A nursing home in Galesburg received a $50,000 fine from the state of Illinois for failing to provide a resident with the proper medication, an oversight that led to the man’s death last year.
Marigold Rehabilitation, located at 275 East Carl Sandburg Drive, was fined by the Illinois Department of Public Health for neglecting to provide medication to a man living at the home on multiple occasions, which the agency said led to the man’s death last October. IDPH said that Marigold failed to ensure the man was free from neglect and failed to ensure he had the proper medications.
The facility was also accused of not intervening when it became clear that medications weren’t being provided, according to the report.
IDPH’s report says that the man had arrived at the facility on Oct. 21, 2025, after having been hospitalized for a month with acute on chronic respiratory failure; acute respiratory distress; COPD; pulmonary hypertension; congestive heart failure and chronic cor pulmonale. The man came to the facility with a long line of medications he was required to take, such as Diamox for heart failure, clonazepam for seizures, ipratroprium for COPD and prednisone and fluticasone for swelling. The man’s age was not listed in the report.
A skilled nursing note from his first day at the facility indicated that he was alert, albeit with some short term memory problems. His decision making was said to be unimpaired and had no indication of mood or behavioral issues. He did suffer from some incontinence in both his bowel and bladder and would have some shortness of breath at times. The man did require a bi-pap for respiratory support and a nebulizer treatment with oxygen.
However, according to a nursing progress note signed by a licensed practical nurse at the facility, at 11:39 a.m. on Oct. 23, a nurse went into his room to give him medication when they discovered he stopped breathing. He didn’t appear to have a heartbeat or a pulse and didn’t have any visible signs of life. The facility’s interim nursing director confirmed that the man had died, just 15 minutes after staff had last spoken with him.
A long list of medications were on his physician order sheet when he arrived, but IDPH’s report says that none of them were provided at the required times for two straight days. There was also no documentation that nursing management was made aware of the missed doses or that the man’s doctors were notified of the missed medications.
IDPH said that on Jan. 3, they observed a medication dispenser that showed several of the medications that were supposed to be provided to him, such as albuterol, Prozac, prednisone, simvastatin, spironolactone, torsemide and ipratroprium.
The licensed practical nurse spoke with IDPH one day prior and said that when someone is admitted to the facility, a minimum data set coordinator or the assistant nursing director puts medication orders into their system, noting that pharmacy deliveries are made from 8 p.m. to 10 p.m. each weekday, except for weekends when deliveries are made in the late afternoon.
She said that if a resident is admitted prior to that time, the medications would be delivered later that evening, with a locked medication cart containing a wide range of products. If a resident were to run out of medicine, or their medications hadn’t arrived yet, they could contact the pharmacy and get the medications with a code provided that would allow them to unlock the machine where they are dispensed.
Patient found dead after medication issues
On the two days that the man had resided at the facility prior to his death, the nurse said that his medications had not yet arrived and that he hadn’t received medications on those two dates. She said that certified nursing assistants were going to his room at the time he was found to provide him with his lunch, but found him dead and notified her of their findings.
She said that she examined the man and found him without a pulse and not breathing.
The man’s doctor was also interviewed by IDPH, telling them on Jan. 2 that his medications shouldn’t have been placed on hold as he moved into the facility. While he didn’t directly say that not receiving his medications led to the patient’s death, he felt that it couldn’t have helped his condition in any way. The doctor felt that he should have been notified if there were any changes made by the facility to his treatment plan, he should have been notified.
An advanced practice nurse told IDPH later that day that she didn’t specifically recall giving an order to hold the man’s medications until they were available, saying that she expected the medications to be available or for the facility to obtain them quickly via a pharmacy or in-house dispensing machine.
She said that she wouldn’t expect medication to be unavailable for a resident for 48 hours and that she or the man’s doctor should have been notified of the delay. Had she been notified, a new treatment plan could have been created to alleviate the issue, she said.
The facility’s critical care pharmacist told IDPH on Jan. 5 that a delivery slip for several medications had been delivered for the patient on Oct. 21, but two of the medications – Lovenox and Budesonide – had been discontinued. By the morning of Oct. 23, a large amount of medications had been delivered to the facility.
The facility’s interim nursing director said that same day that no nurses had told her that the man’s medications weren’t available or provided to him as directed. She did confirm that the man hadn’t received medications from Oct. 21-23, including ones like aspirin, vitamin D3 and hydroxychloroquine, used as an anti-rheumatic in this case.
The licensed practical nurse spoke with IDPH again on Jan. 5 and said that she did not get medications from the dispensing machine for the man on Oct. 21-22, and didn’t notify his doctor that he hadn’t been receiving his medications. She had no explanation as to why his Diamox or his Breztri inhaler was not provided at 8 a.m. each day he was at the facility, even though they had been delivered on Oct. 21.
She said that on the day he died, she was busy before she was called in by the CNAs after they found his body. In addition, she told IDPH that she did not notify nursing management about the man missing his medications on the days he was living at the facility, the report said.
According to the man’s death certificate, he died from heart failure, with COPD being a significant factor contributing to his death.
Marigold declined a phone request for comment by the Journal Star.
This article originally appeared on Journal Star: Galesburg nursing home fined by the state after patient death
Reporting by Zach Roth, Peoria Journal Star / Journal Star
USA TODAY Network via Reuters Connect
By Zach Roth, Peoria Journal Star | USA TODAY Network
