Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rose Garden Of Pana during CMS and state inspections, most recent first.
A resident with documented pain and a heel spur was repeatedly observed in bed with both heels pressing against the mattress while ordered heel protectors were left in a chair. The resident reported sores and blisters to the heels and legs, described the heel pain as horrible, and said he could not get relief until the heel protectors were applied; staff confirmed the resident could accurately report pain and had received a new pain order.
The facility did not schedule an RN to be on duty for at least 8 consecutive hours per day over an 88-day review period, despite having 71 residents. Staffing schedules and daily staffing sheets showed no RN coverage on any of the reviewed days. During the survey, a regional nurse was the only RN present, and CNAs reported that while the DON and regional nurse were in the building, they did not know if they were working the floor as nurses. The regional nurse confirmed that the facility did not have an RN providing services for 8 consecutive hours a day, contrary to the facility’s staffing policy requiring daily RN coverage.
Opened multidose insulin pens and vials on a medication cart were found without open dates, and an opened multidose Tuberculin vial in the med room refrigerator was also missing an open date and was expired. An LPN stated that opened insulin products are dated when first used and have shortened beyond-use dates, while a Regional Nurse confirmed the Tuberculin vial was open, in use, and should have been dated and discarded when expired.
Food temperatures were not verified with a calibrated thermometer when a cook checked food temps without calibrating the device first. The cook did not know how to calibrate it, and the Dietary Mgr stated the facility's digital thermometers were not calibrated, only changed with a new battery. Several residents reported the food was cold, and the Resident Council Concern Report noted cold eggs.
Delayed Care Plan Updates for Residents With Falls and Changing Conditions: The facility failed to timely develop and revise care plans for residents with repeated falls and significant medical and cognitive impairments. A resident with CHF and multiple falls, a resident with epilepsy and severe cognitive impairment, a resident with a femur fracture and lung cancer, and a resident with dementia and a lap restraint all had care plan interventions entered after the related events or orders had already occurred.
Failure to Implement and Update Fall Interventions: The facility did not use progressive fall interventions, did not timely implement fall-reduction measures, did not complete required post-fall assessments, and did not ensure care plan interventions were in place for multiple residents with repeated falls. Records showed a resident with severe cognitive impairment had numerous falls with injuries and the same intervention was continued, while other residents with CHF, atrial fibrillation, dementia, fractures, and impaired mobility had repeated falls without documented fall risk reassessments after each event.
The facility failed to ensure resident dignity and respect related to call light response and toileting needs. Several residents with varying levels of cognition and urinary incontinence reported long waits for call light response, leading to situations where they had accidents or felt compelled to toilet themselves, which made them feel embarrassed or awful. Night-shift staff, including an LPN and multiple CNAs, reported that there were not enough CNAs on the units at night, that management and call nurses did not respond when contacted, and that they nonetheless tried to answer call lights as quickly as possible while recognizing that having to wait and become incontinent would be embarrassing. An Ombudsman rights document referenced by surveyors stated that the facility must support residents' physical and mental health and their sense of satisfaction with themselves at the highest practical level.
A resident with venous and non-pressure wounds and multiple comorbidities had physician orders for daily skin checks and nightly dressing changes with specific wound care procedures, along with care plan requirements for ongoing wound assessment and documentation. Review of TARs over several months showed multiple missed or undocumented daily skin checks and dressing changes. Observation found a wound dressing dated from the prior day with yellow-green drainage, and the resident reported the dressing had not been changed when agency staff worked the previous night. LPNs reported that agency nurses often did not complete ordered treatments and that night-shift dressing changes were inconsistent, contrary to the facility’s wound care policy requiring thorough documentation of wound care and assessments.
Failure to Document and Properly Use a Lap Restraint: A resident with dementia, psychosis, anxiety, prior CVA, and a traumatic subdural hemorrhage was ordered a lap restraint for frequent falls and decreased mobility. The record lacked evidence of least restrictive attempts, the duration of use, risk/benefit documentation, and ongoing monitoring. The resident was observed unable to release the restraint when asked and was later seen eating lunch while the lap restraint remained in place, despite the order stating it should be removed during meals.
