Country Lane Gardens: Behavior Plan Failures - OH
That admission came from a certified nursing assistant who was present. She had watched it occur.
The incident, which took place between 10:00 and 11:00 in the morning on the facility's dementia floor, involved a female resident identified in inspection records as Resident #14 and a male resident identified as Resident #50. Resident #14 was 31 years old at the time of her admission in February 2025, carrying diagnoses that included anoxic brain damage, dementia, bipolar disorder, major depressive disorder, post-traumatic stress disorder, anxiety disorder, opioid use disorder, psychoactive substance abuse, insomnia, and nightmare disorder. Despite that constellation of conditions, a cognitive assessment completed in the months before the incident rated her cognition as intact.
Her care plan, initiated the day after she was admitted and revised as recently as September 15 — four days before the incident — listed her history of sexually inappropriate behaviors as a known problem. The interventions written into that plan included administering medications, involving behavioral health as needed, monitoring for wandering, providing safe-practice education, and removing her from situations where inappropriate behavior occurred, using one-to-one supervision when necessary.
What the care plan did not produce, inspectors found, was any documented individualized behavioral strategy that might have prevented contact with another resident before something happened.
CNA #167 told inspectors on the morning of September 24 that she had personally observed Resident #14 inappropriately touching Resident #50. She said she was not aware of any preventive measures that had been in place before the incident. After it occurred, Resident #14 was placed on one-to-one supervision. That lasted a few hours. Then she was moved to 15-minute checks.
LPN #248, interviewed the same morning, said she had been told about the incident rather than witnessing it herself. She was uncertain who had actually observed it. She told inspectors she believed Resident #14 needed placement in a female-only facility, citing her age and her history of anoxic brain injury. She also said she was concerned that housing Resident #14 on the dementia floor created risk for other residents. She described Resident #14's behaviors as ongoing.
The regional director confirmed to inspectors that the facility moved Resident #14 to a locked unit following the incident. He also confirmed that no alternative interventions or individualized behavioral strategies had been documented before that move was made. The facility's response to a resident-on-resident sexual contact incident was to change the unit. The paperwork explaining why, or what had been tried first, did not exist.
The Social Services Director and HR Director, interviewed together on September 24, acknowledged that psychosocial assessments had been completed for both residents involved, but only verbally. Nothing had been written down. They told inspectors a late progress note would be submitted using witness statements as a reference.
Resident #14's guardian spoke with inspectors that same morning. She confirmed the facility had moved her ward to a new unit after the incident. She said she believed Resident #14 would engage in sexual activity if she wanted to, and she recommended placement in an all-female facility.
By the following day, the regional director and the facility administrator told inspectors they were planning to find a more appropriate placement for Resident #14 elsewhere and would maintain one-to-one supervision until that placement was located.
What the inspection record does not show is any documented moment, in the months between February and September 2025, when staff identified a specific behavioral strategy tailored to what Resident #14's history actually predicted. Her care plan named the problem. It listed generic responses. It was revised on September 15. Four days later, the incident it was supposed to prevent occurred, and a nursing assistant told inspectors she had no awareness of any preventive measures at all.
LPN #189, who confirmed the timing of the September 19 incident, told inspectors that after Resident #14 was removed from the room, she was placed on one-to-one supervision, but that no additional interventions were completed before she was moved to the locked unit.
The inspection was conducted on October 15, 2025, as part of a complaint investigation. Inspectors reviewed three residents' records for behavioral health services and found this deficiency in one of them. The facility's census at the time was 94.
The harm level was classified as minimal harm or potential for actual harm. That classification belongs to the regulatory framework. What it does not capture is Resident #50, who is named in the record only as a male resident on the dementia floor, and whose own assessments were completed verbally and never written down before inspectors arrived five days after the incident to ask what had happened.
The regional director said staff moved Resident #14 because of her sexual behaviors. He did not describe any documented discussion of what else might have been tried. The care plan had been in place for seven months. The behavior it documented was described by nursing staff as ongoing. The facility's answer, when it finally materialized, was a room change and a plan to find somewhere else for her to go.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 10, 2026 · Our methodology
COUNTRY LANE GARDENS REHAB & NURSING CTR in PLEASANTVILLE, OH was cited for violations during a health inspection on October 15, 2025.
That admission came from a certified nursing assistant who was present.
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.