Country Lane Gardens Rehab & Nursing Ctr

F 0580 Level of Harm - Minimal harm or potential for actual harm

an unknown source, or other change in condition. Prior to notifying the physician, the nurse will make detailed observations and gather relevant information and pertinent information for the provider. Unless otherwise instructed by the residents, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental or psychosocial status.This deficiency represents non-compliance investigated under Complaint Number 2583218.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Country Lane Gardens Rehab & Nursing Ctr

7820 Pleasantville Road Pleasantville, OH 43148

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

stated Resident #14 was not crying but stated it did hurt pretty bad. CNA #122 could not recall the exact date the resident had told her about this.Interview on 08/13/25 at 1:15 P.M. with CNA #125 revealed Resident #14 informed her she had a fall and it was also passed along in report. Resident #14 stated she had fallen and hurt her foot but did not mention how. CNA #125 stated Resident #14 did not specify how much pain she had, just that it hurt. CNA #125 stated she reported the resident complaints to the nurse (unable to recall which nurse), and the nurse stated she would let the doctor know. CNA #125 could not recall which day this occurred.Interview on 08/13/25 at 1:19 P.M. with CNA #130 revealed Resident #14 stated her left ankle was hurting her and she had reported she had a fall on 07/26/25. Resident #14 did not provide details of the fall. CNA #130 stated Resident #14 told her she had multiple falls, and her foot and ankle were hurting. CNA #130 stated Resident #14 appeared to be in pain because every time staff touched her leg or went to move her, she would grimace. Resident #14 reported it was a sharp pain, like

she sprained the ankle. CNA #130 stated she reported to LPN #107 who stated she was aware, and the dayshift nurse would have to take care of it.Multiple attempts were made to contact LPN #107 and were unsuccessful.Interview on 08/13/25 at 1:27 P.M. with CNA #133 revealed he recalled Resident #14 had been lowered to the floor by her spouse around 6:30-7:00 P.M. on either Friday (07/25/25) or Saturday (07/26/25) and he let the nurse know. CNA #133 stated he assisted in getting Resident #14 up prior to the nurse coming since her husband had already started to pick her up. CNA #133 stated Resident #14 did not complain of pain until later in the night. Resident #14 had a scrape to one of her legs below the knee from her wheelchair and complained of pain in the ankle. CNA #133 stated he told LPN #105 about the incident who went to Resident #14's room immediately.Interview on 08/13/25 at 2:03 P.M. with the Administrator confirmed there were no nursing notes (from 07/25/27- 07/27/25) related to falls or pain for Resident #14 until the x-ray was ordered (07/28/25). The x-ray note only indicated it was due to pain and no information about why the new onset of pain was occurring. The Administrator confirmed a late-entry note dated 07/29/25 for the date of 07/26/25 entered by LPN #105 revealed Resident #14 had a fall 07/26/25, after the note regarding the x-ray was entered. The Administrator confirmed the x-ray results were not in the nursing notes.Interview on 08/14/25 at 6:32 A.M. with CNA #140 revealed she was aware of several falls occurring for Resident #14. CNA #140 stated upon the beginning of their shift Saturday night (07/26/25) CNA #133 told her Resident #14 had a fall with her husband. CNA #140 stated when she saw Resident #14, she had complained of pain in her left foot. CNA #140 stated Resident #14 had another fall around 3:00 A.M. and when asked for assistance, CNA #133 came in to help her and they just lifted Resident #14 off the ground prior to any vitals or assessment being completed. CNA #140 stated this was confusing to her because other facilities she worked at followed protocol, like waiting for the nurse to assess the resident and take vitals. CNA #140 stated there was also a third fall later in the morning. CNA #140 stated Resident #14 was complaining of pain throughout the night. CNA #140 stated she wrote a statement and took a picture of it because she was told they (staff statements) usually go missing. CNA #140 stated her statement did not have many details because she was afraid of retaliation and her coworkers treating her poorly.Review of a policy titled Change in Condition dated 12/2016 revealed the nurse would notify the physician when there has been an accident or incident involving the resident, discovery of injuries of an unknown source, or other change in condition. Prior to notifying the physician, the nurse would make detailed observations and gather relevant information and pertinent information for the provider.This deficiency represents non-compliance investigated under Complaint Number 2583218

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