Infection control guidelines were not followed for two residents on contact isolation and enhanced barrier precautions. CNAs entered a resident’s room without the required gown and did not consistently perform hand hygiene, then provided catheter and incontinent care while using soiled gloves and handling contaminated items. For another resident, CNAs performed incontinent care without gowns and continued care with urine-soiled gloves while applying clean linens and repositioning the resident. The facility’s hand hygiene policy required handwashing or ABHR use before and after direct resident care, after contact with bodily fluids, after removing gloves, and when moving from contaminated to clean body sites.
A resident with dementia, chronic kidney disease, and heart failure experienced several days of vomiting, decreased intake, and lethargy. Staff did not thoroughly assess the resident's gastrointestinal symptoms or promptly notify the physician or family representative of the change in condition. This delay led to the resident being hospitalized for small bowel obstruction, dehydration, and related complications, requiring advanced interventions.
The facility failed to provide an RN for at least 8 consecutive hours a day, 7 days a week, and did not employ a DON. The administrator confirmed insufficient RN coverage, with only one RN working three days a week. The former DON left in July, and a newly hired DON did not complete employment. The RN on staff worked only on weekends, leaving the facility without adequate RN coverage on multiple days, affecting all 53 residents.
The facility did not post daily nursing staff hours, affecting all 53 residents. Observations over several days revealed no postings of resident census and licensed nursing staff numbers. The administrator was unaware of the lapse, assuming the former DON handled it. An LPN noted it was previously posted on the former DON's office door and should be updated daily.
A facility failed to prevent a severely cognitively impaired resident from wandering unsupervised, leading to multiple incidents where he entered other residents' rooms, causing distress. Despite reports from several residents and documented grievances, the facility lacked a specific policy on resident rights, and interventions were inconsistent.
A facility failed to supervise two residents adequately, leading to incidents of wandering and a fall without proper follow-up. One resident with dementia wandered unsupervised, entering other residents' rooms, while another resident with Alzheimer's fell and sustained injuries without an incident report or updated care plan. Staff interviews revealed a lack of awareness and communication, and the facility's fall prevention policy was not followed.
The facility failed to label, date, and dispose of food items in the refrigerator and freezer, potentially affecting four residents. Items such as pears, thickened juices, and various frozen goods were found improperly stored, contrary to the facility's policy requiring all items to be covered, labeled, and dated. The Dietary Manager admitted to not following the policy, leading to this deficiency.
The facility failed to provide timely Medicare notices to two residents regarding service termination and potential liability for non-covered services. One resident did not receive the required two days' notice before Medicare Part A coverage ended, and another resident's family did not receive evidence of the mailed notice. The facility lacked a policy for beneficiary notification, contributing to this deficiency.
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving resident-to-resident altercations. A cognitively intact resident reported being struck by a severely cognitively impaired resident with dementia. Another incident involved a verbal argument escalating into physical aggression between two residents, and a third resident reported being elbowed multiple times by the same impaired resident. The facility's policy on abuse prevention was not effectively implemented, contributing to these occurrences.
A resident with Alzheimer's and severe cognitive impairment fell, sustaining injuries, but the facility failed to update the care plan with new fall prevention interventions. The incident was not documented in the EMR, leading to a lack of awareness and follow-up by the care plan coordinator and resident care coordinator, contrary to facility policy.
