Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, observation, and record review, the facility failed to identify and treat a pressure ulcer on 1 of 2
residents (R38) reviewed for skin impairments in the sample of 31.
Residents Affected - Few
The findings include:
R38's admission Record documents, R38 was admitted to the facility on [DATE].
R38's Medical Record, documents, R38's diagnosis includes Heart Failure, Chronic Obstructive Pulmonary
Disease, Unspecified Dementia, Hyperlipidemia, Essential Hypertension, Unspecified Osteoarthritis,
Rheumatoid Arthritis, Gastro-Esophageal Reflux Disease, Major Depressive Disorder, Anxiety Disorder,
Unspecified Psychosis, and Edema.
R38's Care Plan dated 06/13/2023, documents, R38 has an actual impairment to skin integrity of the right
buttocks, related to pressure. The goal is R38's skin injury, pressure injury of the right buttocks will be
healed by review date. R38's Care Plan interventions include, follow facility protocols for treatment of injury,
identify/document potential causative factors and eliminate/resolve where possible, monitor/document
location, size and treatment of impairment, report abnormalities to Medical Doctor, pressure reducing
cushion to wheelchair to protect skin while up, and continues weekly treatment documentation to include
measurement of each area of skin breakdown's width, length, and depth.
R38's Minimum Data Set, (MDS), dated [DATE], documents, R38 has moderate cognitive impairment and
requires total dependence on staff for toileting hygiene and transfers. R38's MDS also, documents, R38
requires substantial/maximal assistance with turning and repositioning.
On 11/15/2023 at 8:50 AM, V13 and V14 both Certified Nursing Assistants/CNAs assisted R38 into bed via
mechanical lift. V13 and V14 then assisted R38 with incontinence care. A dime sized wound/open area was
observed on R38's left buttock. Scarring was also observed on both buttock from previous skin
impairments. No treatment was in place on the wound to R38's left buttock. R38 did not have a pressure
reducing cushion in her wheelchair during this observation or on 11/13/2023 and 11/14/2023. V4 (Licensed
Practical Nurse/Care Plan Coordinator), V13, and V14 all agreed that R38 has a pressure injury on her left
buttock region. V4 stated, she was unaware of R38 currently having a pressure injury. V3 (Licensed
Practical Nurse/Resident Care Coordinator) stated, she oversees skin care for the residents, and she was
not aware of R38 currently having an open area to her buttock. V3 stated, she will have the contracted
wound care company consult with R38.
On 11/16/2023 at 8:45 AM, no documentation regarding R38's skin impairment on left buttock has been
(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 13
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
11/16/2023
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 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
entered into R38's medical record including no Physician notification of skin impairment and no treatment
order for R38's wound on left buttock. R38's Care Plan has not been updated to include the skin impairment
on R38's left buttock.
On 11/16/2023 at 8:55 AM, V3 stated, she did contact the wound care company regarding R38's open area
and she will document it in the progress notes.
The facility Decubitus Care/Pressure Areas Policy dated 1/2018 states: It is the policy of this facility to
ensure a proper treatment program has been instituted and is being closely monitored to promote the
healing of any pressure ulcer. 1.Upon notification of skin breakdown, the QA form for newly acquired skin
condition will be completed and forwarded to the Director of Nurses. 2. The pressure area will be assessed
and documented on the treatment administration record or the wound documentation record. 3. Complete
all areas of the treatment administration record or wound documentation record. It continues, 4. Notify the
physician for treatment orders. 5. Documentation of the pressure area must occur upon identification and at
least once each week on the TAR, (Treatment Administration Record), or Wound Documentation Form.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145411
If continuation sheet
Page 2 of 13
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
11/16/2023
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 ensure there was sufficient supervision to
prevent falls and ensure care plan interventions were appropriately in place for 2 out of 3 (R28, R36)
reviewed for falls in a sample of 31. This failure resulted in R28 being sent to local emergency room with an
acute to subacute right lateral 9th rib fracture, subacute to acute right anterolateral 3rd rib fracture and also
had multiple healed rib fractures from other falls.
