Inspection·September 20, 2022

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide supervision, investigate falls thoroughly to develop a root cause and analysis and implement progressive interventions to prevent falls for 2 of 5 residents (R1, R31) reviewed for falls. This failure resulted with R1 dislocating his shoulder multiple times, receiving 2 staples for a head laceration and hematomas. Findings include: 1. R1's admission Profile, undated, documents R1 was admitted on [DATE]. R1's September 2022 Physician Orders documents that R1 has diagnoses of Depression, Anxiety, and unspecified neuro cognitive disorder. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 has moderately impaired cognition and is totally dependent on one staff member for locomotion on the unit using a wheelchair. R1's Care Plan, with start date of 2/18/22 documents Resident has risk factors that require monitoring and intervention to reduce potential for self-injury. (Consider medical conditions, sensory altercations, balance, gait, assistive devices, cognition, mood/behavior, safety awareness, compliance, medication, restrictions, restraints. Risk factors include poor safety awareness, dementia, agitation, anxiety, weakness as evidence by related diagnoses/ condition/history. R1's Goal for this problem documents Resident will follow safety suggestions and limitations with supervision and verbal reminders for better control of risk factors thru next 90 days. The following are R1's Care Plan Approaches/Interventions all dated 2/18/22: Review quarterly and prn (as needed) resident's ADL (activities of daily living), mobility, cognitive, behavior and overall medical status. IDT (Interdisciplinary team) review of changes and needs with Resident and/or responsible party (when choose to attend) during care plan. Discuss fall related (information to review and revise plan as needed; Review quarterly and as needed during daily care and services of resident's plan for safety, giving verbal cues as needed to gain resident participation in minimizing risk factor and injury, encourage and assist placement of proper non-skin footwear; Attempt to anticipate needs-toileting, hydration, hunger and provide care before resident attempt to fulfill on own; observe for unsteady/unsafe transfer or ambulation and provide stand by or balance support as needed; Fall risk assessment quarterly and as needed with change in condition or falls status; IDTG review of ADL status and fall potential changes in condition or fall status. Report significant finding to MD for follow up; Monitor for changes in condition such as appetite, sleep patterns, balance, ADL assist level, swelling, muscle weakness, less socialization. Report to nurse for follow up assessment and MD notification. An intervention, dated 2/11/22 documents Low bed. (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 10 Event ID: 145411 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 145411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Garden of Pana 900 South Chestnut Pana, IL 62557 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)