Failure to Manage Resident Heel Pain
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident who had documented pain related to type 2 diabetes, heart disease, BPH, HTN, muscle weakness, HLD, and a calcaneal spur to the right foot. The resident’s care plan directed staff to administer analgesia as ordered, give it 30 minutes before treatments or care, anticipate the resident’s need for pain relief, respond immediately to complaints of pain, and evaluate pain relief 30 to 60 minutes after analgesics were given. The resident’s MDS also documented pain, and a physician order required heel protectors while in bed. During observation, the resident was repeatedly found lying in bed with both heels pressing against the mattress while the heel protectors were in a chair next to the bed. The resident stated he had sores and blisters to his legs and heels, that the areas were closed but not healed, and that his heels hurt a lot, describing the pain as horrible and saying he could not get relief because his heels pressed on the bed. Later, after the heel protectors were applied, the resident stated his feet felt better and that the pain was improved. Staff interviews confirmed the resident was alert, could communicate pain accurately, and had received a new pain order.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to schedule a Registered Nurse (RN) to be on duty for at least 8 consecutive hours each day, as required by regulation and the facility’s own staffing policy, for all 88 days reviewed in December 2025, January 2026, and February 2026. Review of working schedules and daily staffing sheets showed that no RN was scheduled on any day from 12/01/25 through 12/31/25, from 01/01/26 through 01/31/26, and from 02/01/26 through 02/26/26. During the survey, the Regional Nurse (V4) was the only RN present in the building, and the facility’s CMS-671 dated 02/23/26 documented that 71 residents resided in the facility. During interviews on 02/26/26, two CNAs (V23 and V22) reported that the DON (V2) and the Regional Nurse (V4) were in the facility but did not know whether they were working on the floor as nurses. At 9:45 AM on the same day, the Regional Nurse (V4) confirmed that the facility did not have an RN providing services for 8 consecutive hours a day. The facility’s policy titled “Staffing, Sufficient, and Competent Nursing,” revised August 2022, states that an RN must provide services at least eight consecutive hours every 24 hours, seven days a week, and may be scheduled for more than eight hours depending on resident acuity. Despite this policy and the presence of 71 residents, the required RN coverage was not provided during the entire review period.
Medication Labeling and Expired Stock Not Properly Managed
Penalty
Summary
The facility failed to properly store medication and discard expired medication. During inspection of the 200-hall medication cart, surveyors found opened and partially used multidose insulin products for R23, R38, R68, and R36, including Novolin FlexPen, Lantus SoloStar, Toujeo SoloStar, and Lantus vial, with no open dates documented on the containers. An LPN stated that when insulin is first accessed and used, the date is placed on the multidose vials and pens, and that these insulins have shortened expiration dates, typically 28 or 30 days after opening. Surveyors also inspected the medication room refrigerator and found an opened and partially used multidose vial of Tuberculin inside a plastic bag with no open date on either the vial or the bag. The bag was dated, but the vial’s expiration date had passed. A Regional Nurse verified that the Tuberculin vial was open, in use, and lacked a handwritten date on the vial or bag, and stated that it was expired and should have been disposed of rather than kept in use. The facility’s medication labeling and storage policy states that opened multidose vials are dated and discarded within 28 days unless the manufacturer specifies otherwise, and the medication administration policy states that the date opened is recorded on the container.
Food Temperatures Not Verified With Calibrated Thermometer
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and at a safe and appetizing temperature because kitchen staff failed to calibrate a thermometer before using it to check food temperatures. On 02/23/26 at 10:55 AM, a cook took the temperature of food without calibrating the thermometer first. When asked how he calibrated the thermometer, the cook stated he had no idea and went to ask the Dietary Manager, then returned and said the thermometer could not be calibrated. On 02/26/26, the Dietary Manager stated the facility used digital thermometers and did not calibrate them, and that the only way to calibrate them was to put in a new battery. On 02/24/26, several residents stated the food was cold, and the Resident Council Concern Report dated 02/26/26 documented that eggs were cold that morning. The facility's policy stated that staff use a thermometer that is clean, sanitized, and calibrated to ensure accuracy, and the CMS 671 documented 71 residents in the facility.