Findings include:
1. R28's Face Sheet, print date of 11/16/23 documents R28 has the following diagnose Type II diabetes
mellitus with hyperglycemia, multiple fractures of ribs, Alzheimer's disease, dementia, Hypertension.
R28's Minimum Data Set (MDS), dated [DATE], documents R28 is severely cognitively impaired and
requires substantial/maximal assistance with transferring, oral hygiene, toileting hygiene, shower/bath,
dressing, and personal hygiene, he is frequently incontinent of bladder, and always continent of bowel.
R28's Care Plan, not dated, documents the resident has had an actual fall. Root cause may be related to
(r/t) Cognitive Impairment- Does not understand limits, Cognitive Impairment- unaware of safety needs,
poor Balance, and unsteady gait. Interventions include but are not limited to for no apparent acute injury,
determine and address causative factors of the fall, Major injury- Pressure alarm under buttocks and under
torso while in bed, and Major injury- signage posted in room to use call light for assist.
R28's Physician's Orders, dated 05/10/23, documents pressure pad alarm at all times.
R28's Incident Audit Report, dated 10/06/23 at 5:38 AM, documents R28 had an unwitnessed fall. He was
found face down on the floor beside his bed. R28 attempted to get up to the bathroom without calling for
assistance. He had a hematoma noted to the top of his scalp. It further documents in the notes section root
cause of this fall noted to be resident attempting to get out of bed to toilet self without assistance. Resident
had shut off pressure alarm. Intervention is to place a pressure alarm under resident's bottom and another
under his torso.
R28's Progress Notes, dated 10/06/23 at 8:57 AM, documents the writer received in report R28 had and
unwitnessed fall in his bedroom. He was found in the prone position attempting to roll over and get his
self-up. He was noted to have a hematoma on his forehead above his left eye and he complained of pain
and discomfort to his right arm/shoulder when the writer was assessing and doing range of motion. Neuro
checks were in place due to it being an unwitnessed fall. His blood pressure at 6:25 AM was 158/101 and
his pulse was 98. He was able to recall the fall to writer without difficulty he agreed to be sent out to the
local hospital to be evaluated and treated, and doctor and his power of attorney was notified.
R28's Hospital Report, dated 10/06/23 at 9:24 AM, documents Computed Tomography (CT) scan report
impression: Acute to subacute right lateral 9th rib fracture. Subacute to acute right anterolateral 3rd rib
fracture. Multiple healed rib fractures.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145411
If continuation sheet
Page 3 of 13
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
11/16/2023
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
On 11/14/23 at 1:43 PM, R28 is up and in his wheelchair. Tab alarm noted to be attached to the back of his
shirt. No pressure pad alarm noted in his wheelchair.
Level of Harm - Actual harm
Residents Affected - Few
On 11/15/23 at 1:20 PM, R28 is lying in bed with his eyes open. Fall mat beside his bed, bed in low
position, there was a tab alarm observed hooked to his shirt and the other end lying in his bed. There were
no pressure pad alarms observed by this surveyor.
On 11/15/23 at 1:22 PM, this surveyor went and asked V2 (Director of Nursing/DON) if R28 was supposed
to have pressure pad alarms under him while he was in bed and she stated, yes. This surveyor asked V2 if
she could please come down to R28's room. This surveyor and V2 went down to R28's room and V2
checked under R28 to see if he had pressure pad alarms under him and there wasn't any noted at this
time.
On 11/15/23 at 1:24 PM, V2 stated she would expect for the pressure pad alarms to be placed under R28
when he was in bed.
On 11/16/23 at 10:00 AM, V4 (MDS Coordinator) stated they discontinued R28's tab alarm on 06/28/23,
due to him taking it off and carrying it and then they ordered him the one pressure pad alarm. She said
after the fall on 10/06/23, is when they ordered the second pressure pad alarm for him. V4 stated R28
should not have a tab alarm on.
