Country Lane Gardens: Narcotics Missing, Resident Died - OH
That was it. No investigation. No pharmacy review. No report to the governing body. The nurse was back on the floor the following week.
Federal inspectors visiting the facility in September 2025 found that the problems at Country Lane Gardens ran far deeper than one missing card of oxycodone. By the time the survey team finished its work, the record showed a resident who developed a bone infection in her foot because the facility failed to provide ordered medication and transportation, a resident who died of severe dehydration after staff missed a significant change in her condition, and serious medication errors involving at least two other residents. The regional directors overseeing the facility told inspectors they had not known about any of it.
The narcotic discrepancy centered on RN #227 and two residents. On August 28, 2025, Resident #81 had two count sheets and two cards of Alprazolam that needed to be signed into the narcotic count. RN #227 signed in only one sheet and one card. The unit manager, LPN #175, confirmed to inspectors on September 17 that this would make the count wrong "unless a card and sheet were removed by someone."
The following day, August 29, a card of oxycodone belonging to Resident #51 went missing. She did not receive any oxycodone from August 28 through August 31, when a new supply arrived from the pharmacy.
Resident #51 had told staff that RN #227 was stealing her medications. The Director of Nursing confirmed to inspectors that she had not been aware of that accusation. What she did know, she said, was that the unit manager had called RN #227 directly to ask whether she had given the medication. That call, apparently, closed the matter as far as anyone at the facility was concerned.
The Director of Nursing said she became aware of the allegation on September 3, 2025, five days after the oxycodone went missing and six days after the Alprazolam count came up short. Her response that day was to provide education to nursing staff. She notified the pharmacy the same day. She confirmed to inspectors that the pharmacy was not involved in any investigation into the missing narcotics.
Because the allegation named RN #227, the nurse was drug tested. The test came back negative on September 6. The Director of Nursing confirmed to inspectors that the facility did not investigate the underlying allegation: that RN #227 had signed in an incorrect amount of Alprazolam for Resident #81. A negative drug test and a phone call to the accused nurse were the sum total of the facility's inquiry.
RN #227 was observed by inspectors working on B-Hall on September 16 and again on September 17, 2025.
The QAPI committee, the facility's internal quality oversight body, met on September 3, the same day the Director of Nursing said she first understood the scope of the problem. The meeting did not identify any issues with misappropriation of narcotics.
When inspectors interviewed Administrator #188 on September 29, she confirmed there were no attendance records for any QAPI meetings. She confirmed there was no evidence that the governing body had been involved with any QAPI meetings. She confirmed there was no evidence of the weekly meetings that were supposed to track progress on a transportation contract, a gap that had already contributed to harm.
Resident #79 developed osteomyelitis of the foot, a serious bone infection, after the facility failed to provide her with ordered medication and failed to arrange transportation she needed. Osteomyelitis can require prolonged antibiotic treatment, hospitalization, or surgery. The inspection record does not detail how long the failures persisted before the infection took hold.
Resident #95 died.
Inspectors documented that staff failed to identify a significant change in her condition, and that she died of severe dehydration. A significant change in condition requires a formal reassessment and, in most cases, notification of the physician and family. None of that happened in time to matter.
The Regional Director of Operations and the Regional Director of Clinical Services both told inspectors on September 29 that they had not previously known about any of the issues the survey team identified: not the missing narcotics, not the bone infection, not the dehydration death, not the medication errors affecting Residents #3 and #40. The facility's own quality improvement structure had not surfaced any of it to the people responsible for overseeing the facility.
The QAPI program exists precisely to catch these failures before they compound. The facility's own policy, dated July 2016, described a committee that would identify actual and potential negative outcomes, conduct root cause analysis, and report to the administrator and governing body. The policy described a standing committee with specific goals. The records showed a committee with no attendance logs, no governing body involvement, and a September meeting that looked directly at a period when narcotics were going missing and found nothing worth noting.
What the inspection record captures, across multiple residents and multiple failures, is a facility where the mechanisms for catching problems had stopped working, and where no one in a position to fix that understood what was happening on the floors.
Resident #51 went four days without oxycodone. The inspection report does not describe her diagnosis, her pain levels during those four days, or what it cost her to wait. It records only that she had told staff a nurse was stealing from her, that the facility called the nurse to ask about it, and that the Director of Nursing learned of the accusation only after the fact.
The nurse was working the day shift when inspectors arrived.
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.
Download the official CMS inspection PDF from Medicare.gov
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 9, 2026 · Our methodology
COUNTRY LANE GARDENS REHAB & NURSING CTR in PLEASANTVILLE, OH was cited for violations during a health inspection on October 15, 2025.
No report to the governing body.
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.