Delayed Care Plan Updates for Residents With Falls and Changing Conditions
Penalty
Summary
The facility failed to develop complete care plans within 7 days of the comprehensive assessment and failed to prepare, review, and revise care plans in a timely manner for 4 residents. The report identified that care plan interventions were added late for residents with repeated falls and significant medical and cognitive impairments, and that the care plans did not reflect identified problem areas in a timely way after changes in condition and fall events. R34 had diagnoses including CHF, paroxysmal atrial fibrillation, muscle wasting and atrophy, and unsteadiness on feet, and was documented as cognitively intact with moderate assistance needed for transfers. His care plan identified moderate fall risk with multiple risk factors, including psychotropic medications, diuretics, incontinence, visual impairment, and cognitive impairment. Progress notes documented multiple falls, including being found on the floor in the hallway, near his bed, in the therapy room while trying to get on a scale, and later on the floor with head bleeding after falling while trying to use his urinal. Several interventions on the care plan were entered after the events they addressed. R64 had diagnoses including epilepsy with status epilepticus and paroxysmal atrial fibrillation and was severely cognitively impaired, requiring substantial to maximal assistance with transfers. His care plan identified fall risk related to epilepsy, cognitive impairment, HTN, T2DM, and antidepressant use, but interventions were entered after multiple falls had already occurred, including falls during transfers between his bed and wheelchair and a later fall with right shoulder pain requiring hospital transfer. R86 had a left femur neck fracture and lung cancer, was cognitively impaired, and was dependent on staff for transfers and sit-to-stand. His care plan listed fall risk factors including pain, fracture, lung cancer, impaired cognition, psychotropic drug use, and total dependence with ADLs, yet progress notes documented falls from bed and from a wheelchair, and some interventions were not added until after those events. R7 had diagnoses including traumatic subdural hemorrhage, dementia, psychosis, anxiety, leukemia, osteoporosis, and cerebral infarction, and was severely cognitively impaired with a restraint order for a lap restraint due to frequent falls and decreased mobility; however, the restraint care plan and fall interventions were not created or added in a timely manner after the restraint was ordered and after prior falls occurred.
Failure to Implement and Update Fall Interventions
Penalty
Summary
The facility failed to implement progressive fall interventions, failed to implement fall reduction interventions in a timely manner, failed to complete post-fall assessments per policy, and failed to ensure fall interventions were in place per care plans for 4 of 10 residents reviewed for falls. The report identifies repeated falls and repeated use of the same interventions without documented progression for one resident with severe cognitive impairment and multiple diagnoses including traumatic subdural hemorrhage, dementia, psychosis, anxiety, osteoporosis, and cerebral infarction. The resident’s record showed multiple falls in June and July 2025, including falls in the hallway, dining room, TV room, and near a housekeeping cart, with injuries such as lacerations, facial pain, head strike, blood loss, and discoloration. Surveyor interview documented that the regional nurse agreed that continuing the same fall interventions was not a progressive fall intervention. For another resident, the record showed a moderate fall risk with diagnoses including CHF, atrial fibrillation, muscle wasting, and unsteadiness on feet. The resident had multiple falls documented in progress notes, including being found on the hallway floor and on the ground near the bed. The care plan included interventions such as a call-don’t-fall sign, pressure pad alarm, 15-minute checks, moving the resident closer to the nursing desk, and education to walk slowly, but the record review showed no fall risk assessment completed after the documented falls on 12/24/25 and 01/02/26. A third resident with cognitive impairment, a left femur neck fracture, lung cancer, pain, psychotropic drug use, and total dependence for ADLs had falls documented after being found on the floor next to the bed, on the floor during the night, and slipping out of the wheelchair in the living room. The care plan listed interventions including 15-minute checks, keeping the bed low, moving the resident closer to the nursing station, and a non-skin cushion with a pressure alarm, but the record review showed no fall risk assessments completed after the falls on 01/12/26 and 02/22/26. The facility policy required a fall risk assessment after each fall and required staff to identify and implement resident-centered interventions when falls recur, but the records reviewed did not show that these requirements were completed for the residents identified in the report.
