Rose Garden of Pana
900 South Chestnut · Pana, IL · 62557 · 2175623996
105 certified beds For profit - Individual Chain: Pointe Management
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Staffing levels are well below research benchmarks for safe care.
- Federal penalties on record: $25,200 in fines in the last 24 months.
- 3 citations involved actual harm to residents.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
RN staffing in the bottom 10% nationally
0.10 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
Total nurse staffing below 3.0 hours per resident-day
2.55 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 3 of 5 Staffing: 1 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 2.55 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.10 | 0.55–0.75 |
| Weekend hours / resident-day | 2.36 | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 2 · $120,442 |
Inspection citations (27 in the current record)
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Potential for harm · D February 26, 2026 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected March 11, 2026 · Resident Rights
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Potential for harm · D February 26, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 11, 2026 · Quality of Life and Care
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Potential for harm · F February 26, 2026 · found via complaint
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected March 11, 2026 · Nursing and Physician Services
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Actual harm · G October 28, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 31, 2025 · Quality of Life and Care
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Potential for harm · E October 31, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected November 14, 2024 · Resident Rights
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Potential for harm · D October 31, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected November 14, 2024 · Resident Rights
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Potential for harm · D October 31, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected November 14, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D October 31, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected November 14, 2024 · Resident Assessment and Care Planning
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Potential for harm · E October 31, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected November 14, 2024 · Quality of Life and Care
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Potential for harm · F October 31, 2024
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected December 6, 2024 · Nursing and Physician Services
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Potential for harm · F October 31, 2024
Post nurse staffing information every day.
Corrected November 14, 2024 · Nursing and Physician Services
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Potential for harm · E October 31, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected November 14, 2024 · Nutrition and Dietary
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Actual harm · G November 16, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 8, 2023 · Quality of Life and Care
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Potential for harm · D November 16, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected December 13, 2023 · Quality of Life and Care
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Potential for harm · D November 16, 2023
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected January 17, 2024 · Pharmacy Service
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Potential for harm · F November 16, 2023
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected December 8, 2023 · Nutrition and Dietary
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Potential for harm · D November 16, 2023
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected December 8, 2023 · Nutrition and Dietary
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Potential for harm · E November 16, 2023
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected December 8, 2023 · Nutrition and Dietary
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Potential for harm · D November 16, 2023
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected December 8, 2023 · Nutrition and Dietary
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Potential for harm · F November 16, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 18, 2024 · Nutrition and Dietary
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Potential for harm · D November 7, 2023 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected November 22, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · F November 7, 2023 · found via complaint
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected January 20, 2024 · Nursing and Physician Services
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Actual harm · G September 20, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 17, 2022 · Quality of Life and Care
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Potential for harm · F September 20, 2022
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected October 17, 2022 · Nursing and Physician Services
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Potential for harm · F September 20, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 17, 2022 · Nutrition and Dietary
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 26, 2026 | Fine | $25,200 |
| November 7, 2023 | Fine | $95,242 |
| November 7, 2023 | Payment Denial | 37 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 145411 · certified since August 8, 1980. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.