Inspection·May 24, 2023

F 0684 R2's Nurse's Note, dated 5/13/23 at 10:30 PM, documented, outside Xray company arrived at the facility to perform the Xray. Level of Harm - Actual harm Residents Affected - Few R2's Radiology Report, for date of service 5/13/23 and faxed 5/14/23 at 01:?? AM (time cut off), documents, left knee replacement is identified. A fracture is noted involving the distal femur (lower part of thigh). The posterior lateral (back of knee on the outer side) displacement of fracture fragment is noted. R2's Nurse's Note, dated 5/13/23 [sic] at 2:30AM, documented report received of a left fracture of distal femur and faxed to the physician. R2's Nurse's Note, dated 5/14/23 at 6:30 AM, V6 documents, slight bruising to knee area noted. R2's Nurse's Note, dated 5/14/23 at 7:00 AM, documents, writer (V6) called Doctor, left message for the doctor to call the facility. At 7:05 AM, continues to document, V1 (Administrator) was made aware of Xray report. Nurse's Note continues to document at 8:15AM, a telephone physician order was received to send R2 to emergency department for evaluation and treatment and at 9:00 AM, R2 was transferred to Emergency Department. R2's Hospital consultation, dated 5/14/23 at 6:03PM, documented, left knee pain, Xray acute fracture of distal supracondylar femur around the femoral component of the replacement hardware acute comminuted fracture of the supracondylar distal fracture above the cemented femoral knee replacement. It also documents a preop assessment was done and R2 was cleared for surgical repair. On 5/18/23 at 1:50PM, V6 (LPN) stated she was scheduled to work on 5/13/23 (Saturday) morning at 6:00 AM, at 6:30 AM, had noticed a physician fax order for a Xray to be done, dated 5/11/23 on R2 which was located in a filing basket at the nursing station. V6 stated she went through R2's medical records Nurse's Notes and noticed R2 had a fall on 5/10/23 at 9:00PM and documentation on 5/11/23 early morning that R2 complained of left leg pain with bruising and no documentation on 5/12/23. V6 stated that she identified there was no treatment provided or if a nurse followed-up with the fax transmittal order that was submitted on 5/11/23 to V14 (Physician). V6 stated she notified V14 immediately at 8:00 AM, to receive an order that R2 receive a Stat (immediate) Xray due to visible bruising on the left knee and left inner thigh with decrease range of motion to that left leg. V6 continues to state, R2's Xray was not performed till 5/13/23 late at 10:30 PM, with results received on 5/14/23 around 1:00 AM in the morning that identified a fracture to the left femur and was not sent out for treatment till the morning of V6's shift at 8:00 AM. On 5/24/23 at 4:15 PM, V2 (Director of Nursing), stated the physician was notified on 5/11/23 for the Xray. V2 also stated this situation is subjective to the individual nurse. The facility's Notification for Change in Resident Condition or Status policy and procedure, dated 12/7/17, documents, The facility staff shall promptly notify physician of changes in the resident's medical/mental condition and/or status, further documents, a discovery of injuries, abnormal complaints of pain, a need to transfer the resident to a hospital/treatment center. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145411 If continuation sheet Page 2 of 4 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 05/24/2023 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)