On 11/16/23 at 10:05 AM, this surveyor and V4 went down to R28's room together. R28 was observed to be
sitting up in his wheelchair with a tab alarm placed on the back of his wheelchair and hooked to the back of
his shirt. There was no pressure pad alarm noted to be under him at this time. V4 stated R28 should have a
pressure pad alarm placed in his wheelchair and she said they are supposed to put it on R28 every time
they change his position.
On 11/16/23 at 10:35 AM, V4 stated she was just made aware the pressure pad alarms are broken and will
be fixed and here within the next couple of hours. She said until the new/fixed pads get here they are using
the pull tab alarm and doing 15-minute visual checks on R28. She said she isn't sure how long the pressure
pad alarms have been broken she was just made aware of it today when she questioned staff about them.
She said she would expect the Certified Nursing Assistants (CNAs) to notify the nurses and the nurses to
notify management about the pressure alarms being broken so they could rectify the situation.
2. R36's face sheet documents that R36 was admitted to the facility on [DATE] with a diagnosis of right hip
fracture, C5 compression fracture and L1 compression fracture resulting from a fall at home.
R36's other medical diagnosis includes Unspecified Dementia, Anxiety Disorder, Major Depressive
Disorder, Hypertension, and Hyperlipidemia.
R36's Minimum Data Set (MDS), dated [DATE], documents R36 is severely cognitively impaired and is
totally dependent on at least two staff members for bed mobility and transfers.
The facilities incidents by incident type report, dated 11/13/2023, documents R36 has had a fall on
7/21/2023, 9/4/2023, 9/13/2023, 9/14/2023, and 10/19/2023.
R36's Care Plan, dated 7/5/2023, documents the resident has had an actual fall. The root cause may
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145411
If continuation sheet
Page 4 of 13
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
11/16/2023
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
be related to cognitive impairments as she does not understand limits, unaware of safety needs, poor
balance, poor communication/comprehension and has an unsteady gait. Interventions: bed to be in low
position, fall mat placed beside bed, bed against wall, foam positioning aids on both sides, staff educated
on safe resident positioning, and continue interventions on the at-risk plan.
Residents Affected - Few
R36's progress notes dated 7/21/2023 at 9:28 AM, documents, during breakfast resident rolled out of bed,
no injuries from fall, and the right hip incision had nothing to do with the fall.
The facility Incident Audit Report, dated 7/21/1023, documents the root cause of this fall was resident was
not positioned in the center of the bed and rolled off edge of bed into floor. Intervention is staff education of
safe positioning of residents.
R36's progress notes, dated 9/4/2023, documents on doing rounds, CNAs found resident on the floor
beside her bed, lying on her left side, head was rested up against bedside table and bleeding noted from
right ear. Ambulance was called and resident was transported to the local emergency room. R36's ear
injury was treated with medical glue and R36 returned to the facility.
The facility Incident Audit Report, dated 9/4/23, documents the root cause of this fall was resident fell out of
bed. Intervention is a fall mat on floor beside bed. Bed also to be in lowest position.
R36's progress notes dated 9/13/2023 at 8:20 PM, documents resident noted on floor in her room. Laying
on left side beside bed. Clothes and linens saturated with urine. Bed not in low position. Floor mat not in
place. Small skin tear to left elbow. Cleansed and band aid applied. Resident assisted back to bed and care
given.
The facility Incident Audit Report, dated 9/14/2023, documents R36's bed was not in low position, floor mat
was not in place and R36 was saturated with urine. Root cause of this fall was resident rolled out of bed.
Intervention is foam positioning aids on each side of resident's bed while resident is in bed.
R36's progress notes dated 9/14/2023, documents resident was on the floor next to her bed, nurse checked
resident over, she was fine and voiced no complaints of pain. Fall was unwitnessed.
