Rose Garden of Pana

In the surveyor’s words

From the most serious findings on record at Rose Garden of Pana, in the surveyor’s own words.

• Immediate jeopardy, patternF684Aug 4, 2022

  Based on observation, interview and record review, the facility failed to provide nursing care/services and implement care in accordance with residents' plan of care to attain residents' highest practicable physical and psychosocial well-being for 7 of 13 residents (R1, R2, R3, R6, R7, R8, R12) reviewed for quality of care in the sample of 13. These failure resulted in an Immediate Jeopardy which was identified to have begun on 6/27/22 for numerous situations observed upon the arrival of the state agency as follows: When it was found the nursing staff failed to assess and monitor R8's peripherally inserted central catheter (PICC) line and provide care to prevent ongoing urinary tract infections, failed to provide incontinent care/service to prevent R3's non-pressure ulcer skin injury in… […]

• Actual harm, isolatedF697Feb 26, 2026

  Based 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. Findings include:R3's Care Plan, dated 10/16/2026, documents PAIN: The resident has occasional pain r/t (related to) T2DM (type 2 diabetic), heart disease, BPH (benign prostatic hyperplasia), HTN (hypertension), muscle weakness, HLD (Hyperlipidemia), and calcaneal spur to right foot. It also documents Administer analgesia as per orders. Give 1/2 hour before treatments or care. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. […]

• Actual harm, isolatedF684Oct 28, 2025

  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. […]

• Actual harm, isolatedF689Nov 16, 2023

  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. […]

• Actual harm, isolatedF684May 24, 2023

  Based on interview and record review, the facility failed to ensure timely treatment for a change in condition for 1 of 3 residents (R2) reviewed for quality of care in the sample of 6. This failure resulted in a delay in treatment for left femur fracture around a previous left knee replacement. Findings include: 1. R2's Fall Risk Assessment, dated, 4/27/23 prior to fall incident date of 5/10/23, documented R2 was at High Risk for falls. R2's Minimum Data Set, dated dated , 4/27/23, documented mild impaired mental cognition. […]