Rose Garden of Pana

Inspectors wroteBased on observation, interview, and record review the facility to manage pain for 1 of 3 (R3) residents reviewed for pain management in a sample of 41. This failure resulted in R3 experiencing unrelieved horrible pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 88 of the 88 days reviewed for December 2025, January 2026, and February 2026. This failure has the potential to affect all 71 residents that resides in the facility. Findings Include: During this investigation was V4 (Regional Nurse) was the only RN in the building. The facility's working schedules and daily staffing sheets were reviewed and documents the following: December 2025, there was no RN scheduled from 12/01/25 through 12/31/25. January 2026, there was no RN scheduled from 01/01/26 through 01/31/26. February 2026, there was no RN scheduled from 02/01/26 through 02/26/26. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to properly store medication and discard expired medication. This failure has the potential to affect all 71 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility kitchen staff failed to calibrate a thermometer prior to taking the temperature of the food. This failure has the potential to affect all 71 residents who reside at the facility. Findings Include:On 02/23/26 at 10:55 AM, V7 (Cook) took the temperature (temp) of the food. V7 did not calibrate the thermometer prior to taking the temps. On 02/23/26 at 10:57 AM, V7 was asked how he calibrates the thermometer. He stated, I have no idea let me go ask. V7 talked with V6 (Dietary Manager) and came back and stated V6 said it can't be calibrated. On 02/24/2026 at 10:00 AM, R23, R35, R5, R46, R21 all stated that the food is cold. On 02/26/26 at 11:20 AM, V6 (Dietary Manager) stated that their thermometers are digital and they do not calibrate them and the only way to calibrate it is to put a new battery in it. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to add identified problem areas and to update care plans in a timely manner for 4 residents of 35 residents (R7, R34, R64, R86) whose care plans were reviewed in the sample of 35. Findings Include:1. R34's Face Sheet, print date of 02/25/26, documents he has diagnoses of but not limited to congestive heart failure (CHF), paroxysmal atrial fibrillation, muscle wasting and atrophy, multiple sites, and unsteadiness on feet. R34's Minimum Data Set (MDS), dated [DATE], documents R34 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 13 out of 15 and he requires partial/moderate assistance with sit to stand, transfer chair/bed-to-chair transfer, and toilet transfers. R34's Care Plan, admission date of 12/05/24, documents R34's review shows moderate risk for falls. [...]

Inspectors wroteBased on observation, interview, and record review, 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 the facility policy, and failed to ensure fall interventions were in place per resident Care Plans for 4 of 10 residents (R7, R34, R64, R86) reviewed for falls in the sample of 35. Findings Include: 1. R7's Face Sheet, print date of 2/25/26, documents R7 has diagnoses including traumatic subdural hemorrhage, dementia, unspecified psychosis, generalized anxiety disorder, chronic myeloid leukemia, osteoporosis, and cerebral infarction. R7's MDS (Minimum Data Set), dated 1/21/26, documents R7 is severely cognitively impaired. R7's Fall Risk Evaluation dated 7/20/23 documents R7 is at risk for falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure dignity and respect for 4 of 5 (R23, R21, R35 and R46) residents reviewed for call lights in a sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physical restraints were used to treat a medical symptom, failed to provide evidence of least restrictive methods attempted prior to initiating a physical restraint, failed to identify the amount of time the restraint will be used for, failed to identify risks versus benefits of restraints, failed to provide ongoing monitoring documentation of the restraint, and failed to remove the restraint at meals for 1 of 1 residents (R7) reviewed for physical restraints in a sample of 35. Findings Include: R7's Face Sheet, print date of 2/25/26, documents R7 has diagnoses including traumatic subdural hemorrhage, dementia, unspecified psychosis, generalized anxiety disorder, chronic myeloid leukemia, osteoporosis, and cerebral infarction. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to complete dressing changes and daily skin checks as ordered by the physician for wounds for 1 of 3 residents (R73) reviewed for wounds in a sample of 35. Findings Include: R73's Face Sheet, admission date of 02/24/23, documents R73 has diagnoses of but not limited to rheumatoid arthritis, sepsis, peripheral vascular disease, cellulitis of left lower limb, and atherosclerosis of native arteries of right leg with ulceration of other part of lower leg. R73's Minimum Data Set (MDS), dated [DATE], documents R73 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 out of 15 and she is dependent on staff for most of her activities of daily living (ADLs). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control guidelines were in place and implemented for 2 of 3 (R3, R65) residents reviewed for infection control in a sample of 35.

Inspectors wroteBased 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.

Inspectors wroteBased on interview, observation, and record review the Facility failed to provide a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The facility also failed to employ a Director of Nursing (DON). This has the potential to affect all 53 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the Facility failed to ensure the daily nursing staff hours were posted and easily visible to residents. This failure has the potential to affect all 53 residents residing in the Facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed protect residents' private space from wandering residents for 5 out of 5 residents (R11, R12, R14, R36, and R45) reviewed for resident rights in a sample of 27.

Inspectors wroteBased on interview, observation, and record review, the facility failed to complete an incident report, failed to investigate, and determine the root cause of the fall, and failed to implement new fall prevention interventions. The facility also failed to provide adequate supervision to prevent resident from wandering into other resident's rooms on multiple occasions for 2 (R47 and R48) of 4 residents reviewed for falls/supervision in a sample of 27.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to label, date, and dispose of food items stored in the refrigerator and freezer with potential to affect 4 out of 4 residents (R2, R7, R18, and R23) reviewed for expired food in a sample of 17.

Inspectors wroteBased on interview and record review the facility failed to provide Medicare written notice regarding the right to an expedited review of a service termination (Notice of Medicare Non-Coverage/NOMNC) and/or the written notice of the resident's potential liability for a non-covered stay (Skilled Nursing Facility Advance Beneficiary Notice/SNF ABN) for 2 of 3 residents (R17 and R44) reviewed for Beneficiary Protection Notification in the sample of 17.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from physical abuse for 3 of 3 residents (R11, R37, and R48) reviewed for abuse in a sample of 27.

Inspectors wroteBased on interview, observation, and record review, the facility failed to update R47's care plan with new fall prevention interventions for 1 resident (R47) of 14 residents whose care plans were reviewed in the sample of 17. Findings Include: R47's face sheet dated 10/30/24 documented R47 has diagnoses of Alzheimer's disease, major depressive disorder, anxiety disorder, hypertension, and osteoporosis. R47's MDS (Minimum Data Set) dated 9/8/24 documented R47 is severely cognitively impaired. R47's care plan with a print date of 10/29/24 documented the resident has had an actual fall with no apparent injury. This care plan does not address R47's fall with injury that occurred on 9/30/24 including a root cause analysis and new fall prevention interventions. R47's progress note dated 9/30/24 at 4:30 am documented resident today fell on shift at 0400 while ambulating in hallway. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview, observation and record review the facility failed to provide a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 55 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to self-report an allegation of a medication overdose/suicide attempt to the state survey agency for 1 (R2) of 3 residents reviewed for Improper Nursing Care in the sample of 5.