Health inspection·November 7, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to self-report an allegation of a medication overdose/suicide attempt to the state survey agency for 1 (R2) of 3 residents reviewed for Improper Nursing Care in the sample of 5. Findings include: On 11/2/2023 at 10:09 AM, V9 (Certified Nursing Assistant/CNA), stated, (R2) sometimes complains about pain, but nothing major. She does have some major bad behaviors. I heard she was holding her heart pills and took them all at once. On 11/2/2023 at 2:40 PM, V5 (Licensed Practical Nurse/LPN) stated, I went to her (R2's) room to ask her why she refused breakfast. She proceeded to tell me she saved up some pills and took them. She (R2) said, they were her heart medication. She (R2) said, she saved them in some napkins. I looked in her trash can- no napkins. She also said she hadn't had anything to drink all night, so I asked her how she took the pills. She said she took them at 3:30 AM and it was around 7:30 in the morning when she told me. I told her I would have to send her to the Hospital to make sure she was ok, and she said, 'I just didn't do it right this time'. V5 continued to state she was sent out prior to this day, due to complaints of groin pain. V5 stated, R2 had a massive infection that required a wound vacuum. V5 stated, R2 got Dilaudid (a very strong pain reliever) at the hospital. V5 stated, she also had to call the Doctor to get R2's PRN (as needed) order changed from every 6 hours to every 4 hours. R2's Emergency Department (ED) Physician's Note dated 10/29/2023 documents, R2 was seen at the local ED at 8:19 AM. It continues to document Chief Complaint: NH (Nursing Home) states that patient told her she has been hoarding her cardiac medications and took a pill cup and a half of pills this morning at 0300 (3 AM). Patient takes Digoxin and Procardia. It further documents, Assessment/Plan Intentional Drug Overdose and Suicidal behavior with attempted self-injury. R2's ED Notes dated 10/29/2023 continue to document, Patient was brought to ED from the Nursing Home by ambulance for complaints of an overdose. Patient states, 'I am tired of life, and I want to die'. She (R2) reportedly took 'a bunch of cardiac meds' around 3 AM. The meds were likely Digoxin and Procardia. R2's Physician's Order Sheet (POS) dated 11/6/2023 documents, R2 was started on Cymbalta 50 mg by mouth daily due to Major Depressive Disorder on 10/16/2023. R2's POS dated 11/6/2023 also documents R2 was taking Digoxin (Cardiac medication) 250 mcg (micrograms) daily, Hydrocodone 5/325 MG (milligrams) every four hours as needed for pain and Nifedipine (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 3 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 11/07/2023 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)