Resident 79 underwent an angiogram with intervention to open and dilate his right leg artery on May 23, 2025. The vascular surgeon ordered him to begin taking Plavix 75 mg daily and continue Aspirin 81 mg daily upon discharge. He never received either medication.
The facility's Vice President of Clinical Operations confirmed during inspection that the resident had not received the prescribed Plavix. She also confirmed he had not received the Aspirin as ordered, believing it had been discontinued on November 14, 2024.
Nurse Supervisor 700 at the vascular surgeon's office explained that Plavix is used with Aspirin following angioplasty with stenting to prevent the stent from closing. Not receiving the Plavix medication could impair the stent and cause occlusion of blood flow, she said. Impaired blood flow in the legs could cause worsening of wounds and osteomyelitis.
The surgeon's office began calling the facility on May 30 to schedule a follow-up visit. They had difficulty reaching anyone and had to call five times to get someone to answer the phone.
Finally, on June 3, they reached someone and scheduled a follow-up visit for July 2. The facility called on July 2 and cancelled the appointment due to lack of transportation.
The facility did not call back to reschedule until September 2025.
Testing was scheduled for September 8 and a follow-up visit for September 10. The facility cancelled both appointments on September 5, again citing no transportation available.
The resident had not been seen by the vascular surgeon since his procedure on May 23.
CNP 202 told inspectors on September 22 that she was aware the facility could not transport residents to appointments who required going by cot. However, she was not aware that Resident 79 had missed follow-up appointments with the vascular surgeon.
The facility's Medical Director said during his September 22 interview that he was aware the resident had the angiogram with intervention on May 23. Going to a follow-up appointment would have checked to see if things were still okay, he acknowledged.
The nurse supervisor at the vascular surgeon's office told inspectors the purpose of follow-up appointments was to verify how the patient was progressing after their procedure. The patient should have been transported to the appointments to be evaluated by the physician and monitor healing, she said.
The facility confirmed the resident had not been seen by the vascular surgeon since May 23, despite the surgeon's discharge orders requiring follow-up care and daily medications to prevent complications from the stent procedure.
The inspection was conducted in response to multiple complaints filed against the facility.
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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