The facility Incident Audit Report, dated 9/14/2023, documents the root cause of R36's fall was resident
rolled out of bed. Mattress changed to better fit foam positioning aids.
R36's progress notes dated 10/19/23 at 4:11 AM, resident found on the floor beside her bed face down and
on right side. Noted to have a large goose egg above her right eye and facial bruising noted. The floor mat
was on the opposite side of the bed and the foam positioning aid was slid off the bed on the floor also.
The facility Incident Audit Report, dated 10/19/2023, documents the root cause of R36's fall was that
resident rolled out of bed. Intervention will be a bolstered mattress.
R36's fall risk assessment, dated 8/10/2023, documents R36 was high risk for falls with a score of 13. A
score of 10 or more equals high risk.
On 11/13/2023 at 9:10 AM, R36 was observed to have light blue/green bruising to the right side of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145411
If continuation sheet
Page 5 of 13
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
11/16/2023
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
her face near the temporal region. V12 stated the bruising was from a previous fall.
Level of Harm - Actual harm
On 11/14/2023 at 6:21 PM V10 (Licensed Practical Nurse) stated she (R36) did not have her bed in low
position and her mat was not on the floor when she fell on September 13, 2023.
Residents Affected - Few
On 11/15/2023 at 1:40 PM V2 (Director of Nursing) stated she would expect fall interventions to be in place
according to the care plan.
The Facility's Fall Prevention Policy, dated 11/10/18, documents 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. 1. Conduct Fall Assessments on the day of admission, quarterly, and with a
change in condition. 2. Identify, on admission, the resident's risk for falls. All staff must observe residents for
safety. If residents with a high-risk code are observed up or getting up, help must be summoned, or
assistance must be provided to the resident. 3. Assessments of Fall Risk will be completed by the
admission nurse at the time of admission. Appropriate interventions will be implemented for residents
determined to be at high risk at the time of admission for up to 72 hours. 5. Immediately after any resident
fall, the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall
huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate
interventions. 6. The unit nurse will place documentation of the circumstances of a fall in the nurses notes
or on an AIM for Wellness form along with any new interventions deemed to be appropriate at the time. The
unit nurse will also place any new interventions on the CNA assignment worksheet. 7. Report all falls during
the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning
Quality Assurance meeting and any new interventions will be written on the care plan.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145411
If continuation sheet
Page 6 of 13
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
11/16/2023
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure the medication refrigerator temperature
was monitored, dispose of expired and discontinued Intravenous medications, as well as follow their policy
regarding dating opened medications for 3 of 3 residents (R16, R30, and R52) reviewed for Medication
Storage in the sample of 31.
Findings include:
1. On [DATE] at 2:20 PM the Medication storage room was observed with V11 (Licensed Practical
Nurse/LPN). At this time V11 stated, insulin and other medications that require refrigeration are kept in the
locked refrigerator. Located on the outside of the refrigerator was a paper titled, Insulin Fridge dated
[DATE]. At this time V11 stated, night shift nurses are responsible for checking and documenting the
temperature on the paper.
The document does not a have temperature recorded for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE],
or [DATE].
On [DATE] at 1:52 PM V2 (Director of Nurses/DON), stated, the refrigerator temperatures are to be checked
and documented, once daily by the night shift nurse. V2 reviewed and verified that there were multiple
dates when the temperature had not been monitored or documented.
2. On [DATE] at 2:20 PM, there was an opened bottle labeled (R52) Gabapentin Oral Solution. There was
no date listed on the bottle to indicate when it was opened.
3. On [DATE] at 2:21 PM there was an opened bottled with liquid in it labeled, (R16) Lidocaine. There was
no date listed on the bottle to indicate when it was opened.
On [DATE] at 1:53 PM, V12 (LPN) and V2 verified this information and V12 added, That's been a while
since he has used that.
