F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the Facility failed to assess a resident with a change in condition for 1 of 3
residents (R2) reviewed for quality of care in the sample of 3. The facility also failed to notify the physician
and resident representative of a change of condition. This failure resulted in a delay in hospitalization for R2
for the diagnoses of small bowel obstruction, dehydration, nausea, and vomiting. R2 required nasogastric
decompression and endured three attempts at midline catheter placement to achieve intravenous access
for fluid resuscitation. Findings include: R2's Face Sheet documents R2 was admitted to the facility on
[DATE] with diagnoses including dementia, chronic kidney disease, and congestive heart failure.R2's
Minimum Data Set (MDS) dated [DATE] documented R2 was moderately cognitively impaired and required
substantial assistance with bed mobility and transfer.On 10/23/25 at 4:35 PM, V9 (R2's Family) stated she
came to visit R2 over the weekend of 10/10/25-10/11/25. R2 was asleep in the dining room which was
unusual for her. V9 did not see R2 vomit that day, but when she was admitted to the hospital on [DATE],
hospital staff told her the Facility reported R2 had been vomiting for three days prior to admission.On
10/24/25 at 12:30 PM, V2 (Director of Nursing/DON), stated R2 did not have a known history of nausea or
vomiting.On 10/24/25 at 12:52 PM, V12 (Memory Care Coordinator) stated R2 was vomiting during
breakfast on 10/14/25, and V7 (Licensed Practical Nurse/LPN) was notified.On 10/24/25 at 12:59 PM, V10
(Certified Nursing Assistant/CNA), stated R2 vomited during dinner on 10/11/25 and did not eat breakfast
or lunch on 10/12/25.On 10/24/25 at 1:55 PM, V13 (CNA) stated R2 was not feeling well on 10/12/25 and
was not eating her meals.R2's Progress Note by V7 (LPN) on 10/14/25 at 5:23 PM documents, Resident
has had emesis x2 today, food contents mixed with stomach acids. She states she doesnt {sic} feel to {sic}
bad. Will put a call into MD (Medical Doctor) in the AMOn 10/24/25 at 1:07 PM, V7 (LPN) stated she had
been off work for a few days and had no knowledge of R2 having any gastrointestinal issues. She stated,
(Nursing) reports aren't always the greatest because we have agency, and they are not always the best. V7
stated R2 was alert and said she did not feel too bad, so she went on to finish her medication pass. She did
not assess R2's abdomen for bowel sounds or distention and was unsure of the time of R2's last bowel
movement. She worked until around 6:00 PM and gave report to V6 (LPN) with a plan to call the doctor the
next day.R2's Progress Note by V6 (LPN) on 10/15/25 at 2:02 AM documents, Res (resident) had emesis
x3 this shift. Vitals still WNL (Within Normal Limits). Bowel sounds present. Res c/o (complained of) LUQ
(Left Upper Quadrant) pain upon palpations. Attempted to push fluids this evening, res would feel nauseous
after a sip. Res c/o of being light headed. Res has had increased confusion, trying to climb out of the
recliner and yelling. R2 was send to (Local Hospital) for further evaluation.On 10/24/25 at 10:53 AM, V6
was unavailable for interview.R2's (Local) Hospital Records dated 10/15/25 R2 was having nausea and
vomiting for several days prior to admission and had large protuberant abdomen on examination. Computed
Tomography (CT) Scan showed small bowel obstruction. Nasogastric tube was placed for gastric
Residents Affected - Few
(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 2
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
10/28/2025
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 0684
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
decompression, and midline catheter required three attempts to achieve intravenous access for fluid
resuscitation. emergency room physician notes for the assessment/plan documents, 1. Small bowel
obstruction. 2. New onset atrial fibrillation. 3. Elevated troponin. 4. Nausea & Vomiting. 5. Hyperkalemia. 6.
Dehydration. 7. Chronic kidney disease, stage 3. 8. Urinary tract infection. 9. Lactic acidosis. Discharge
Disposition: transferred to (higher level of care hospital name) ICU (intensive care unit).On 10/24/25 at 2:10
PM, V11 (Medical Doctor/MD), stated he would have expected Facility nurses to examine R2's abdomen,
listen for bowel sounds, check for distention and tenderness, and call him with any changes in condition.On
10/28/25 at 11:20 AM, V2 (DON) stated nursing staff did what they should have and there was no delay in
R2's hospitalization. V2 stated the physician does not need to be contacted just because a resident has
emesis. V9 (R2's Family) was in the Facility visiting R2 all weekend and knew she had been doing fine. Staff
called V9 when R2 went to the hospital. The Facility does not have a policy specific to gastrointestinal
assessment. The Facility's Change in a Resident's Condition or Status Policy dated 2001 documents, Our
facility promptly notifies the resident, his or her attending physician, and the resident representative of
changes in the resident's medical/mental condition and/or status.
Event ID:
Facility ID:
145411
If continuation sheet
Page 2 of 2