Failure to Ensure Dignity Related to Call Light Response and Incontinence
Penalty
Summary
Surveyors identified a failure to ensure dignity and respect related to call light response for four residents. One resident with moderately impaired cognition and frequent urinary and occasional stool incontinence reported that when staff did not answer her call light and she had to go to the bathroom, she sometimes had accidents that did not feel good and embarrassed her. Another resident with intact cognition and frequent urinary incontinence due to taking a diuretic stated she was always incontinent but, when she had to wait, she thought about other residents who also needed help and were not getting it. A third resident with intact cognition and occasional urinary incontinence reported that it took a long time for night shift to answer her call light, so she would get up and go to the bathroom on her own. A fourth resident with intact cognition and occasional urinary incontinence stated that if she had to wait a long time to use the toilet and had an accident, it made her feel awful. Staff interviews further described conditions contributing to delayed call light response. A night-shift LPN reported that they usually staffed 2 to 3 CNAs for three units (100, 200, 400) and 1 CNA for the memory care unit at night, and stated that this was not enough CNAs to get everything done and that 1 CNA was not enough on the unit. A CNA reported that management did not answer when staff tried to contact them, including call nurses, and stated that night shift did not have enough staff and that they needed 5 CNAs on nights, including 2 on the memory unit. Additional CNAs stated they tried to answer call lights as soon as possible and acknowledged that, if they themselves had urinated on themselves while waiting for a call light to be answered, they would feel embarrassed. The Ombudsman Residents' Rights document cited by surveyors stated that the facility must provide services to keep residents' physical and mental health and sense of satisfaction with themselves at their highest practical levels.
Failure to Consistently Complete and Document Ordered Wound Care and Skin Checks
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care and daily skin checks as ordered for a resident with multiple comorbidities and documented venous and non-pressure wounds. The resident, cognitively intact and dependent on staff for most ADLs, had care plan interventions requiring ongoing wound assessment and documentation, including weekly measurements and monitoring for signs of infection. Physician orders directed daily skin checks on day shift with CROPs documentation on the TAR each Friday, and nightly dressing changes to the right anterior lower leg with specific cleansing and dressing procedures. Review of the Treatment Administration Records (TARs) for December, January, and February showed multiple dates where daily skin checks and ordered dressing changes were not documented as completed. On observation, the resident was seen in a wheelchair with a right lateral ankle dressing dated the previous day and showing a moderate amount of yellow/green drainage, and the resident reported that the dressing, usually changed by night shift, had not been changed the prior night when agency staff were working. Interviews with LPN staff indicated that many agency nurses do not complete ordered treatments, with one LPN stating she found dressings unchanged two days after she had last performed them, and another describing dressing changes on night shift as “hit or miss,” particularly when agency staff were on duty. The regional nurse stated she expects dressings to be changed as ordered. The facility’s wound care policy requires detailed documentation of wound care, including type of care, date and time, assessment data, resident tolerance, and any problems or refusals, which was not consistently reflected in the TARs for this resident.
Failure to Document and Properly Use a Lap Restraint
Penalty
Summary
The facility failed to ensure a physical restraint was used for a medical symptom and failed to document required restraint elements for one resident, R7. R7’s record showed diagnoses including traumatic subdural hemorrhage, dementia, unspecified psychosis, generalized anxiety disorder, chronic myeloid leukemia, osteoporosis, and cerebral infarction. The MDS dated 1/21/26 documented that R7 was severely cognitively impaired and had a physical restraint. A physician order dated 7/16/25 directed use of a lap restraint in the wheelchair due to frequent falls and decreased mobility, with release every 2 hours and removal during meals. The restraint evaluation effective 7/17/25 documented the lap restraint for frequent falls and decreased mobility and stated it was off during mealtimes and released every 2 hours, but it did not document the duration of restraint application. The care plan documented the device in place related to injury, repeated falls, dementia, poor safety awareness, and unsteady gait, with interventions to apply the lap restraint when in the wheelchair, release it every 2 hours and during meals, and document restraint use and release per facility protocol. The facility’s restraint policy required restraints only after other alternatives had been tried unsuccessfully, only to treat a medical symptom, and with documentation of the least restrictive alternative, ongoing reevaluation, and required monitoring. On 2/24/26, R7 was observed in a wheelchair in the Memory Care Unit with the lap restraint on, and when a CNA asked R7 to remove or release it, R7 did not demonstrate understanding and could not release it. On 2/25/26, R7 was observed eating lunch in the memory care dining room while the lap restraint remained in use during the meal. The Regional Nurse stated restraints are supposed to be removed during meals and later stated she could not find any restraint reduction attempts or restraint monitoring documentation for R7.
