Country Lane Gardens: Antipsychotic Given Without Cause - OH
That is what inspectors found at Country Lane Gardens Rehab & Nursing Center, a 7820 Pleasantville Road facility that was the subject of a complaint investigation completed October 15, 2025.
The drug was Haldol. It was administered at 4:54 a.m. on September 22, 2025. The resident had pulled the fire alarm the day before. That was the only event inspectors could connect to the order.
The acting director of nursing, identified in the inspection report as staff member number 303, confirmed during an interview on September 24 that there was no documented reason for giving the Haldol at that hour. She told inspectors that in order to administer the drug, there would have had to be an imminent danger to the resident or to others. There was no evidence of that, she said.
She then explained where the order had actually come from. It had been obtained the previous day, on September 21, when the resident refused to get off a stretcher after returning from the hospital.
So the order was written for one situation. The drug was given, hours later, in a different one. And no one documented why.
Haldol is a powerful antipsychotic. It is not a sedative of convenience. The inspection report notes the drug is considered appropriate in a narrow set of circumstances: conditions such as schizophrenia, Tourette's disorder, Huntington's disease, hiccups, nausea tied to cancer treatment, or behavioral symptoms caused by mania or psychosis. Even within those categories, the bar is specific. The behavioral symptoms have to present a danger to the resident or others, and they have to be identified as stemming from hallucinations, delusions, paranoia, or grandiosity. Or behavioral interventions have to have been tried first and documented in the care plan.
Pulling a fire alarm is not among the listed criteria. Refusing to get off a stretcher is not among them either.
The inspection report notes that diagnoses alone do not justify antipsychotic use. The implication is plain: whatever this resident's diagnosis was, it did not make the 4:54 a.m. administration appropriate on its own.
The deficiency was tagged F0605 and assigned a harm level of minimal harm or potential for actual harm, with few residents affected. It was described as an incidental finding from a broader complaint investigation.
That classification, minimal harm, reflects the regulatory scoring, not necessarily the experience of a person woken in the night and injected with an antipsychotic while the paperwork behind the decision sat blank.
The acting director of nursing confirmed the lapse herself. There was no documented reason. There was no documented imminent danger. The order came from a different moment, a different refusal, a different day. And the drug was given anyway, before dawn, with nothing written to explain it.
What happened to the resident after 4:54 a.m. on September 22 is not recorded in the inspection report.
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 2025-10-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 25, 2026 · Our methodology
COUNTRY LANE GARDENS REHAB & NURSING CTR in PLEASANTVILLE, OH was cited for violations during a health inspection on October 15, 2025.
It was administered at 4:54 a.m.
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.