Marigold Rehabilitation and Health Care Center

In the surveyor’s words

From the most serious findings on record at Marigold Rehabilitation and Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jul 31, 2025

  Based 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. […]

• Immediate jeopardy, patternF600Jul 6, 2024

  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. […]

• Immediate jeopardy, isolatedF600Jan 9, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF684Jan 9, 2026

  Based 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. […]

• Actual harm, isolatedF600Apr 21, 2026

  Based 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.Findings include:Facility Abuse, Prevention, and Prohibition Policy, dated November 2025, documents Each resident has the right to be free from abuse. Residents must not be subject to abuse by anyone, including but not limited to staff, and other residents. This facility prohibits mistreatment, neglect, or abuse of residents. Resident to resident abuse includes the term willful. […]