Infection Control and Hand Hygiene Failures During Resident Care
Penalty
Summary
The facility failed to ensure infection control guidelines were in place and implemented for two residents reviewed for infection control. One resident had a care plan documenting contact isolation for an ESBL infection in the urine, was cognitively impaired, had a catheter, and was dependent on staff for toileting. The resident’s door sign directed staff to clean hands before entering and leaving the room and to wear gloves and a gown before room entry and discard them before exit. During observation, two CNAs entered the resident’s room, washed their hands, and applied gloves, but did not clean their hands before entering and did not apply gowns. They assisted the resident in bed, opened the incontinent brief, and observed dark red and brown drainage from the resident’s penis covering the catheter. They then replaced the cover and left the room without cleaning their hands or using the required gown and gloves before entry. Later, the ADON and the same CNAs were observed applying gown and gloves outside the room, but catheter care was performed with repeated use of soiled gloves. A washcloth was placed on the floor and then handled again, and the resident’s penis and catheter were cleansed using wet washcloths and foam cleaner while the same gloves were used to apply a clean incontinent pad, reposition the resident, place a clean sheet, and adjust the head of bed and remote. A second resident had a care plan for enhanced barrier precautions due to an indwelling medical device and was cognitively impaired and totally dependent on staff for toileting. The resident’s door sign required hand hygiene before entry and exit and gloves and gown for high-contact care activities. During incontinent care, two CNAs entered the room, performed hand hygiene and applied gloves, but did not perform hand hygiene before entry or apply gowns. One CNA changed gloves with each wipe but did not perform hand hygiene, while the other removed urine-soiled brief and gown with the same urine-soiled gloves and then applied clean gown, clean brief, clean covers, and repositioned the resident and nearby items before removing gloves. The facility’s hand hygiene policy required handwashing or ABHR use before and after direct resident care, after contact with bodily fluids, after removing gloves, and when moving from contaminated to clean body sites.
Failure to Assess and Notify Change in Condition Resulting in Delayed Hospitalization
Penalty
Summary
The facility failed to properly assess a resident who experienced a change in condition, specifically regarding symptoms of nausea, vomiting, and decreased oral intake. The resident, who had a history of dementia, chronic kidney disease, and congestive heart failure, was observed by staff and family to be unusually lethargic and to have episodes of vomiting over several days. Despite these symptoms, nursing staff did not perform a thorough assessment, such as checking the resident's abdomen for bowel sounds or distention, nor did they document the time of the last bowel movement. Communication among staff was inconsistent, with some staff unaware of the resident's gastrointestinal issues, and there was a lack of prompt notification to the physician regarding the resident's change in condition. Additionally, the facility did not notify the resident's physician or representative in a timely manner as required by policy when the resident's condition changed. The delay in assessment and notification resulted in the resident being hospitalized with a diagnosis of small bowel obstruction, dehydration, and other complications, requiring nasogastric decompression and multiple attempts at intravenous access for fluid resuscitation. The facility lacked a specific policy for gastrointestinal assessment, and staff interviews revealed gaps in communication and follow-through on reporting and assessing significant changes in the resident's health status.
