The woman, identified in state inspection records as Resident #14, fell on July 26 around 6:30 or 7:00 in the evening. Her husband had already started helping her up when nursing assistant CNA #133 arrived to assist. The resident scraped her leg on her wheelchair during the fall and later complained of ankle pain.
Multiple nursing assistants heard her pain complaints over the following days. She told CNA #130 her left ankle was hurting and described "sharp pain, like she sprained the ankle." Staff noticed she grimaced every time they touched her leg or tried to move her.
"She appeared to be in pain because every time staff touched her leg or went to move her, she would grimace," CNA #130 told state inspectors.
The resident had two more falls that same weekend. CNA #140 witnessed another fall around 3:00 AM on July 27, and said there was a third fall later that morning. Each time, nursing assistants simply lifted the woman off the ground without waiting for a nurse to assess her condition or take vital signs.
CNA #140 found this concerning. She told inspectors the approach "was confusing to her because other facilities she worked at followed protocol, like waiting for the nurse to assess the resident and take vitals."
Despite multiple staff members knowing about the falls and ongoing pain complaints, no nursing notes were written about the incidents. The facility administrator confirmed to state inspectors that nursing records from July 25 through July 27 contained no documentation about falls or pain complaints for Resident #14.
The first documentation appeared July 28 when a nurse ordered an X-ray due to the resident's pain. Even then, the order provided no information about what caused the new onset of pain.
It wasn't until July 29 that nurse LPN #105 made a late entry documenting the July 26 fall. This note was entered after the X-ray had already been ordered, and the X-ray results were never added to the nursing notes.
Several nursing assistants reported the resident's complaints to nurses during those three days, but the information never made it into official records. CNA #125 said she told a nurse about the resident's pain complaints, and "the nurse stated she would let the doctor know." CNA #130 reported the pain to LPN #107, "who stated she was aware, and the dayshift nurse would have to take care of it."
State inspectors tried multiple times to reach LPN #107 but were unsuccessful.
The documentation failures occurred despite the facility's own policy requiring nurses to notify physicians about accidents or incidents involving residents. The policy, dated December 2016, states that before contacting the doctor, nurses should "make detailed observations and gather relevant information and pertinent information for the provider."
CNA #140 was so concerned about the handling of the incidents that she wrote her own statement about what happened and photographed it. She told inspectors she took the photo "because she was told they (staff statements) usually go missing."
However, CNA #140 said she kept her written statement vague because "she was afraid of retaliation and her coworkers treating her poorly."
The resident told different staff members about her pain throughout the weekend. She informed CNA #122 that her foot hurt "pretty bad," though CNA #122 couldn't recall the exact date of this conversation. CNA #125 said the resident reported falling and hurting her foot but didn't specify how much pain she was experiencing.
CNA #130 said Resident #14 told her about multiple falls and complained that both her foot and ankle were hurting. The resident described the sensation as sharp pain similar to a sprained ankle.
The inspection was conducted in response to a complaint filed as number 2583218. State inspectors found the facility failed to ensure proper documentation of resident incidents and changes in condition, citing minimal harm or potential for actual harm affecting few residents.
The three-day gap between the fall and its documentation meant physicians and other care team members had no official record of why the resident was experiencing new onset pain, potentially delaying appropriate treatment and follow-up care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Country Lane Gardens Rehab & Nursing Ctr from 2025-08-15 including all violations, facility responses, and corrective action plans.
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