R16's Physician's Order Sheet dated [DATE] does not include a current order for Lidocaine Elixir.
4. On [DATE] at 2:23 PM, there were 3 bags of IV solution with R30's name on them. The bag was labeled
Cefepime and included an expiration date of [DATE].
On [DATE] at 1:53 PM V2 stated, the bags of IV fluids should have been disposed of because they can't
send them back to pharmacy once they've been mixed.
The Facility's Procurement and Storage of Medications Policy dated [DATE] documents, All medication
containers shall be labeled with the date opened by the person breaking the container seal. It continues to
document, All discontinued/expired non-controlled medications are to be removed from the active
medication storage area, and the quality should be noted on the medication sheet. All medications should
then be returned to pharmacy or destroyed per facility policy as soon as practical.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145411
If continuation sheet
Page 7 of 13
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
11/16/2023
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 0801
Level of Harm - Minimal harm
or potential for actual harm
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the
food and nutrition service, including a qualified dietician.
Based on observation and interview the facility failed to ensure a Certified Dietary Manager was in place.
This has the potential to affect all 51 residents who reside at the facility.
Residents Affected - Many
Findings include:
On 11/13/23 at 8:45 AM, the initial tour of the kitchen was done at this time. While doing the kitchen
inspection V5 (Activities Director) was observed in the kitchen. Her name badge stated her name and her
current title of Activities Director. No Dietary Manager was observed in the kitchen at this time.
On 11/13/23 at 9:00 AM, V5 (Activities Director) stated, the facility currently doesn't have an active Dietary
Manager. She said she use to be the Dietary Manager, but she is currently the Activities Director.
On 11/14/23 at 11:45 AM, there was no Dietary Manager observed in the kitchen at this time.
On 11/14/23 at 11:47 AM, V7 (Cook) stated, the facility doesn't have a Dietary Manager at this time, and
she stated, as far as she knows the facility doesn't have a Registered Dietician.
On 11/15/2023 at 1:35 PM, V1 (Administrator) stated, the facility hasn't had a Dietary Manager for about
two months. She said she has interviewed someone for the position, and they will let her know if they are
going to take it by Friday. V1 stated, V5 does the ordering, and the department heads were having to help in
the kitchen.
On 11/16/23 at 9:24 AM, V2 (Director of Nursing) stated, the facility doesn't have a policy regarding the
Dietary Manager or staffing.
CMS-671, dated 11/13/23, documents the facility currently has 51 residents residing at the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145411
If continuation sheet
Page 8 of 13
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
11/16/2023
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview and record review, the facility failed to ensure diet orders prescribed by a
physician were followed as well as update/post an accurate menu and for 2 of 5 residents, (R3, R13)
reviewed for Dietary Services, in the sample of 31.
Findings include:
1. On 11/13/23 at 11:14 AM, R3 stated that she does not always receive a Renal Diet. R3 stated, that she
was served tomato soup for supper last night and she is not supposed to eat tomatoes. Resident also
stated, she has brought this to the attention of staff.
R3's Face Sheet dated 11/16/2023 documents, R3 has a diagnosis of End Stage Renal Disease and is on
Renal Dialysis.
R3's Order Audit Report dated 11/16/2023 documents, R3 is on a Renal Diet.
On 11/14/2023 at 2 PM, V15 (Dietary Aid) stated, the menu provided was Week 2.
The menu for Sunday Week 2 documents, the residents on a Renal Diet were supposed to be served
mixed vegetables instead of tomato soap.
2. On 11/13/2023 at 12:25 PM the menu board located on the wall in the dining room documented,
November 12 and the meal to be served was fried chicken and mashed potatoes.
On 11/14/2023 at 10:25 AM, R13 stated, I've worked so hard to get them keep the board updated with the
menu for the day. They will not keep it updated. It aggravates the heck out of me. As a Diabetic, I've always
ran my life by planning my meals out for the day. It will say one thing, they'll come up and erase it and serve
something else.
