Rose Garden of Pana: Nursing Failures Sent Resident to ICU - IL
The resident, identified in inspection records as R2, required decompression, a midline catheter, and three separate attempts before emergency room staff could establish intravenous access for fluid resuscitation. The emergency room physician's notes listed her conditions on arrival: small bowel obstruction, new onset atrial fibrillation, elevated troponin, nausea and vomiting, hyperkalemia, dehydration, chronic kidney disease at stage three, a urinary tract infection, and lactic acidosis. She was discharged from the emergency room directly to the ICU at a higher-level care hospital.
Her family had been at the facility visiting her all weekend and believed she had been doing fine. Staff called the family when R2 was sent to the hospital.
The facility's own physician described what he would have expected nurses to do. On October 24, the doctor told inspectors he would have expected nursing staff to examine R2's abdomen, listen for bowel sounds, check for distention and tenderness, and call him with any changes in her condition. The record does not indicate they did any of those things.
The Director of Nursing saw it differently. On October 28, at 11:20 in the morning, she told inspectors that nursing staff had done what they should have and that there was no delay in R2's hospitalization. She added that the physician does not need to be contacted just because a resident has emesis.
That position, that vomiting alone does not require a call to the doctor, now sits in the inspection record alongside the list of what R2 was diagnosed with when she arrived at the emergency room.
The facility had no policy specific to gastrointestinal assessment. Its general policy on changes in a resident's condition, last updated in 2001, stated that the facility promptly notifies the attending physician and the resident's representative of changes in medical or mental condition. Inspectors cited the facility under F0684, which covers the standard of care residents are entitled to receive, and classified the violation as causing actual harm to a small number of residents.
What the policy said and what happened to R2 are not the same thing.
Lactic acidosis occurs when the body produces more lactic acid than it can clear, often a sign that tissues are not getting enough oxygen or that organ systems are under severe stress. Hyperkalemia, elevated potassium in the blood, can trigger dangerous heart rhythms. Elevated troponin signals stress or damage to the heart muscle. New onset atrial fibrillation in a nursing home resident is not a background finding. Taken together, the diagnoses on R2's emergency room chart describe a person whose body had been in serious distress for some time before she left the facility.
It took three attempts to get an IV line into her.
The family had spent the weekend there. They thought she was fine.
The Director of Nursing told inspectors there was no delay.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rose Garden of Pana from 2025-10-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
ROSE GARDEN OF PANA in PANA, IL was cited for violations during a health inspection on October 28, 2025.
She was discharged from the emergency room directly to the ICU at a higher-level care hospital.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.