Rose Garden of Pana: Nursing Failures Sent Resident to ICU - IL
She was discharged from the emergency room directly to the ICU at a higher-level care hospital....
Latest reports, citations, and penalties from CMS data
She was discharged from the emergency room directly to the ICU at a higher-level care hospital....
Inspectors who arrived October 28, 2025 found the facility wasn't keeping that promise....
The citation, tagged F0694, came out of a complaint inspection completed October 29, 2025....
The inspection, conducted November 15, 2025, resulted in a citation under pharmacy service deficiencies....
That's what a federal inspector documented at Glenburnie Rehab & Nursing Center on the morning of October 28, 2025....
At Riverside, the Kardex was not matching the care plan....
The inspection, completed October 30, 2025, was triggered by a complaint....
The distinction matters less than it might sound....
What happened after that is what federal inspectors came to document....
The violation was documented as a pattern, meaning inspectors determined this wasn't a one-time lapse....
The resident, identified in inspection records as R1, used an EZ stand and required assistance with transfers....
The resident developed a wound to the groin and genital area....
The deficiency, tagged F0610, affected a small number of residents....
The Director of Nursing told inspectors that all the nurses know which patients are NPO and that the medication was given via tube....
The inspection report does not say how many....
It is among the first things taught in certified nursing assistant training....
She was not describing this from a chair or a bed....
Federal health inspectors documented both failures during a complaint inspection conducted November 13, 2025....
The citation, issued under F0689, covers accidents resulting in injury....
The resident, identified in inspection records only as Resident 4, received Narcan on July 29, 2025....