrams) were delivered on 11/4/2023. Amount # 30 tablets. R1's Reorder Form from the Pharmacy, dated 11/11/2023, documents the following: Tramadol 50MG dispensed on 11/3/2023. Date received/delivered to facility on 11/3/2023. [...]

Inspectors wroteBased on interview and record review the facility failed to establish a system for the reconciliation of controlled drugs for one of three residents (R1) reviewed for controlled drugs on the sample list of 3. Findings Include: R1's Delivery Receipt, dated 11/3/2023, documents the following: R1's Tramadol 50MG (pain reliever) (milligrams) were delivered on 11/4/2023. Amount # 30 tablets. R1's Reorder Form from the Pharmacy, dated 11/03/2023, documents the following: Tramadol 50MG dispensed on 11/3/2023. Date received/delivered to facility on 11/3/2023. On 12/5/2023 at 8:11AM V1/DON (Director of Nurses) stated, I interviewed all the nurses that worked the 500/600 cart V3/LPN, V4/LPN (Licensed Practical Nurse), V11/RN (Registered Nurse) and V12/LPN. On 11/11/2023. All four nurses said, they counted the narcotic, but did take the card out of the locked box to count them. [...]

Inspectors wroteBased on record review and interviews the facility failed to provide a safe resident transfer for one of three residents (R1) reviewed for falls on the sample list of three. This failure resulted in R1 falling on 11/2/2023, hitting the back of R1's head, requiring transfer to the local hospital. R1 sustained a 2-centimeter (cm) laceration to the back of R1's head requiring staples, head pain and a subdural hematoma. Findings Include: R1 has the following diagnosis: Cerebrovascular disease with a stroke, Chronic Atrial Fibrillation, Heart Failure, Weakness, COPD (Chronic Obstructive Pulmonary Disease.) R1's Fall Risk Evaluation dated 6/26/2023, documents the following: Gait/Balance 1.) Balance problem while standing 2.) Balance problem while walking 3.) Decrease muscular coordination. On 11/15/2023 at 8:05AM, R1 was alert and able to answer questions appropriately. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure smoking safety equipment was utilized for four residents (R33, R58, R63, R89) of 8 residents reviewed for smoking on the sample list of 45.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the appropriate indication for use of antipsychotic medications and document resident specific behaviors staff are to monitor for. This failure affects six residents (R42, R43, R60, R79, R80, R83) with diagnosis of dementia reviewed for unnecessary psychotropic medications in the sample of 45.

Inspectors wroteBased on interview and record review, the facility failed to allow a resident to chose when to transfer to his recliner for one resident (R1) out of 18 residents reviewed for choices on the sample list of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions for reducing or discontinuing restraints. The facility also failed to provide ongoing monitoring and evaluation for one (R38) of one residents reviewed for restraints on the sample list of 45.

Inspectors wroteBased on interview and record review the facility failed to develop a substance abuse care plan for one resident (R89), who was found to have an illegal drug in his room in the facility of 18 residents reviewed for care plans on the sample list of 45.

Inspectors wroteA. Based on interview and record review, the facility failed to provide incontinence briefs for one resident (R44) out of four resident reviewed for incontinence in a sample of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent cross contamination during cares for one (R73) of 18 residents reviewed for infection control on the sample list of 45.

Inspectors wroteBased on interview and record review, the facility failed to inform resident representatives within 24 hours of being notified of a new positive COVID-19 case in the facility for four residents (R12, R17, R41 and R79) out of 10 residents reviewed for infection control out a sample of 31. Findings Include: Facility COVID-19 Control Measures, revised 3/25/22, documents Notifications: 1. Verbal communication will be given immediately to the resident and the resident's family/representative whenever confirmation is received of a resident having COVID-19. The facility's Resident COVID Testing tracking sheet documents: (R65) test date 6/27/22, resulted 67/29/22. COVID Positive. (R38) test date 7/4/22, resulted 7/6/22. COVID positive. The facility's Employee COVID Testing tracking sheet documents 14 staff members testing positive from 6/16/22 through 8/4/22. [...]