Pana Health And Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of property for one resident (R1) of three residents reviewed for misappropriation in the sample of 3. Findings include:R1's admission Record documented an admission Date of 11/26/24 and listed Diagnoses including Chronic Obstructive Pulmonary Disease, Arteriosclerotic Heart Disease, Atrial Fibrillation, and Diabetes Type 2. R1's Minimum Data Set, dated [DATE] documented that R1 has minimal deficits in cognition. R1's Care Plan dated 12/3/25 documented a problem area, Resident has potential to gift money to the staff.A Police Department Call Detail Report dated 12/4/25 at 3:11pm documented, (V1) called from the facility to let us know that (R1) whom is hospitalized at this time, a family member was alerted by card services that some money had been taken from his debit card that was at the facility. An IDPH Initial Report dated 12/4/25 documented, (R1) Alleged abuse: Misappropriation of property.An IDPH…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure that out dated Tuberculin Purified Protein Derivative (TB) solution was removed from the 300 hallway medication refrigerator. This failure has the potential to affect all the residents residing on the 300 hall. Findings include: On 04/01/24 at 02:53 PM, the refrigerator in the 300 hall medication room was inspected and observed to have an open vial of TB solution that was half full with an open date of 11-21 written on the vial. On 04/01/24 at 02:55 PM V5, Registered Nurse (RN), stated that yes everyone in the facility uses the TB solution. She continued to state that each hallway may have their own vial but she wasn't sure, and that she isn't sure for how long the solution is good for after it's opened. She continued to state that night shift does the TB test, so she wasn't really a good person to ask that. V5 verified the open date on the TB solution vial was 11-21. On 04/04/24 at 11:35 AM, V1, Administrator, stated that the TB solution should be discarded 30 days after opening. The TB solution box…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the Facility failed to follow their policy by not providing written documentation of a bed hold notice for 1 of 1 residents (R76) reviewed for hospitalizations, in the sample of 29. Findings include: On 4/1/2024 at 12:26 PM, R76 stated that he had been hospitalized recently for water on my legs. R76's Progress Notes, dated 3/21/2024, documented that R76 was sent to the local emergency room (ER) due to complaints of having difficulty breathing as well as a weight gain. On 4/2/2024 at 2:53 PM, V10, Licensed Practical Nurse (LPN), stated that when a resident is transferred to the hospital/ER the nurses fill out a form in the computer (Electronic Medical Record/EMR) and provide the resident with a bed hold policy. On 4/2/2024 at 3:07 PM, R76's Bed Hold Notification was requested. On 4/3/2024 at 8:40 AM via Electronic Mail (Email), V1, Administrator (ADM), stated that she was unable to provide the notice as requested. On 4/4/2024 at 9:05 AM, V12, Business Office Manager (BOM) stated, We are supposed to (provide the bed hold notice), but we haven't…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to ensure a resident on blood thinning medication was examined for potential complications following a fall with head injury for 1 of 24 residents (R80) reviewed for quality of care, in the sample of 29. Findings include: R80's Facesheet, dated [DATE], documented that R80 was admitted to the facility on [DATE] and was discharged on [DATE]. R80's Care Plan, dated [DATE], documented that R80 was on a Short term stay in facility for rehabilitation. It further documented that R80 is on anticoagulant therapy, Eliquis (blood thinner medications). It continues to document that the facility was to monitor and report adverse reactions such as blood tinged or red blood in urine and to avoid activities that could result in injury and take precautions to avoid falls. R80's Progress Notes, dated [DATE] at 12:48 PM documented, MD (Medical Director) made aware of resident having blood in catheter tubing. NOR (New Order Received) to hold Eliquis (Blood thinning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the Facility failed to follow their Contact/Droplet Precautions Policy while administering medications to 1 of 3 residents (R34) reviewed for Transmission Based Precautions (TBP), in the sample of 29. Findings include: On 4/2/2024 at 8:05 AM, V6, Registered Nurse (RN) was observed passing medications. At this time, there was a Contact/Droplet Precaution sign outside of R34's room. At this time, V6 donned a gown and N95 (mask) and was wearing eyeglasses. V6 did not apply gloves. At this time, V6 stated, (R34) has a Coronavirus, but it is not COVID 19. He (R34) went to the ER (Emergency Room) because he had a temp (elevated temperature). He (R34) is on isolation while he is taking his antiviral