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 observation, interview and record review, the facility failed to provide safe transfers for 2 of 3 residents (R2, R6) reviewed for falls in a sample of 6. This failure resulted in R2's fall during a transfer sustaining a left leg fracture requiring surgical repair. Findings include: 1. R2's Fall Risk Assessment, dated 4/27/23 prior to fall incident date of 5/10/23, documented R2 was at High Risk for falls. R2's Minimum Data Set (MDS), dated [DATE], documented mild impaired mental cognition. R2's Physical Therapist Progress and Discharge summary, dated [DATE], documents, Discharge summary, patient progressed in muscle strength from start of care but was with limited progress due to poor safety with use of mechanical sit to stand Lift. Ultimately it was decided that patient is safer transferring with (full mechanical transfer lift) versus sit to stand (partial transfer lift) and CNAs (Certified Nurse Assistants) were instructed to continue to use (full mechanical transfer lift) with resident. R2's Physician Order Sheet (POS) dated 4/25/23, documented, may use (full mechanical lift) for transfers. R2's Nurse's Notes, dated 5/10/23 (Wednesday) at 9:00PM, documents, resident lowered to floor in sit to stand no apparent injury. R2's Investigation Report for Falls, undated, documented transfer from shower chair to bed using a standing mechanical lift, the lift belt buckle was not secure and R2 was barefoot after returning from a shower during the transfer. R2's Nurse's Note, dated 5/11/23 (Thursday) at 1:30AM, documents, resident c/o (complained of) left leg pain. Light bruising noted to left knee. Res (resident) yelling out in pain when left leg straightens. R2's Radiology Report, dated 5/13/23 and faxed 5/14/23 at 01:?? AM (time cut off), documents, left knee replacement is identified. A fracture is noted involving the distal (lower part of thigh) femur. The posterior lateral (back of knee on the outer side) displacement of fracture fragment is noted. R2's Hospital consultation, dated 5/14/23 at 6:03PM, documented left knee pain, Xray acute fracture of distal supracondylar femur around the femoral component of the replacement hardware acute comminuted fracture of the supracondylar distal fracture above the cemented femoral knee replacement. It also documents a preop assessment was done and R2 was cleared for surgical repair. R2's Care Plan, dated 1/13/22, documents, assist to transfer resident using mechanical device of (full mechanical lift device) and 2 staff members, and a revised handwritten, date of 1/25/23, documents, may use sit to stand for toileting and shower transfers, as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145411 If continuation sheet Page 3 of 4 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 05/24/2023 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)

F 0689 Level of Harm - Actual harm On 5/23/23 at 11:15AM, V8 (MDS Coordinator) stated the Interdisciplinary Team decided that R2 could use a Sit to Stand for transfers, as R2 requested the facility to use. V8 also stated there is no documented assessment of this change in R2's mode of transfer, however, R2 at times does well with a sit to stand but most the times she cannot. Residents Affected - Few On 5/18/23 at 1:50PM, V6 (Licensed Practical Nurse/LPN), stated that R2 is not able to bear weight to her lower legs and requires the use of a full mechanical lift for all transfers. On 5/18/23 at 2:10PM, V7 (Certified Nurse Assistant/CNA), stated R2 had received a shower and was brought back to her room to be placed in bed, using a sit to stand. At this time, R2 was at the edge of the shower chair when being raised with sit to stand and her legs became weak and was lowered down to the floor with the sit to stand. On 5/23/23 at 1:40PM, V9, V10, and V11 (all CNAs) stated that R2 cannot stand, both of her feet are bowed outward, she cannot straighten her feet, she cannot bear weight with her legs, R2 requires a full mechanical lift for transfer. On 5/23/23 at 11:00AM, R2 was lying in bed, the left leg was propped up on a pillow with the leg wrapped in a support brace with dressings. R2's left and right feet were angled out away from her body and was unable to straighten her feet. On 5/23/23 at 4:20PM, V1 stated, so a re-assessment of R2's transfer status needs to be completed. 2. R6's POS, dated 4/27/23, documented high back wheelchair, may use (full mechanical transfer lift) as needed. R6's Care Plan dated 05/3/23 documented, dependent with transfer using (full mechanical transfer lift) and 2 staff members. On 5/23/23 at 2:38PM, V7 and V15 (CNAs) transferred R6, from the bed using a full mechanical lift. During the transfer, R6's bed was not locked and R6's high back wheelchair also was not locked when R6 was being lowered into the chair. The facility's Full Mechanical Lift Operating Instructions, dated 7/2014, documented to lift the patient while in bed, ensure the bed brakes are in locked position and lowered into a wheeled chair, ensure the chair wheels are locked. The facility's Fall Prevention policy and procedure, dated 11/18, documented, to provide for resident safety and to minimize injuries related to falls, decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145411 If continuation sheet Page 4 of 4