Deficiency in RN Coverage and Lack of DON
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, and did not employ a Director of Nursing (DON). This deficiency was identified through interviews, observations, and record reviews. The facility's administrator confirmed the lack of a DON and insufficient RN coverage, with only one RN working three days a week. The facility's management team document indicated the DON position was vacant, and during the survey period, no DON or RN was observed on duty. The facility's Licensed Practical Nurse (LPN) stated that the former DON's last day was in July, and a newly hired DON left after only two hours without completing employment paperwork. The RN on staff, identified as V15, worked only on Fridays, Saturdays, and Sundays, with documented absences on multiple days in October, leaving the facility without RN coverage for 8 hours a day on those days. The facility's nurse staffing policy requires sufficient licensed and unlicensed nursing staff to maintain residents' well-being, but this policy was not adhered to, affecting all 53 residents in the facility.
Failure to Post Daily Nursing Staff Hours
Penalty
Summary
The facility failed to ensure that the daily nursing staff hours were posted and easily visible to residents, affecting all 53 residents residing in the facility. Over several days, from 10/28/2024 to 10/31/2024, the survey team observed that there were no postings documenting the resident census and the number of licensed nursing staff. The administrator, identified as V1, was unaware that the postings were not being made, believing that the former Director of Nursing (DON) had been responsible for posting the nurses' schedules at the nurses' station. An LPN, identified as V5, confirmed that the postings used to be on the former DON's office door and should be updated daily by the person responsible for the schedule.
Facility Fails to Prevent Wandering Resident from Invading Others' Privacy
Penalty
Summary
The facility failed to protect residents' private spaces from a wandering resident, identified as R48, who was observed multiple times moving unsupervised throughout the facility. R48, who is severely cognitively impaired with a BIMS score of 99, was seen entering other residents' rooms and common areas without staff intervention. This behavior was noted on several occasions, including attempts to exit through a secured door and entering dietary areas. R48's care plan indicated he required supervision and had a history of physical and verbal aggression related to dementia. Several residents, including R11, R36, R14, and R12, reported incidents where R48 entered their rooms uninvited, causing distress and fear. R11, who is cognitively intact and suffers from multiple health issues, expressed fear of potential harm due to her frailty. R36 recounted an incident where R48 mistakenly claimed his room and another where R48 took his tea. R14 and R12 also reported similar intrusions, with R14 having to use her call light to get assistance when R48 began undressing in her room. The facility's resident council meeting minutes and grievance records indicated ongoing concerns about resident safety and privacy due to R48's wandering. Despite these issues, the facility lacked a specific policy on resident rights, and staff interventions appeared inconsistent. R48's wife suggested a more structured approach to his care, but the facility's response was limited, with temporary 1:1 supervision only implemented during state surveys or medication changes.
Inadequate Supervision and Fall Management in LTC Facility
Penalty
Summary
The facility failed to adequately supervise and manage the care of two residents, leading to multiple incidents of wandering and a fall without proper follow-up. One resident, diagnosed with dementia and other conditions, was observed wandering unsupervised throughout the facility, entering other residents' rooms, and exhibiting aggressive behavior. Despite documented interventions in the care plan, such as 15-minute checks and 1:1 supervision when agitated, these measures were not consistently implemented. The resident's wife reported that the facility only provided 1:1 supervision temporarily and often lost track of the resident's whereabouts. Another resident, with a diagnosis of Alzheimer's disease and other conditions, experienced a fall that resulted in a head injury and skin tears. The incident was not documented in the facility's risk management system, and no incident report was completed. Consequently, the care plan was not updated with new fall prevention interventions, and no root cause analysis was conducted. The facility's policy requires immediate assessment and documentation of falls, as well as the implementation of new interventions, but these procedures were not followed. Interviews with facility staff revealed a lack of awareness and communication regarding the incidents. The Care Plan Coordinator and Resident Care Coordinator were unaware of the fall due to the absence of an incident report, and the Administrator acknowledged the failure to complete necessary documentation. The facility's Fall Prevention policy outlines specific responsibilities and procedures for managing falls, but these were not adhered to, resulting in inadequate care and supervision for the residents involved.