meds (medications). R34's Progress Note, dated 3/28/2024 at 10:05 PM, documented that R34 returned from the local ER with a diagnosis of a systematic viral illness and was placed on isolation precautions. R34's Progress Note, dated 3/29/2024 at 6:27 AM, documented that R34 continues Droplet isolation due to Coronavirus OC43 and an antiviral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the Facility failed to ensure resident menus and appropriate serving sizes were followed for 4 of 8 (R3, R5, R6, R7) reviewed for therapeutic diets in the sample of 8. Findings include: 1.R5's Order Summary Report dated 9/13/23 documents R5 is on a regular diet with pureed texture and thin liquid consistency starting on 5/4/22. R5's Diet Card for Lunch on 9/12/23 documents pureed texture with pureed beef tips and mushroom entrée. The Facility's Diet Spreadsheet for Day 17 Pureed documents use of #6 Dip (Scoop=6 ounces) for the Pureed Beef Tips and Mushrooms. On 9/12/23 at 12:12 PM, V6, Interim Dietary Manager, stated, We don't have an extra number six scoop for these, so we are using the two-ounce scoop and giving them three scoops each. V9, Dietary Aide, placed two scoops of pureed meat on R5's plate. 2.R3's Order Summary Report dated 9/13/23 documents R3 is on a No Added Salt (NAS) diet, easy to chew (Mech) (EC7) (Easy to Chew 7) texture, thin consistency. R3's Diet Card for Lunch on 9/12/23 documents regular, easy to chew, NAS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen tubing is dated when placed for weekly replacement and stored in plastic bag when not in use for 5 of 9 residents (R8, R12, R48, R52, R128) reviewed for respiratory care in a sample of 34. Findings include: 1. On 03/21/23 at 9:35 AM, R8 was sitting in her wheelchair in her room. R8 had her oxygen on and there was no date noted to be on the oxygen tubing. On 03/22/23 at 8:45 AM, R8 is sitting in her room in her wheelchair with her oxygen in place. There was no date noted to the oxygen tubing at this time. R8's admission Record, print date of 03/22/023, documents R8 has a diagnosis of respiratory failure with hypoxia. R8's Minimum Data Set (MDS), dated [DATE], documents R8 is moderately cognitively impaired. R8's Care Plan, admission date of 08/29/22, documents R8 has impaired gas exchange, has a diagnosis of respiratory failure with hypoxia, administer oxygen as prescribed or per standing order. R8's Physician's Order,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to perform hand hygiene to prevent cross contamination and the spread of infection for 3 of 9 residents (R21, R45, R35) reviewed for infection control in the sample of 34. Findings include: 1. On 03/21/2023 at 12:30 PM, V11, Registered Nurse (RN), and V9, Certified Nurse Assistant (CNA), performed incontinent care for R21. Both V9 CNA and V11, RN, donned and doffed gloves without the benefit of hand hygiene, several times, during the procedure. 2. On 03/21/2023 at 12:45 PM, V8, CNA, and V10, CNA, transferred R45 to the toilet using a gait belt. After R45 was finish using the toilet, V8, with the same gloved hands, took a soapy washcloth and cleansed R45's peri rectal area and buttocks. V8 and V10 then transferred R45 back to her wheelchair with the same gloves they used to cleanse R45 touching the arm rest of R45's wheelchair and gait belt on the resident and then fastened R45 chair alarm seat belt. 3. On 03/21/2023 at 10:55 AM, R35 was sitting on the toilet with call light on, with the sit to stand lift…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to perform complete incontinent care for 2 of 6 residents (R45, R35) reviewed for incontinent care in the sample of 34. Findings include: 1. On 03/21/2023 at 12:45 PM, V8, Certified Nurse Assistant (CNA), and V10, CNA, transferred R45 to the toilet using a sit to stand mechanical lift. After R45 was finish using the toilet, V8 used a soapy wash cloth and cleansed R45's peri rectal area using back and forth strokes and not turning the wash cloth to the clean area. V8 continued to cleanse the buttocks, but did not cleanse the labia, groin area or abdominal folds. V8 and V10 then transferred R45 to her wheelchair. R45's Minimum Data Set (MDS), dated [DATE], documented that R45 requires extensive assist of 2 staff members to use the toilet and was frequently incontinent of urine. R45's Care plan, dated 01/30/2023, documented, TOILET USE: Assist me to the toilet every 2 hours and as needed. I am frequently incontinent and need assistance with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure medications were properly administered and/or stored for 1 of 5 residents (R64) reviewed for medications in the sample of 34. Findings include: 1. On 03/21/23 at 12:20 PM, R64 was sitting in his room. A medication cup with medications in it was setting on R64's over the bed table. When R64 was questioned about the medication on his over the bed table, R64 stated it