Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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 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.
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 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.
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What surveyors actually found near you
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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.
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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 | — | 0 | 0 |
| Shelbyville Manor | 15.6 mi | — | 7 | 0 |
| Taylorville Skld Nur & Rehab | 15.9 mi | — | 0 | 0 |
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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 August 2026) and official state health department websites.