On 11/14/2023 at 11:45 AM, The menu board in the dining room was blank. It did not document, the meal
to be served.
The Facility's Diet Orders Policy dated, 4/15 documents, It is the policy of (Facility) to establish procedures
for writing and communicating diet orders. Interpretation of the Diet Order shall be made in conjunction with
the Facility's Diet Manual or materials provided by the Physician.
The Facility's Cycle Menu Policy dated 4/21 documents, It is the policy of (Facility) that a four-week cycle
menu shall be used to: 1. Ensure resident food preferences are considered. 2. Ensure nutritional needs of
residents are met. It continues, Renal- this diet may be prescribed for individuals with chronic kidney
disease. It further documents, Temporary changes to the menu shall follow the substitution policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145411
If continuation sheet
Page 9 of 13
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
11/16/2023
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 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the Facility failed to ensure food items were served at an
appetizing temperature and were thoroughly cooked for palatability for 5 of 5 residents, (R4, R13, R43,
R45, and R208) reviewed for Dietary Services in the sample of 31.
Residents Affected - Some
Findings include:
On 11/14/2023 at 2 PM, V15 (Dietary Aid) stated the menu provided was Week 2.
The Menu for Monday Week 2 documents Lunch as: Salisbury steak with gravy, baked potatoes with butter,
peas, and pumpkin cake.
1. R4's Minimum Data Set (MDS), dated [DATE] documents, R4 is cognitively intact.
On 11/13/2023 at 12:25 PM, R4 was served a baked potato. There was no steam present coming from the
plate. R4 was observed struggling to put butter on the potato. At this time R4 stated, Look, the butter won't
even melt, and my fork can't even stick through it. This statement was verified by observation by the potato
was not hot & was hard, because it was not cooked all the way.
2. R208's MDS dated [DATE] documents, R208 is cognitively intact.
On 11/13/2023 at 12:29 PM, R208 stated, My peas are cold, and the potatoes are hard as a rock.
3. R3's MDS dated [DATE] documents, R3 is cognitively intact.
On 11/14/2023 at 10:15 AM, R3 stated, The other night, (R208) ordered a hot dog and it was cold. R3 also
stated, the potatoes served on 11/13/2023 were not done and the peas were also cold. R3 stated, the only
thing served for lunch on 11/13/2023 that was warm was the gravy and that even it wasn't as warm as it
should have been.
4. R45's MDS dated [DATE] documents, R45 is cognitively intact.
On 11/14/2023 at 10:16 AM, R45 added to R3's statement regarding the cold hot dog served and R45
stated, Just like the potatoes yesterday (11/13/2023). I think they only put them in the microwave for like 10
minutes, maybe even just 5 (minutes). R45 stated the potatoes served on 11/13/2023 were not done and
the peas were also cold.
5. R43's MDS dated [DATE] documents R43 is cognitively intact.
On 11/14/2023 at 10:26 AM, R43 stated, They can't even fix my (noodles) right. How can you mess that
up? It's like that all the time. They cooked them too long. They were all stuck together in a 'glob' and slimy. It
made me gag. R43 also stated the potatoes served on 11/13/2023 were not done and the peas were also
cold.
On 11/15/23 at 3:50 PM, R43 stated, I already told them I'm not going to the dining room to eat. That's how
bad I dislike the food.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145411
If continuation sheet
Page 10 of 13
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
11/16/2023
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 0804
Level of Harm - Minimal harm
or potential for actual harm
The Facility's Cycle Menu Policy dated 4/21 documents, It is the policy of (Facility) that a four-week cycle
menu shall be used to: 1. Ensure resident food preferences are considered. 2. Ensure nutritional needs of
residents are met.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145411
If continuation sheet
Page 11 of 13
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
11/16/2023
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 0806
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food that accommodates resident allergies,
intolerances, and preferences, as well as appealing options.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the Facility failed to consider individual preferences for 1 of 5 residents (R43)
reviewed for Dietary Services, in the sample of 31.