was his Gabapentin he takes. He said he knows he should have taken it when the nurse handed it to him, but he didn't because he likes to take it with food. R64's admission Record, print date of 03/22/23, documents R64 has a diagnosis of Peripheral Vascular disease, unspecified, Muscle wasting and atrophy, and Type I Diabetes Mellitus. R64's Minimum Data Set (MDS), dated [DATE], documents R64 is cognitively intact. R64's Care Plan, with admission date of 02/02/23, does not have any documentation regarding R64 being able to administer his own medications. R64's Physician's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation interview and record review the facility failed to provide food at a palatable temperatures during meal service. This had the potential to affect all 72 residents in the facility. Findings include: Resident Council minutes dated 11/2/21, 12/6/21 and 1/3/22, documented, the food continues to be served cold. The concerns addressed to the dietary manager, with dietary manager documentation of, hot food is always temped where it should be before going onto the steamtable. The Facility's Quality Assurance Performance Improvement, (QAPI) dated, 1/3/22, documented an action Plan titled, COLD food, that addresses issues of, monitor temperatures in the kitchen before serving, with the first tray and last to be served on each cart, monitor pass times, educate staff to keep door closed to cart during serving and random interviews with residents after meals. On 02/07/22 at 11:45 AM, entered kitchen food was placed in the steam table. The following meal service was temped for the following; Ham slices at 152 degrees (F), (Fahrenheit), Peas at 162 degrees( F), Sweet Potatoes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to attempt Gradual Dose Reductions (GDR's) and put resident centered behavior tracking in place for 4 of 5 residents (R18, R27, R33, R53) reviewed for psychotropic medications in the sample of 41. Findings include: 1. R18's Face Sheet, print date of 2/1/22, documents R18 was admitted on [DATE] with diagnoses of Major Depression Disorder and Anxiety. R18's Pharmacy Recommendation, dated 6/29/21, documents, Resident receives the following medication used for depression: Cymbalta 60 mg (milligram) Q (every) AM for Depression since 3/22/2020 resident also continues on Buspar 5 mg bid (twice a day) and hydroxyzine 25 mg q 6 hours prn (as needed) itching. The Centers for Medicare and Medicaid Services (CMS) requires attempts at dosage reductions on antidepressant medications used for managing behavior, stabilizing mood, or treating psychiatric disorders twice a year, in two separate quarters (with at least one month between attempts), within the first year of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to complete a restraint assessment including the risk versus benefits of a seat belt with alarm for 1 of 2 residents (R24) reviewed for physical restraints in the sample of 41. Findings include: R24's admission Record, admission date of 9/16/19, documented a medical diagnosis of Alzheimer's disease, Dementia, history of falling, muscle weakness, unsteadiness on feet, urgency of urination. R24's Physician Order Sheet, dated 2/8/22, documented an order for seat belt chair alarm in wheelchair, release every two hours and as needed, order dated 12/9/21. R24's Physical device/Psychoactive Medication initial Quarterly Evaluation, dated for the following; R24's admission quarterly evaluations dated from 2/19/20 through 12/2/20 documented, device recommendations of a lap buddy when up in wheelchair for a medical diagnosis of; symptom interference of with judgement, gait, unable to transfer without assistance, physical limitation, history of falls and balance issues and a medical diagnosis of Alzheimer's dementia. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to perform proper hand hygiene to prevent the spread of infection for 3 of 5 (R5, R39, R47) residents reviewed for and infection control in the sample of 41. Findings include: 1. On 02/08/22 at 9:40 AM, V22, Certified Nurse Aide (CNA), provided incontinent care for R5. V22 put gloves on without hand hygiene prior to glove placement, pulled R5's incontinent brief down which was soiled front and back with a large amount of loose smeared brown stool. V22 took a wet cloth and put cleanser on the cloth, cleansed her front perineal area, rolled R5 on her right side, removed the soiled depends, with the same gloves V22 picked up a wet wash cloth and took the bottle of cleanser and put some cleanser on the cloth, cleansed the rectal area. V22 then removed her gloves washed her hands, placed a new incontinent brief down on the bed. On 2/9/22 at 8:45 AM, V2, Director of Nursing (DON), stated, she would expect staff to use appropriate hand hygiene and use hand hygiene prior to applying gloves. The facility Policy and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.