Improper Food Storage and Labeling in Facility
Penalty
Summary
The facility failed to properly label, date, and dispose of food items stored in the refrigerator and freezer, which had the potential to affect four residents reviewed for expired food. During an initial walkthrough of the kitchen, several items were found improperly stored, including pears with an open date, thickened juices without open or use-by dates, and various frozen items with freezer burn that were undated and unlabeled. The facility's policy requires all items in refrigerators and freezers to be covered, labeled, and dated, but this was not adhered to. The Dietary Manager acknowledged the practice of keeping fruit in the refrigerator for a week and was unsure about the requirement for dating opened thickened juices. The manager also stated that any undated, unlabeled, or freezer-burned items should be discarded, which was not done. The facility's storage policy mandates that leftovers be stored in covered, labeled, and dated containers, but this procedure was not followed, leading to the deficiency.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required Medicare written notices to residents regarding the right to an expedited review of a service termination and potential liability for non-covered services. Specifically, for two residents reviewed, the facility did not issue the Notice of Medicare Non-Coverage (NOMNC) and/or the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) in a timely manner. Resident 17 was not given at least two days' notice before the end of Medicare Part A coverage, as the SNF ABN was signed on the last day of coverage. Resident 44's Medicare A coverage ended without the facility providing the NOMNC, and there was no evidence that the SNF ABN was mailed and received by the resident's family. The facility's staff, including the Regional Director and Social Service Director, acknowledged the expectation of providing at least two days' notice before the end of Medicare Part A coverage. However, the facility lacked a policy for beneficiary notification, which contributed to the oversight. The absence of a documented policy and evidence of notification for Resident 44 highlights the facility's failure to comply with the required notification procedures, resulting in a deficiency in beneficiary protection notification.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving resident-to-resident altercations. Resident R11, who is cognitively intact, reported being struck in the back by another resident, R48, who is severely cognitively impaired and diagnosed with dementia. This incident occurred when R48 attempted to push R11's walker, and upon being told to stop, R48 became upset and hit R11. The incident was not witnessed by staff, and although no physical injuries were noted, R11 expressed fear of R48 following the altercation. Another incident involved residents R36 and R48, where a verbal argument escalated into physical aggression. R36, who is nearly cognitively intact, pushed R48 with his hip, leading to R48 grabbing R36, who then hit R48 in the head. This altercation was partially witnessed by staff, who intervened to separate the residents. R48, who has a disorganized thought process and is easily overstimulated, was involved in this altercation due to his wandering behavior and poor safety awareness. Additionally, resident R37 reported being elbowed multiple times by R48, causing her concern for her safety. This incident was witnessed by a staff member who intervened to redirect R48. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents involving R48 and other residents. The facility's failure to adequately monitor and manage R48's behavior contributed to these occurrences, highlighting a deficiency in ensuring resident safety and preventing abuse.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update a resident's care plan with new fall prevention interventions following a fall with injury. The resident, who has diagnoses including Alzheimer's disease and severe cognitive impairment, experienced a fall on 9/30/24, resulting in a head laceration and skin tears. Despite the incident, the care plan was not updated to reflect the fall or include new interventions, and no root cause analysis was conducted. The incident was not documented in the electronic medical record (EMR) risk management program, which led to the care plan coordinator being unaware of the fall. The facility's policy requires that an incident report be completed for each fall, but this was not done. Consequently, the resident care coordinator did not investigate the fall or add any interventions to the care plan. The facility's policies on comprehensive care planning and fall prevention were not followed. The care plan coordinator and the resident care coordinator both stated that they expect nurses to complete incident reports for falls, but this expectation was not met in this case. The lack of documentation and follow-up resulted in a failure to address the resident's fall and implement necessary interventions.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 22 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pana Health And Rehab Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Nokomis Hc & Senior Living | 11.4 mi | ★★★★★ | 0 | 0 |
| Shelbyville Healthcare & Senior Living | 15.5 mi | ★★★★★ | 1 | 1 |
| Shelbyville Manor | 15.6 mi | ★★★★★ | 9 | 0 |
| Taylorville Skld Nur & Rehab | 15.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.