Findings include:
R43's MDS dated [DATE] documents, R43 is cognitively intact.
On 11/14/2023 at 10:25 AM, R43 stated, I can't eat chocolate or anything citrus. When they bring me
something like that, I tell them I can't eat it, but they don't bring another dessert. I have made that list, (of
preferences/dislikes), 3 times already. I get a migraine if I eat chocolate and I have a hiatal hernia, so I can't
eat citrus. Yesterday they served me chocolate and I tell them all the time. They don't offer me anything else
usually, but today they gave me an Oatmeal cookie, which I don't like either.
R43's Dietary Card documents, R43's dislikes are Oatmeal, citrus and chocolate.
R43's Care Plan dated 7/24/2023 documents, R43 is potentially at risk for altered nutritional status and/or
weight loss. It also documents, Honor food preferences, replace disliked foods when possible. Definite food
dislikes.
The Facility's Cycle Menu Policy dated 4/21 documents, It is the policy of (Facility) that a four-week cycle
menu shall be used to: 1. Ensure resident food preferences are considered. 2. Ensure nutritional needs of
residents are met.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145411
If continuation sheet
Page 12 of 13
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
11/16/2023
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure the kitchen had labeled and dated
opened food and ensure there were no food items stored on the storeroom floor for 1 out of 2 kitchen visits.
This has the potential to affect all 51 residents who reside at the facility.
Findings include:
On 11/13/23 at 8:45 AM, the initial tour of the kitchen was done, and the following was observed.
1. A large container of opened Mayonnaise was observed to not have an open date.
2. A large container of opened Barbeque Sauce was observed with no open date noted.
3. A large container of opened Coleslaw with no open dated observed.
4. There was a container of resident's food that was brought in and appeared to be Potato Salad with no
date observed when it was brought into the facility.
5. There were two opened packages of Lunch Meat observed with no open date on the bag.
6. There was an open package of Hotdogs that were not in any kind of sealed bag, there was no opened
date observed, and the expiration date was 11/04/23.
7. The freezer was observed to have an opened bag of frozen Fish Squares, Hamburger Patties, and
Chicken Cordon Blue Patties that were not sealed up and had no open date on them.
On 11/13/23 at 09:05 AM, The kitchen storeroom was inspected, and the following was observed.
8. Two cases of Applesauce, Fruit Cocktail, one case of Mandarin Oranges, Orange Juice, and [NAME]
Cream Icing Mix were all observed to be sitting on the storeroom floor.
On 11/13/23 at 09:00 AM, V5 (Activities Director) stated, the facility currently doesn't have an active Dietary
Manager. She said she use to be the Dietary Manager, but she is currently the Activities Director. She
stated, the foods should be sealed closed with a tie and they should be labeled and, have an open date on
them and the other items in the refrigerator, should be labeled with an open date.
On 11/13/23 at 9:07 AM, V5 stated there shouldn't be any food items on the floor.
The facility food storage policy, revised date of 10/20, documents It is the policy of the facility that food shall
be stored in shelves in areas that provide the best preservation. Food shall be stored at the proper
temperature and for appropriate lengths of time to protect quality of food and food cost. Procedure: 1. All
items will be dated upon receipt. Individual cans or [NAME] shall each be dated to ensure that stock is
rotated properly. It further documents 5. Store leftovers in covered, labeled and dated containers under
refrigeration or frozen. 6. When using only part of a product, the remaining product should be in the original
package or airtight container and labeled and dated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145411
If continuation sheet
Page 13 of 13
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
8 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the November 16, 2023 survey of ROSE GARDEN OF PANA?
This was a inspection survey of ROSE GARDEN OF PANA on November 16, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ROSE GARDEN OF PANA on November 16, 2023?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.