Country Lane Gardens: Fall Ignored for Days - OH
The resident, identified in inspection records as Resident #14, was first lowered to the floor by her husband sometime between 6:30 and 7:00 in the evening on July 26, 2025. A nursing aide, CNA #133, said he helped get her up before the nurse arrived because her husband had already started to lift her. He told a nurse about the incident. Resident #14 had a scrape on her leg below the knee from her wheelchair and complained of pain in her ankle. She did not complain of pain immediately, he said, but the pain came later in the night.
It was not the last time she fell.
Around 3:00 in the morning, Resident #14 fell again. CNA #140, who had come on shift that Saturday night after CNA #133 told her about the earlier fall, said she called for help when Resident #14 needed assistance getting up. CNA #133 came in and the two of them lifted Resident #14 off the ground. No nurse came first. No vitals were taken. No assessment was completed. A third fall followed later that same morning.
CNA #140 said Resident #14 complained of pain in her left foot throughout the entire night.
"This was confusing to her," inspectors noted in their summary of her interview, "because other facilities she worked at followed protocol, like waiting for the nurse to assess the resident and take vitals."
CNA #140 said she wrote a statement about what she witnessed and photographed it, because she had been told that staff statements at the facility tend to go missing. She said her statement did not include many details. She was afraid of retaliation and of her coworkers treating her poorly.
The nursing record for those days was nearly empty. The administrator confirmed to inspectors on August 13 that no nursing notes existed for Resident #14 related to falls or pain from July 25 through July 27. The first documentation appeared on July 28, when an x-ray was ordered. That note said only that the x-ray was due to pain. It contained no information about what caused the pain, no mention of any fall, and no mention of the night that preceded it.
A late-entry note, dated July 29 but written for July 26, was entered by LPN #105 after the x-ray note already existed in the chart. That note acknowledged a fall had occurred on July 26. The x-ray results themselves never appeared in the nursing notes at all.
CNA #130 told inspectors that Resident #14 had described multiple falls and said her foot and ankle were hurting. CNA #130 said the resident appeared to be in pain because she would grimace every time staff touched her leg or moved her. Resident #14 described it as a sharp pain, like a sprained ankle. CNA #130 said she reported this to LPN #107, who told her the dayshift nurse would handle it. Inspectors made multiple attempts to contact LPN #107 and were unsuccessful.
The facility's own policy on changes in condition required nurses to notify a physician after an accident or incident, and to make detailed observations and gather relevant information before making that call. None of that happened on the night of July 26, or in the two days that followed.
The complaint investigation, completed August 15, 2025, covered a violation rated at minimal harm or potential for actual harm, affecting few residents. The rating reflects regulatory language, not the experience of a woman who spent a night falling, grimacing through pain each time someone touched her leg, and whose chart showed almost nothing about any of it until four days had passed.
Her husband had been there when she first fell. He had tried to pick her up himself.
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 2025-08-15 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 22, 2026 · Our methodology
COUNTRY LANE GARDENS REHAB & NURSING CTR in PLEASANTVILLE, OH was cited for violations during a health inspection on August 15, 2025.
A nursing aide, CNA #133, said he helped get her up before the nurse arrived because her husband had already started to lift her.
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.