PLEASANTVILLE, OH. Nursing assistants repeatedly warned that Resident #95 had discolored hands and feet and wasn't acting like herself, but nurses never assessed the woman's condition or called a doctor. She died days later after being transferred to hospice care with a terminal diagnosis.
The failure to act on clear warning signs from certified nursing assistants on June 27, 2025 triggered an immediate jeopardy citation at Country Lane Gardens Rehab & Nursing Center. State inspectors found that multiple staff members reported the resident's deteriorating condition, but no nurse evaluated her or documented the changes in her medical record.
CNA #249 told inspectors during a September interview that she had reported the resident's dusky-colored hands and feet to nursing staff. But when investigators tried to reach RN #237 for comment, the nurse never returned their voicemails despite multiple attempts.
LPN #198, who worked every other weekend, told inspectors she didn't recall the resident having discolored extremities on June 27 when she cared for her. She also said no other staff reported any concerns to her that evening.
The resident's medical record contained no documentation of her status for June 27, 28, or 29 before her hospital transfer.
Medical Director #301 confirmed he was never notified of the resident's condition change. He told inspectors that if nursing staff had contacted him about the deteriorating condition, he would have documented it in his progress notes. The medical director said his expectation was that nurses would evaluate residents experiencing condition changes and then notify him, the certified nurse practitioner, or the on-call medical provider to obtain orders.
Acting Director of Nursing #303 acknowledged the facility's failures during a September 24 interview. She confirmed that Resident #95 should have been assessed when CNAs reported the changes, and that medical providers should have been contacted immediately. The resident should have been transferred to the hospital or transitioned to hospice and end-of-life care discussions, she said.
The Acting DON verified that a root cause analysis completed after the incident identified the cause as the facility's failure to assess the resident when nursing assistants reported she was exhibiting condition changes. The CNAs had specifically noted discolored hands and feet, oxygen use, and behavior that wasn't normal for the resident.
The delay in assessment and medical notification resulted in the resident being transported to the hospital, where her condition was determined to be terminal. She was then transferred to a hospice facility and died.
The facility didn't identify the delay in treatment until the State Survey Agency raised the concern, meaning no investigation had been initiated before state inspectors arrived.
The Acting DON confirmed that nursing staff should have assessed the resident when changes were reported and notified medical practitioners about her needs, including her oxygen use. Additional treatment orders or interventions could have been implemented if proper protocols had been followed.
Country Lane Gardens' own policy on changes in resident condition requires staff to promptly notify the resident, attending medical provider, and resident's representative of any changes in medical or mental condition. Nurses are required to record information about condition changes in the resident's medical record.
None of this happened for Resident #95.
The facility's assessment documents state that Country Lane Gardens manages medical conditions through assessment and early identification of problems or deterioration. All newly hired personnel receive orientation training on identifying resident condition changes, including how to recognize medical issues and determine if symptoms require intervention.
Despite these policies and training requirements, nursing assistants' warnings about a resident's declining condition went unheeded for days. The woman's discolored extremities and changed behavior should have triggered immediate medical evaluation under the facility's own protocols.
The immediate jeopardy citation represents the most serious level of violation, indicating that the facility's failure created immediate risk to resident health and safety. The deficiency was investigated under complaint number 2615387, suggesting family members or other concerned parties had raised concerns about the resident's care.
Resident #95's death highlights the critical gap between what nursing assistants observe during daily care and what registered nurses and medical providers know about residents' conditions. When that communication breaks down, residents pay the ultimate price.
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.
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